In a Volatile Political Climate MSAs & Professional Administration Provide Much Needed Assurances

These first few of months of 2017 have been, to put it mildly, volatile in national politics.  The incoming Trump Administration and a Republican Congress are poised to tackle the federal budget, Medicaid, and the Affordable Care Act (Obamacare) among many other federal programs.  All of these issues have sharp partisan divides, however no matter where your views lay on the political spectrum, if you are a professional involved in the workers compensation industry, these issues may have a big impact on how you can be successful at your job.

 

This article looks at what impact the Trump administration and a Republican-controlled Congress may have on Medicare Set-Asides (MSAs) in the context of the legislative and regulatory history of the Medicare Secondary Payer (MSP) Act and how the uncertainty resulting from potential changes to federal healthcare programs results in MSAs and professional administration being even more relevant in the settlement of workers’ compensation cases.

 

 

The MSP Act Has Been and Remains Bipartisan

 

A review of the history of the MSP Act demonstrates a noticeably bipartisan effort to improve and expand its applicability and enforcement mechanisms.  The MSP Act was enacted in 1980 during President Carter’s administration.  Subsequent to its passage, provisions were added over the Reagan, George H.W. Bush and Clinton administrations, all emphasizing Medicare being secondary to group and non-group health plans.  The most notable legislative expansion occurred in 2007 when a Democratic-controlled Congress passed, and President George W. Bush signed into law, the Medicare, Medicaid and SCHIP Extension Act which included Section 111 Mandatory Insurer Reporting provisions for group and non-group health plans.  There also continues to be a decade long effort to pass bipartisan legislation which would implement certain reforms to the Workers’ Compensation Medicare Set-Aside (WCMSA) review process.  While the most recent WCMSA reform bill died in the last Congress it is expected a new bill will be reintroduced in 2017.

 

Besides legislative expansion of the MSP Act, during President George W. Bush’s administration there occurred the release of the July 23, 2001 CMS memo, commonly called the “Patel Memo.”  The Patel memo and subsequent CMS memos effectively formalized a process for CMS to review and approve WCMSAs.

 

MSA reviews continued, Medicare conditional recovery processes expanded and Section 111 was implemented all during the course of President Obama’s administration.  The only legislative change to the MSP Act occurring during the Obama years was the passage of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (SMART Act) which was a successful bipartisan effort to address deficiencies identified in the MSP Act, particularly Section 111 reporting and Medicare conditional payment recovery.

 

Since the enactment then of the MSP Act in 1980 it has continued to be expanded and enforced consistently across both Republican and Democratic Presidents and Congresses.

 

Why has there not been a partisan divide? The simple reason is that the MSP Act forces entities other than the federal government to pay which has benefits for both political parties. For Democrats it demonstrates their protecting the viability of a federal government entitlement program while for Republicans it demonstrates their protecting taxpayers by shifting costs away from the government. While the Trump administration has to our knowledge never issued any MSP policy statements, based upon the past bipartisanship on this issue, our expectation is the administration will continue and possibly expand the MSP compliance programs at CMS.

 

 

Uncertainty Over Federal Healthcare Programs to Drive Assurance with MSAs

 

President Trump has indicated repeatedly that he will not reduce benefits to Medicare beneficiaries.  Nonetheless, Medicare beneficiaries are facing premium increases. Notably, a Kaiser Family Foundation report indicated Part D premiums are rising by an average of 9% in 2017.  As for Medicaid, the Trump administration is supporting a block grant program which would give more discretion to the states in formulating and implementing their own Medicaid programs compared to the present process which includes significant federal oversight.  Finally, and most significant, is the Republican-led initiative to “repeal and replace” the Affordable Care Act, commonly known as ObamaCare. These potential changes to statutory programs create uncertainty for injured workers contemplating settlement of medical in their workers’ compensation cases.

 

Uncertainty for injured workers exists with programmatic changes to Medicare and private group health plans which are increasingly driven by a more value-based approach to healthcare delivery.  A value-based approach provides incentives to medical providers to be more cautious with prescribing treatments and medications which may have limited value to the patient.  This is also usually tied in part to a utilization review process which places limits on care through the use of evidence-based medicine.  While in the past some injured workers have settled medical stemming from their work related injury confident that they could shift their ongoing work-related care, if any, to their group health plan, such coverage may now be limited.  And when it comes to shifting costs to Medicare, CMS’s long-standing policy is such costs must be accounted for in an MSA.

 

 

A Flight to Certainty

 

Accordingly, injured workers and their attorneys when settling their workers’ compensation cases will look for certainty where it can be obtained so that they have the assurance of access to medical care for their future injury-related care.  For claimants who are Medicare beneficiaries or are close to becoming Medicare beneficiaries, such assurance can be obtained by a properly allocated MSA which is CMS-approved, when necessary, and professionally administered to maintain the MSA funds over life-expectancy in compliance with CMS rules.

 

A best-in-class MSP Compliance company will provide employers and claimants a reasonable MSA allocation which, along CMS guidelines, properly accounts for future injury-related and Medicare-covered medical care without unnecessary overfunding.  This often includes the company reaching out to treating physicians to confirm current care regimens or clarity regarding ongoing medication and treatment prior to submission of the MSA to CMS.

 

While CMS approval of the MSA and subsequent funding provides assurance at the point of settlement that funds for injury-related medical have been provided, equally important is proper administration of those funds such that an injured worker can be assured the funds for his or her care will last over their life expectancy and that there will be a seamless transition to Medicare for payment if the funds every run out.

 

Professional MSA administration can secure the injured party discounts on their medical treatment, and prescription costs. All the while they are free from utilization review allowing them to not have to worry about their treatment being rejected. Additionally, professional administration can make sure all MSA expenses are accounted for in the eyes of Medicare.  These programs are in place to protect the injured worker post-settlement and ensure compliance with CMS requirements for MSA administration.

 

In this current era of high uncertainty, all parties can rest easy by focusing on known methods to protect themselves and the injured party throughout the claim handling and settlement process.  That’s why many believe it is more critical than ever to obtain an adequate MSA that will cover the ongoing medical care of the injured party and, upon settlement, to have a professional administrator help the injured party make the funds last as long as possible and do all the required Medicare reporting.

 

Author Dan Anders, Chief Compliance Officer, Tower MSA Partners. Dan oversees the Medicare Secondary Payer (MSP) compliance program. In this position, he is responsible for ensuring the integrity and quality of the MSA program and other MSP compliance services and products. Based upon his more than a decade of experience in working with employers, insurers, TPAs, attorneys and claimants, Dan provides education and consultation to Tower MSA clients on all aspects of MSP compliance. Contact: (847) 946-2880 or daniel.anders@towermsa.com

 

Author Porter is the Chief Strategy Officer of Ametros. Prior to Ametros, Porter worked in corporate development, private equity investing and as an investment banker. He has experience leading acquisitions, launching new products and building the teams to support them. Porter has a passion for directing the growth strategy of rapidly growing businesses in the healthcare and financial services industries. pleslie@ametrosfinancial.com

WCRI Recap: Single Biggest Factor To Turn-Around Opioid Crisis

WCRI Recap – 3 Part Series

  1. WCRI Recap – Impact of Donald Trump and 2016 Election
  2. WCRI Recap: 3 Factors That Most Impact Worker Outcomes
  3. WCRI Recap: Single Biggest Factor To Turn-Around Opioid Crisis

 

It’s been two weeks since the WCRI Conference recently held in Boston. I’m Michael Stack with Amaxx. Today I want to give you some highlights and recap from that recent conference from the notes that I took and the perspective that I had on it.

 

The next session that I took some detailed notes on was how are states battling the opioid epidemic. I took a lot of different notes in this session, but Dwight Lovan who was formerly with the Kentucky Department of Workers Comp Claims made one statement that I think is the only statement that really needs to resonate with our industry and with state lawmakers.

 

 

 

Single Biggest Factor To Turn-Around Kentucky Opioid Crisis

 

We all know, or a lot of people know, that Kentucky was the epicenter of opioid overdose deaths and opioid drug problem, so they took this head on. He talked about really how they addressed it in Kentucky and the progress that they’ve made, which has been significant. He made one comment, and he said, and he kind of almost said it in passing, but I wrote it down and I highlighted it and I starred it and I bolded it, because he said, “The biggest impact and the one thing that they did that made the biggest difference was they required their physicians to check the PDMP data.” They made a mandate that required their physicians to check the PDMP data. If you’re not familiar with the prescription drug monitoring program it’s a database that basically doctors can check. It takes maybe 5-15 seconds to see what other drugs that injured worker is taking so they don’t overprescribe, so prevents doctor shopping. A lot of those biggest challenges that cause overdose deaths, so they made a mandate that required the physicians to check this PDMP data before they prescribe the drugs.

 

That made the biggest impact at the epicenter of opioid overdoes deaths and the significant progress that they have made. I checked this research. I researched it a little bit online. I’m not sure how accurate this data is, but it said 16 states have since implemented this mandate and it should be implemented in every single state, in all 50 states. If this made the biggest impact at the biggest problem area in our country, it’s an easy fix and it only takes five to 15 seconds to save a life, so hugely important point on this how states are combating opioids. If you have not implemented this in your state talk to our lawmakers. Let’s make this mandatory across the board.

 

 

Non-Pharmalogical Treatment of Pain

 

The last session was non-pharmacological treatment of pain as alternatives to opioids. This was a fantastic session. The information covered was very impactful and very moving for the results that it can give for each individual injured worker.

 

Dr. Dawn Ehde and I apologize because I’m probably pronouncing that wrong, from the state of Washington. She gave a tremendous presentation. Here’s the highlights of what she covered. She covered the idea that this medical model, or the currently medical model as far as the treatment of pain. It just doesn’t work. It doesn’t work because the biopsychosocial factors in all the different elements that go into how an individual perceives their own pain. This reinforces that idea of the do you think you’ll be back to work in four weeks. It reinforces that same idea, the perception of that individual person is such a huge factor on how well they’re going to do, and a huge predictive indicator of how well that claim’s going to go.

 

She talked about some of the current different options of what’s currently being used out there today. She talked about cognitive behavior therapy and she talked about mindfulness, so two different popular options which you may or may not be familiar with. What she went into a more detail, which I thought was extremely interesting and compelling was this idea of collaborative care. That’s what I want to cover here today.

 

 

Collaborative Care Model

 

It’s very much in sync with the best practice that I recommend, which is the weekly claims round table. It’s about looking at an individual claim, bringing in perspective some different experts to collaborate and come up with the best solution for that individual person because the solution for Tom’s going to be different than the solution for Sally is going to be different than the solution for Joe. Each individual person needs their own path and their own direction. You get the perspective from different experts to work together, collaborate for that outcome. That was really what she reinforced here.

 

She drew out this picture of the injured worker really being at the center of this model. You’ve got the providers up here. You have a care manager down here, and over here you have what she called consultants, and these consultants and everyone ties into here to service the injured worker. These consultants are psychiatrists, they’re different experts that can bring in and share some expertise with this care manager and with this provider to all work together to collaborate on the different elements that maybe needed to suit that person’s needs, to meet them where they are, to move them towards this positive outcome.

 

I’m oversimplifying this conversation, I’m oversimplifying this presentation, but you get the idea of what we’re trying to accomplish here and what she’s talking about and how they’re addressing this in the state of Washington to hopefully provide a model for the rest of the country to follow for these outcomes. The idea is to collaborate, connect with this injured worker regularly, have conversations with him, set those expectations. We talked about that in the worker outcome studies of how trust is such a huge factor so you build this huge level of trust with this care coordinator and they’re talking to them, that injured worker, about their expectations that do you think you’ll be back to work question is a huge factor in how they’re dealing with their pain, and how they’re going to recover.

 

They implemented, they haven’t done a ton of studies on this idea yet, but they implemented in a case of multiple sclerosis patients. There was 188 patients and it achieved what the medical community deems is the triple aim, which is better outcomes, lower cost, and higher satisfaction. That was the only study and they’re starting to roll this out in work comp, so very exciting for the solutions that can be brought to the table. Very impactful, very practical information as always from the WCRI Conference. I hope that you can take this information and put it into practice today.

 

 

Pick One Idea & Implement!

 

My recommendation is to start with one thing, start with one thing. What is it from that conference that you want to implement today and build that momentum, which is how significant change happens. Again, I’m Michael Stack with Amaxx, remember your success in Workers Comp is to defined your integrity, so be great!

 

 

 

WCRI Recap: 3 Factors That Most Impact Worker Outcomes

WCRI Recap – 3 Part Series

  1. WCRI Recap – Impact of Donald Trump and 2016 Election
  2. WCRI Recap: 3 Factors That Most Impact Worker Outcomes
  3. WCRI Recap: Single Biggest Factor To Turn-Around Opioid Crisis

It’s been two weeks since the WCRI Conference recently held in Boston. I’m Michael Stack with Amaxx and today I want to give you some highlights and recap from that recent conference, from the notes that I took and the perspective that I had on it. The second session was about worker outcomes and what impacts, based on studies and research to define the best outcome.

 

 

What are those factors that we can address? For me, this was the most interesting and impactful session for what I do, which is work with employers, insurance brokers and educating best in class programs. This session is one that I found extraordinarily valuable to get an understanding of, what are those things that impact the outcomes that we can address at the beginning a claim and make sure our success is that much more likely.

 

 

Single Biggest Factor That Impacts Claim Outcome

 

This is a study I’ve quoted a number of times. It was published by WCRI a few years back and they came out with a study and said, “The biggest single factor based on their research that impacts the outcome of that claim is trust.” The biggest single factor that outcome impacts the outcome of a claim, is the amount of trust between an employee and an employer. Hugely important point. Hugely important factor to understand. Now, we’ve seen that one before.

 

 

 

How Does Supervisor Respond to Injury?

 

Glen Pransky from Liberty Mutual gave a presentation about some of their research and their studies. I found it extraordinarily interesting and valuable. Here’s what they came up with. Two different things that impact their outcomes, one of the biggest factors, all things being equal, if how does the supervisor respond to the injured worker at the moment that claim is reported. I’m going to say that again. How does the supervisor respond to the injured worker at the moment that that claim is reported. Do they respond with blame and anger and frustration? There’s that lack of trust there. They’re not trusting that the employee maybe said they get injured and they say, “Yeah, right. You didn’t get injured. Get back to work.”  Or, “How could you do that wrong? You are now in trouble.” That lack of trust there. So, how does that supervisor respond to that injured worker at the time of injury? All things being equal, if they respond positively, it’s going to have a significantly better claim outcome. If they respond negatively, a significantly worse claim outcome. That was number one, “How does a supervisor respond to the injured worker at the time that claim is reported?”

 

 

 

How Does Insurance Adjuster Respond to Injured Worker?

 

Number two, how’s the insurance adjuster respond or how is that first interaction with the injured worker go? Are they using big insurance words that the injured worker doesn’t understand? Things like adjudication and calling him the claimant and all these different things that really foster this lack of trust that they’re going to be taken care of. So, if there’s all these things that they don’t understand and they don’t know what’s going to happen, what are they going to do? They’re going to make sure their rights are protected. They’re going to call an attorney and they’re going to be going down this path which makes the claim that much more complicated, because they had a poor interaction with a supervisor and their adjuster’s causing him all this adjudication. They say, “I don’t know what’s going on. I better look out for myself.” So, how you responding to the injured worker, how do those communication interactions, things to train on, things to work on.

 

 

 

Do You Think…

 

Here’s the next piece, which I thought was extremely interesting and something you need to input, impact into your program today. Starting today, do this on every single claim. Here’s what it was, they asked this question, it’s a highly predictive question of the outcome of that claim, “Is do you think, you’ll be back to work within four weeks without any restrictions?” Do you think, you will be back to work within four weeks without any restrictions? Do you think you’ll be back to work in four weeks without any restrictions? Highly, highly predictive question to ask of what that outcome of the claim is. If they say, “no” then you get to ask them why. “Why don’t you think you’ll be back to work?” You can bring in additional resources and support to drive that. If they say, “yes” then they’re setting that expectation in their own mind and it’s only going to drive that success to get them back to work. Highly predictive question and response to that claim’s outcome, “Do you think you’ll be back to work within four weeks without any restrictions?” Start asking that question, every single one of your claims today.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

WCRI Recap: Donald Trump and Impact of 2016 Election

WCRI Recap – 3 Part Series

  1. WCRI Recap – Impact of Donald Trump and 2016 Election
  2. WCRI Recap: 3 Factors That Most Impact Worker Outcomes
  3. WCRI Recap: Single Biggest Factor To Turn-Around Opioid Crisis

 

It’s been two weeks and you still haven’t gotten it done, or maybe you have. I don’t really know, but it’s been two weeks since the WCRI Conference recently held in Boston. Just a real friendly reminder. If there were things that you were supposed to follow-up with, conversations you had, business cards you got were sent from someone, or a tasks you were supposed to do, and if you haven’t done it yet, just get that in your calendar today and get that taken care of.

 

I’m Michael Stack with Amaxx, and today I want to give you some highlights and recap from that recent conference from the notes that I took and the perspective that I had on it.

 

A real quick, just personal story. It’s been an exciting couple weeks for me since that conference. My family and I, I think that some people know that we moved up to Kennebunkport, Maine, just last year. We tried to buy a house, and there were all kinds of challenges. The inspection was a challenge. There were all sorts of other things going on, and it just didn’t work out. We had to move into a short-term rental, and we finally closed on our new house just last Friday. We’re super pumped. It was a great, exciting weekend. The kids are pumped. The families pumped, and the kids took the bus from the new house today. When I was trying to look for my suits this morning, and I couldn’t find them so no suit coat today.

 

 

 

Impact of 2016 Election: Senator Tom Coburn & Congressman Henry Waxman

 

 

Let’s talk about this conference. There’s four sessions that I want to cover here. First one was the impact of the 2016 election. There was really two main points that they talked about. The guests were former Senator Tom Coburn who is a republican persuasion and former U.S. House of Representative’s Henry Waxman which was a democratic persuasion, very strong and polarizing opinions. Two main topics that were talked about. I’m going to try to run through this as quickly as I possibly can and summarize it to hit the main points.

 

 

Donald Trump Relationship With Congress

 

I broke it down really into two main topics. It was Trump they talked about, and they talked about the ACA. I know a lot has happened in the last two weeks with the ACA and the Republicans presenting their new plan. I’m not a hugely political guy so I’m not going to talk about really what those recent events are. It’s out of my area of expertise, but I will cover what they talked about at that conference itself.

 

First top thing they talked about was Trump, and there was two things they talked about were really executive orders that he did. He implemented a lot of executive orders after coming into office and then his relationship of Congress. The question really with this executive order is in the biggest … the first point that they hit during that discussion was one of those orders. Whenever a new regulation is implemented, two regulations have to be abolished so one implemented, two abolished. They weren’t sure what that impact would have.

 

Second thing was really this relationship with Congress. I think it’s something everyone in Washington is watching and trying to figure out how this is going to work between the Executive Branch and the Congress. One thing that they did talk about and really there was this fear, and Congressman Waxman talked about this, was there was this fear that Trump was just going to defer to Congress and rather than driving the ship as maybe past presidents have. There was a fear to defer to Congress but then in the same conversation, they talked about really how power … they felt that power, and Senator Coburn was talking about this, how power has shifted too much to the Executive Branch and how these laws are written. There will be these big, thick laws and the Congress men and women are passing these laws. They don’t understand even what every stipulation has to impact, what the impact will be, or even what it is itself. There’ll be a lot of words that will say, well, whatever the Secretary deems appropriates. They felt like too much power was being given to the Executive Branch. That was basically the discussion. It talked about a lot of different political opinions. It was very interesting discussion, but those were the main points regarding Trump and the Congress relationship.

 

 

Affordable Care Act

 

Next, they moved into the ACA. They were talking about this again very political discussion, Senator Coburn with a republican persuasion and Congressman Waxman with a democratic persuasion. There was basically boil it down to two things to keep it as simple as possible. Senator Coburn said, “We need freedom. People need freedom. We need a free marketplace.” He referenced the Amish community a number of different times. He talked about how the Amish buy healthcare, and they buy it for cash. They go in, negotiate the best price with the best providers, and pay a significantly lower price by negotiating up front in a free market type system.

 

Congressman Waxman said, “The safety net is going to be slashed.” He quoted Trump and said, “It’s going to be a disaster.” You know how this ACA discussion goes, very heated, very interesting to hear their perspectives, and a lot has even happened in the last couple weeks since that presentation. That was very political, but didn’t have much impact on work comp during this discussion.

 

 

Federal Government & Workers’ Compensation

 

The meat of the work comp discussion was talking about this Department of Labor report. This report was issued back in October of 2015. There were eight congressmen and women that signed this and said, “We’re worried about work comp, and the amount of benefits that have been reduced, and how it’s taking from SSDI, and we need to have a renewed interest from the Federal Government in work comp.” Very big concern for us in our industry of what that’s going to impact so the question was asked was now that this new administration is in place, is this sentiment or is this fear still the same? It was an almost comical response.

 

They said, “We got a lot going on. Sure, work comp industry, great, we love you guys but you’re just not that important, and we have a lot of other things on our plate in Washington that we really don’t think we’re going to be getting or having any interest in the work comp industry”, so very short and almost comical response to this Department of Labor report and the Federal Government’s potential interest in the work comp industry.

 

Continued…

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

10 Common Questions Claimants Have When Filing a Worker Comp Claim

Being in the insurance or risk management field we often forget that the workers that get injured do not know nearly as much as we know about claims.  At times, adjusters forget to take the time needed to properly explain what rights injured workers have when these claims occur, and that can lead to a disconnect between the adjuster and the injured worker.  This disconnect can make the claim travel down a bumpy road rather than a nice, smooth, streamlined one.

 

Here are some common questions claimants have when filing a work comp claim.  Please note the answers to these questions can vary by jurisdiction, be sure to consult your adjuster or local legal counsel if you have questions.

 

 

  1. How do I get paid?

 

If your case is deemed compensable, you will receive a workers compensation check, probably in the mail or direct deposit, every week or two after the waiting period has subsided.  This check is meant to replace your lost wages from work.  It will not be 100% of the pay you are accustomed to receiving but rather a percentage of your gross wages based on whatever formula the state of jurisdiction uses.

 

 

  1. When will I get paid?

 

Generally wages are paid after your case has been deemed compensable by the adjuster handling the file.  Usually this can range from a period of a week or two to maybe a month or so.  Other factors can delay payment, including the investigation of the claim and the gathering of the pertinent medical records.

 

 

  1. How much will my work comp check be?

 

This will depend on your jurisdiction.  Typically you will receive anywhere from 66% of your net pay to up to 80%, maybe even more. Fringe benefits that you receive from your employer can also affect the amount of your work comp check.  Anything that you are responsible for regarding your personal medical insurance or 401k may still have to be paid by you, the injured worker.  Work comp pay is not taxable income, and you will not receive a W2 for work comp wages paid out for whatever year you received benefits.

 

 

  1. Can I go to my primary care physician?

 

This will vary by the jurisdiction, but generally the answer is yes. After a certain period of time, you can go to an appointment with your primary care doc, and usually the first one will be paid for by the insurance carrier that is handling the work comp claim.  Whether or not you can continue to treat with your personal doctor is up to your adjuster, and if your personal doctor accepts work comp patients and does proper work comp billing.

 

 

  1. Do I have to go to “your” doctor all the time?

 

Maybe, depending on the jurisdiction and if your adjuster authorizes you to treat with your physician instead of the occupational medicine doctor.

 

 

  1. Why is the work comp doctor’s opinion more important or more crediblethan my doctor?

 

This will depend on what each doctor is saying in their medical reports. Sometimes personal physicians will say one thing with you in the exam room, and meanwhile when they dictate their notes they may mention diagnoses and findings not essentially shared with you personally.  The same is true for the occupational doctor.  The best way to stay the most informed is to request a copy of your medical records from both doctors, this way you can see all of the information that the adjuster is seeing, in regards to the medical chart.

 

 

  1. What if I have two jobs? Do I receive lost wages for both jobs?

 

Usually yes, but again this will depend on the jurisdiction. You will have to provide your adjuster with a copy of your personnel file and wage records from your second employer, and be sure to tell this other employer than you sustained a work comp injury at your other job and that you may not be able to work your job during your healing period until you are fully released from medical care with no more restrictions.

 

 

  1. The light duty job assigned to me pays less than my normal job. Is this legal?

 

Yes it is legal, but the insurance carrier will be obligated to pay you a “partial” wage.  This means that they take the reduced wages you will earn and issue you a supplemental check for the difference.  The amount of this check will depend on the jurisdiction the claim is in.  If you have questions about how this supplemental check is determined, contact your adjuster and have them walk you through the process.

 

 

  1. Why isn’t my adjuster returning my calls?

 

Adjusters can handle and be responsible for hundreds of files, of which you are one of.  These files are all in different stages, and are of varying complexity.

 

Give your adjuster a day or so to have a chance to return your call.  One thing an adjuster hates is someone that calls them every hour. Sadly, the squeaky wheel rarely gets the grease.  Be patient, and allow your adjuster the professional courtesy to get to your claim.  But, you also have to be persistent.  If you have left a few messages and 3-4 days go by without a callback, you can call and ask for their supervisor.  Every adjuster has an obligation to return calls to their claimants, no matter how insignificant the question may be.  Failure to return calls can be considered “bad faith” on the part of the adjuster, and they or their company can incur penalties or fines if they do indeed fail to return your call within a reasonable timeframe.

 

 

  1. Should I consult an attorney?

 

There is no right or wrong answer to this question.  The only person that can answer this question is you.  If you will feel more at ease by talking to a legal professional, then by all means do so.  Having a phone consultation with an attorney doesn’t mean that you are filing a lawsuit against your employer. If it makes you sleep better at night knowing you talked to an attorney, then by all means do so. Better yet, talk to a few attorneys if you have to.

 

 

Summary

 

These questions are normal questions every claimant will have with their work comp claim.  Some people know more about the work comp system than others, but don’t take your fellow coworkers advice about what to do with your claim.  Many coworkers that have a vast experience in dealing with work comp situations will not always give you credible or correct advice.  Your adjuster is the one handling your claim, and they will be there to walk you through the process.

 

If you feel that the adjuster did not answer your question good enough, feel free to consult an attorney.  You want to make sure you are very involved in how your claim is handled.  After all, being injured doesn’t mean that you do not need to know anything about how the process works and what rights you have as an injured worker.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

14 Points To Discuss With Your Injured Worker For Win-Win Outcome

A big mistake made by employers is leaving the injured employee to fend for himself / herself in the world of workers’ compensation.  For most injured employees, the injury is their first workers’ compensation claim and they do not know what to do or what to expect.  Fear of the unknown and not knowing what to expect creates a lot of angst in the employee.

 

 

Fear of Unknown Creates Angst in Injured Employee

 

The smart adjuster during the initial contact with the injured employee will take all the time necessary to answer the employee’s questions about medical treatment, lost wages, light duty return to work, and any other questions the employee might have.  The smart employer will also contact the injured employee and answer all the questions the employee might have about their work comp claim.  When neither the adjuster nor the employer answers the employee’s questions and concerns, the employee will usually find someone who will – an attorney.

 

We always recommend for the employer to call the injured employee immediately after the initial medical treatment.  They will want to ask what the doctor’s diagnosis and prognosis are, when the employee will be returning to work, and if the return to work date is not known, what the work restrictions are.

 

 

14 Points to Discuss With Your Injured Worker

 

  1. The injured employee should be asked to submit a detailed report of how the claim happen, preferably written
  2. Ask the injured employee who were the witnesses to the accident
  3. Verify the injured employee is treating at an employer selected medical provider, if your state allows the employer to select the medical provider
  4. Ask the injured employee if he has ever injured the same body part before, and if so, when
  5. Tell the injured employee you will send him/her a copy of the First Report of Injury being submitted to the insurance company, and ask them to review the Report and advise you if anything is inaccurate
  6. Ask the injured employee if he has discussed all pre-existing medical issues with the doctor (some medical issues like obesity will be obvious, others like hypertension or diabetes need to be disclosed to the medical provider)
  7. Explain to the injured employee how mileage to medical appointments is reimbursed in your state, and the mileage rate
  8. Explain to the injured employee the importance of attending every doctor’s appointment, diagnostic test and physical therapy session (if needed)
  9. If the injured employee is going to be off work, explain to him what the state’s waiting period is for indemnity benefits
  10. Explain to the injured employee how the indemnity benefits will be calculated by the insurance adjuster
  11. Ask the employee to call you after each medical appointment to let you know the doctor’s current plan of treatment
  12. Advise the injured employee to obtain an off-work slip at each doctor’s appointment
  13. Ask the injured employee if he has any questions in regards to how the transitional duty program works
  14. Ask the injured employee if he has any questions about any other aspect of how their workers’ compensation claim will be handled

 

Yes, this is a lot of information to review, and it will take you an extra five minutes.  However, the extra five minutes spent making sure the employee understands how everything will work in their workers’ compensation claim can be the most productive five minutes of your day.  By taking the concerned and caring approach, you will eliminate most of the hassles and headaches that occur when a work comp claim goes bad and save a lot more time later in the claim process.

 

 

On-Going Contact Will Avoid Many Problems

 

Managing and assisting the injured employee does not end with the initial follow up phone call to the employee.  The employee should be encouraged to call you after each medical appointment, and he does not do so, you should call the employee.  Any questions the employee has during the recovery period can be addressed timely in this manner.  By maintaining on-going contact throughout the time the employee is off work, you will avoid most of the problems that can occur with a work comp claim.  You will also be assisting the employee in returning to work the minimal amount of time.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

4 Areas To Manage Workers’ Comp Medical Costs

Medical treatment has comprised the bulk of workers’ comp claim costs in recent years, and the trend seems to have no end in sight. Where indemnity used to be the main expense, medical now represents 60% or more.

 

There are a variety of tools to help manage medical costs; medical bill review, utilization review, provider networks, nurse case management, nurse triage, Medicare Set-asides, and the list goes on. While any of these tools can be effective, they might actually be costing you more than they are saving. You need to look at your return on investment and make sure the medical management services you are using are truly helping your organization save money on medical.

 

 

  1. The Doctors: Costs vs. Outcomes

 

Low-cost medical networks were all the rage in the workers’ comp system for a while. But in recent years, there’s been more and more evidence to show that going cheap on medical providers may come back to bite you.

 

The latest indication comes from a study in which a 63-year-old woman with low back pain was sent for MRIs at 10 facilities in the New York area to see what, if any differences there would be. Sure enough, not a single diagnostic finding out of 49 distinct findings reported was identified by all 10. The woman’s actual diagnosis was stenosis; she was given physical therapy and education and is said to be doing just fine. But had one of the 10 interpretations of her MRI been used, she might have been sent for unnecessary surgery and/or drugs — big expenses with a poor outcome.

 

The adage ‘you get what you pay for’ is as true of medical providers as it is for anything. Try to partner with area providers that A: understand the world of workers’ comp — and if there are none, start educating area physicians; and B: have low litigation rates and high return-to-work outcomes.

 

Likewise for other medical providers, such as physical therapists. Look at the number of treatments, their average cost, and the outcomes.

 

Once you’ve identified the best providers, partner with them and direct injured workers to them where possible. In states where the employer cannot direct care, you can still provide information that lets the injured worker know who the top providers are.

 

 

  1. Pharmacy Benefit Managers

 

Pharmacy benefit managers with good track records can be invaluable to a workers’ comp program. But again, you need to make sure you’re getting one that adds value to your company.

 

Where PBMs initially added value through lower prices, many have implemented clinical management programs to lower costs further and improve outcomes. It’s important to look at a PBM’s overall program to make sure you’re getting the best for your money.

 

Consider such things as pharmacy charges vs. pharmacy costs; the percentage reductions below the state’s fee schedule; the PBM penetration rate; cost per script; percentage of medications dispensed by pharmacies vs. physicians; and first fill rate.

 

 

  1. Involvement of Nurses

 

Nurses can be brought in to help with a claim — nurse case managers; or they can be the initial source to help determine medical treatment — nurse triage.

 

NCMs are the point person for the injured worker and medical providers. Those who do it in-office are telephonic case managers, whereas those who go out of the office are field case managers. Evaluating the effectiveness of NCMs is easiest with a large database, to compare things like the cost of claims and number of lost workdays with and without a NCM. Your insurer and/or third-party administrator may be able to help.

 

To find the value of nurse case triage, you can look at the number of calls divided by the number of claims actually reported for workers’ comp, to get the number of claims avoided by percentage.  It’s also important to look at the training and experience of the nurses involved. One thing to be aware of is how invested the triage nurse is involved in the claim. Triaging is at the initial stage of the claim, not manage the claim — which is the job of the NCM, if there is one.

 

 

  1. Bill Review

 

Medical Bill Review fees can be hidden and pricey, so it’s important to look for transparency from the claims administrator. There are many claim service providers now that have modified their BR fee structures so the costs are more obvious. Ideally you want a lower administrative cost for BR, combined with maximized savings.

 

You can find the net savings of your BR service by taking the gross savings (total charges minus total paid) and subtracting the BR service fees. Additional things you can measure to ensure you’re getting value are the percentage of net savings, the turnaround time, and the denied bill rate.

 

 

Conclusion

 

Price alone should not be the deciding factor for medical management tools; a holistic view of your services is best. However, you also want to make sure you aren’t shelling out more money than you are saving. Whether you are evaluating your current tools or looking for new ones, just make sure they lead to improved outcomes and lower costs, to get the best from your investment.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

3 Steps to Discover the Root Cause of Work Injury

A near miss may be the best thing that ever happens at your company. Depending on what you do afterward, it can be a huge opportunity to save money and headaches.

 

After the initial ‘phew!’ reaction, it’s time to get down to business and find out what happened and why and, most importantly, what you can do to prevent a recurrence that could result in an injury and comp claim the next time.

 

Fact is, most (probably all) workplace accidents have multiple causes. Even the seemingly simple-to-explain incident likely has several underlying factors going on. By getting to the real root of the problem you can avoid potentially costly and preventable claims.

 

Root Cause Analysis

 

Delving into the true causes of workplace injuries requires a team effort, though it doesn’t need to be all that complicated. There are a variety of frameworks for ‘root cause analyses.’  There are templates to make it easier to organize the information. Some organizations use a fishbone diagram to group causes into major categories to identify variation sources. Whatever system is used, there are several keys to successful root cause analysis.

 

  1. Do NOT assign blame! This is the most important aspect in getting to the real root of a problem. It’s tempting to blame someone, punish him, and move on, but that doesn’t fix the underlying problems. Root cause analysis must be done without any finger pointing. Remember, most workplace accidents are the result of a confluence of contributing factors. The job of RCA is to identify and correct them.

 

  1. Ask questions. Then ask more. And a few more after that. The main questions to ask: WHY? You may feel like a 2-year-old asking ‘why, why, why’ – but this is key to getting to the crux of the analysis. As an example, let’s say “Fred” fell off a ladder and, luckily, was not seriously injured. It might be easy to say, ‘well, Fred was being careless, he was in too much of a hurry, so it’s his fault.’ But asking ‘why’ will uncover important details that would prevent future such incidents. The answer to the first ‘why’ could be that one of the rungs on the ladder broke. ‘Why,’ you ask again, and find out it could not hold Fred’s weight. If the rungs were designed to hold 350 lbs. and Fred weighs only 170, what was the extra weight? You discover Fred was carrying materials up the ladder and the combined weight exceeded 350 lbs. But the company has a hoist truck for such jobs, so why was Fred not using it instead of carrying the materials himself? Turns out the hoist truck was being used elsewhere. So why didn’t Fred wait until the hoist truck was available? Because he was under the gun to get the job finished on time and would have missed the deadline otherwise.

 

From the example, several problems come to light. There were not enough hoist trucks available, the ladder’s weight restrictions were ignored, and the deadline did not allow for the job to be done properly. Those are only some of the issues. With continued delving, there would likely be additional factors that contributed to the accident.

 

  1. Get all relevant information — and then some. In addition to the obvious details such as interviews with witnesses, examining any video footage of the incident, and speaking with the injured — or nearly injured — worker, other considerations include:

 

  • The environment. Was the ladder properly placed on the floor? Was there anything surrounding it that might have contributed?
  • Training and skill level. Did Fred have training on using the ladder? Did he understand the weight limit? Had he ever used the ladder before? Was he instructed to avoid carrying materials up the ladder (which, aside from the weight limit, could have caused him to fall)?
  • Was there a specific procedure in place for using ladders? If so, was that procedure communicated to Fred and other employees? Was the procedure ever updated, and the updates communicated? Were workers known to circumvent the procedures?
  • Was it properly maintained? Was there enough available? Had any relevant equipment been updated as needed?
  • Human behavior. We found out Fred was in a rush due to deadline pressure. But why — what were the consequences of not meeting the deadline? Were there too few employees working on the particular job?

 

The Fix

Once you’ve ascertained all the causes (and potential causes) of the incident, it’s time to figure out corrective action. All the ‘why’ questions should end with something that indicates what and how something should be changed.

 

In our Fred scenario, several things could be changed to make the organization run more efficiently and with less chance for an injury. Training would be one area, for example. Fred clearly did not understand (or did not care) that carrying materials on the ladder could exceed the weight limit of the rungs. Procedures may need to be reviewed and changed to prevent people from carrying heavy or awkward items while climbing a ladder.

 

Equipment might need to be upgraded, perhaps with an investment in an additional hoist truck would be warranted. Communication might need to be ramped up to ensure that, while meeting a deadline is important, attention to safety is more important.

 

Conclusion

Workplace accidents, unfortunately, happen and may result in injuries and workers’ comp claims. However, the same incident should never be repeated within an organization.

 

By digging deep you can identify a variety of factors that could lead to an injury. Taking corrective action will help ensure workers stay safe, the job gets done, and you’re not wasting money on preventable problems.

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Worldwide Business Network Chronic Pain Management & Other News Tidbits

Worldwide Business Network w/ Kathy Ireland: Chronic Pain Management

For many injured workers chronic pain can give way to the overuse of pain medications, prolonging the functional restoration and well-being of the individual.  Watch Broadspire Executive VP of Medical Management on a Fox Business segment discuss pain management and early intervention services which put the right processes in place to successfully return injured workers to work.

 

 

 

Tower MSA Partners Selects Patricia Smith as EVP, Clinical Operations

Patricia Smith, RN, BSN, MSCC, CDMS, CLCP has joined Tower MSA Partners as executive vice president of Clinical Operations. In this role, Smith reviews and monitors clinical trends related to Medicare coverage criteria within the confines of Medicare Secondary Payer compliance, develops clinical strategies to support company’s pre- and post-Medicare Set-Aside intervention workflow and manages all clinical and pharmaceutical oversight teams.

 

 

Chicago Area Settlement Planning Consultant joins Ringler

Ringler, the nation’s largest settlement planning company in the nation, is pleased to announce that Derek J. Perkins, CSSC, of Rockford, Illinois, is joining Ringler as a Settlement Planning Consultant.  Mr. Perkins joined the Structured Settlement industry after an extensive career in Finance as a former CPA and having held a management position at Protiviti’s Credit Risk Management practice. His success in settlement services is directly attributed to his financial background that helps to bring credibility to the table.

 

 

4 recent updates to the drug pipeline

Over the past month, Express Scripts’ Emerging Therapeutics team focused on four new drug approvals. n February 6, the U.S. Food and Drug Administration (FDA) approved Gammaplex® 10% (immune globulin intravenous [human], 10% liquid). It is indicated to treat adults who have primary immunodeficiency (PI) or chronic immune thrombocytopenic purpura (ITP). The manufacturer, Bio Products Laboratory, also markets Gammaplex® 5% (immune globulin intravenous [human], 5% liquid in the U.S. Intravenous immunoglobulins (IVIGs), are used as replacement for patients who have immunoglobulin deficiencies. They are dosed by weight. For treating PI, one Gammaplex 10% infusion is recommended every three to four weeks.

 

 

Do What You Love, Where You Love Doing It

Work and play is what life is all about. Wouldn’t it be great to take care of people who work in all types of industries and not worry about billing them?  While doing what you love, where you love to be?

 

 

 

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

4 Questions On Urine Drug Testing To Deliver Better Work Comp Outcomes

Urine drug testing (UDT) is one of the more controversial and misunderstood tools in the workers’ comp system. While medical guidelines support the tests for injured workers who are prescribed opioids, stories of over testing injured workers —and overcharging payers — abound. There are also questions about what type of testing to use, the frequency of the tests, and what to do with the results.

 

UDT used judiciously and paired with clinical expertise can be invaluable in ensuring injured workers get the right medications at the right time. Understanding some of the basics will help you get the best bang for your UDT buck.

 

Types of testing

 

  • Forensic. UDT has been around for decades, beginning with its use to identify illicit drug users in criminal and civil proceedings as well as the workplace. This forensic, or ‘gotcha!’ model is designed to determine yes or no that someone is taking certain, typically illegal drugs. An initial screening — presumptive — test is performed and any positive results are sent for confirmation. The types of tests include in-office point of care. Results from these tests can come in minutes. However, they are not necessarily designed to detect the use of medications at therapeutic doses, something critical in a clinical setting. Also, the tests are not available for all drugs, such as synthetic drugs of abuse. Since oxycodone is a semi-synthetic opioid, it may not always be detected in these tests.
  • Clinical. This model puts the focus on the patient-provider relationship and is used as part of patient care in various settings, including pain management. The idea here is to identify the presence of specific prescribed medications, non-prescribed medications and illicit substances to benefit the therapeutic goals of the patient. Definitive testing, typically used in this model, provides information about specific drugs and metabolites and can detect drugs at much lower concentrations, which presumptive tests do not. The results of these tests, however, may not be available for 24 hours or more.

 

The type of test used for an injured worker depends on a variety of factors, including the physician’s assessment of the patient’s risk. The types of medications also has a bearing on the most appropriate tests. If there are multiple opioids, for example, presumptive tests may not provide enough information to help the physician.

 

Why Test:

 

Guidelines published for prescribing opioids to injured workers support the use of UDT to help identify safe and effective treatment options.  Some of the reasons to undertake UDT include:

 

  • Risk assessment. Research shows many prescribing physicians are not aware of their patients’ past and current drug-taking behavior. Clinical UDT provides clear evidence of the patient’s drug taking behavior, which is vital to the provider’s treatment plan, risk assessment, and interaction with the patient.
  • Clarification. In addition, patients often do not know specifically which drugs they are taking. So the drug test can add to the provider’s understanding of the patient’s current medical treatment.
  • Data consistently shows about 18 percent of workers’ comp patient samples do not indicate they are taking the prescribed drug. Given the problems with diversion, misuse, and abuse, it is clear that workers’ comp patients may be complicit — wittingly or not — in the inappropriate consumption of prescription drugs.

 

How Often to Test

 

How often should an injured worker on opioids be monitored through UDT? This is one of the key questions and problems surrounding UDT. Too much testing is a waste of money, while too little testing may lead to missed opportunities for intervention and cause the claim to deteriorate.

 

Physicians can determine how often UDT should be conducted based on the injured workers’ risk of medication misuse, abuse or diversion; and the importance of adherence, such as if the injured worker is being weaned off certain drugs.

 

  • Low risk. Injured workers who have little to no risk should be tested annually.
  • Moderate risk. Injured workers who have some red flags indicating they are potentially at risk should be tested a few times per year.
  • High risk. Injured workers with a high propensity for medication abuse should be tested frequently, in some cases even monthly.

 

 

What to Do With The Results

 

One of the problems with UDT is the lack of follow through after an unexpected or inconsistent test result. Faced with evidence that the injured worker is not taking her medications as prescribed, and/or is taking medications that were not prescribed — including illegal substances — some intervention is necessary. The results may be a clue that the injured worker is getting medications from more than one provider. At the very least, the provider should discuss the results with the injured worker. Unexpected results occur on average more than half the time.

 

Once the test results are available there are several steps that may be beneficial.

 

  • Work with a PBM. A pharmacy benefit manager can help interpret the test results and provide guidance on what the next steps should be. An unexpected test result may be due to a variety of factors; such as drug-drug interaction, or a contaminated or diluted sample. The answer is not always black and white, and a PBM or other expert can help decipher what the results actually mean.
  • Additional clinical outreach.
  • Follow-up testing.
  • Peer-to-peer review.
  • Change in medication therapy.

 

Conclusion

 

UDT can provide much needed information to help guide a claim. However, it should be part of an overall strategy and not the only tool used. It’s important to know the benefits and limitations of UDT and use it to help understand the whole picture of the injured worker.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

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