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ACA Penalty May Not Deter Workers Comp Claims

What if a worker decided to pay the ACA penalty and file a WC claims for medical treatment?  The Affordable Care Act (ACA) may cause an unintended spike in Workers Compensation claims.

Affordable Care Act ACA Penalty Logo
Wikimedia Commons – Careilly5801

One of the concerns over the years in claims departments is an employee substituting Workers Comp for health insurance.   The ACA may also cause medical treatment rationing.Now that almost two million health policyholders that were previously insured have been dropped by their health insurance carrier, could Workers Comp become a safety-net type of accident insurance?    Claims for many illnesses would be immediately denied by Workers Comp carriers .

The “Monday Morning” claimant is one of the huge red flags when a claim is filed for benefits.   A very limited amount of ailments could be filed by reporting Workers Comp claims.  Any home accident could be reported as a claim upon returning to work the next day.

Picture Nurse Preparing Syringe for Injection Focus on Syringe ACA Penalty Medical Treatment

An  adequate claims investigation will probably uncover the fact that the accident was not related to work.  One of the best places to look is in the history of the injury as recorded by the original treating physician in his/her notes.    One very obvious area is the original date of treatment.  The date may not necessarily match the date of the injury.

Communication between the employer and physician will be tantamount to avoid having to pay for non-work related treatment.   One of the Five Keys To Saving on Workers Comp Claims is having a designated original treating physician.   Some states do not allow the choice of treating physician by the employer.   Other states such as California allow for medical treatment panels or MPN’s.

A rash of Workers Comp claims may not occur due to the ACA.   However,  only two or three claims can wreck what was previously a good Workers Compensation program.

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James J Moore - Workers Comp Expert

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Management Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications


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