California’s OAL Approves DWC’s Final Version of Treatment Schedule

The Office of Administrative Law (OAL) has approved the California Division of Workers Compensation’s (DWC) final version of the Medical Treatment Utilization Schedule (MTUS) regulations that updates the Chronic Pain Medical Treatment Guidelines and adopts Opioids Treatment Guidelines.

 
Following national reports of opioid misuse, DWC proposed issuing guidelines and began the process with a forum for public comment in 2014.

 

The guidelines that have been added to the MTUS provide best practices in appropriately treating injured workers while also enhancing safety in using these medications to manage pain.

 

“We welcome this update and addition to the MTUS. The information in these Guidelines should aid in the provision of safer and more effective care for California’s injured workers,” said DWC Executive Medical Director Dr. Raymond Meister.

 

The changes to the MTUS Chronic Pain Medical Treatment Guidelines are set forth in section 9792.24.2, the Opioids Treatment Guidelines are set forth in section 9792.24.4, and the clarifying changes to the meaning of chronic pain are set forth in section 9792.23(b)(1) of the California Code of Regulations. The MTUS regulations went into effect on July 28, 2016 and will apply to any treatment requests made on or after July 29, 2016.

 

Christine Baker, director of the Department of Industrial Relations, said, “These guidelines are an important step toward improving appropriate and safe care for workers.”

 

DWC Acting Administrative Director George Parisotto added, “DWC will move forward shortly to initiate the process to update all of the current MTUS chapters. This process will include new chapters for chronic pain and opioids. Regardless, the new Chronic Pain Medical Treatment Guidelines and Opioids Treatment Guidelines should be consulted and relied upon when making treatment requests and determining the medical necessity of such requests.”

 

The final regulations are posted on the DWC website.

 

 

 

Author Kori Shafer-Stack, Editor, Amaxx Risk Solutions, Inc. is an expert in post-injury response procedures and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. www.reduceyourworkerscomp.com.  Contact: kstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

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The Enterprise Risk Management Plan

risk-innovationCollecting and prioritizing risk data is only valuable if your organization has a way to transition this knowledge into action. Many companies struggle to go to the next step of making their Enterprise Risk Management (ERM) programs actionable.

 

ERM drives your biggest risk into plans, ones that align with and support your strategic goals. Plans are assigned an owner and provided a repeatable process that insures root cause risks that make up the plan have controls, the controls have owners and the activities that support controls are clear so they can be effectively implemented and monitored.

 

Monitoring of controls, effective reporting on progress and establishing relationships that allow for efficiencies among plans and other important business processes are what drives action.

 

 

Business Continuity & Continuous Improvement

 

Some ERM plans have a limited scope for a specific purpose and others are on-going. On-going plans address an important aspect of your business that requires continuous focus. These on-going plans are the organizations opportunity for business continuity and continuous improvement.

 

ERM plans provide formal documentation on what is currently happening; who owns the activity that is taking place and supporting details on the activities. The objective is to not lose any momentum during times of disruption.

 

Continuous improvement works best when everyone is in the know and able to contribute. Formalized ERM plans give both the birds-eye view and details for all stakeholders involved to enable them to effectively review and provide their perspective. Collective Risk Team input and participation is what drives collaborative efforts and best use of available resources.

 

 

Action is Everything

 

Two questions drive to the core of ERM – #1 What is the value of your organization and #2 What could kill that value. Foundational to ERM is a risk assessment process that identifies risk and missed opportunities that could kill the value.

 

There is no progress if the identified risks and opportunities do not transition into plans. The ERM Plan is the consistent and repeatable process to make what is most important, actionable.

 

  

Repeatable Process

 

Best practice plans force accountability and supports plan owners meeting their objectives. They include clear and concise descriptions on purpose, effective ranking displayed through heat maps and a summary of controls attached to each risk. They also include reasoning for the scoring that takes place, feedback on what could go wrong as well as details on what actions are required.

 

 

Apples to Apples

 

When organizations have multiple plans it can be challenging to determine which plan/which focus is most important at any given time.

 

Scoring on Impact, Likelihood and Assurance feed from each risk within each plan and aggregate up to both Inherent and Residual Indexes which allow for educated decisions on resources both among and within plans.

 

 

Author Mark Bennett, Founder of Risk Innovation Group (RIG), is dedicated to helping large employers face the complexities of risk through innovative Enterprise Risk Management (ERM) practices. ERM programs don’t just help large employers manage business risks more effectively; a well-developed ERM program can protect and create value as well as improve business performance and generate a strong competitive advantage.  Contact: m.bennett@riskinnovationgroup.com

Illinois Employer in Hot Water Once Again

For the second time in two years, federal safety inspectors found workers risking amputations and other serious injuries as they fed parts by hand into an unguarded mechanical press brake at an Illinois trailer manufacturing plant.

 
They also found the company failed to protect welders and other employees from harmful ray emissions during welding operations.

 
On Aug. 5, 2016, the U.S. Department of Labor’s Occupational Safety and Health Administration issued one willful, one repeated and five serious violations to the Newark-based Dierzen Sales LTD. Inspectors found the violations in a follow-up inspection in March 2016. The company faces $153,791 in proposed fines.

 

“Dierzen Sales continues to maintain an environment where employees are exposed routinely to machinery hazards likely to cause amputation,” said Jake Scott, area director of OSHA’s North Aurora office. “The company needs to re-evaluate its safety and health programs to ensure workers are provided with the equipment and the training they need to prevent injury on the job.”

 

OSHA’s inspection found the employer failed to:

 

  • Evaluate powered industrial vehicle operators every three years as required. The company also altered powered industrial vehicles.
  • Promptly remove scrap metal from floors, causing trip and fall hazards.
  • Cover electrical boxes and openings.
    View the current citations here.

 

Dierzen was given 15 business days from receipt of its citations and penalties to comply, request an informal conference with OSHA’s area director, or contest the findings before the independent Occupational Safety and Health Review Commission.

 

 

 

Author Kori Shafer-Stack, Editor, Amaxx Risk Solutions, Inc. is an expert in post-injury response procedures and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. www.reduceyourworkerscomp.com.  Contact: kstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

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Top 5 Take Away Points 2016 National Work Comp & Disability Conf – Part 3

Top 5 Take Away Points 2016 National Work Comp & Disability Conf – Part 1

Top 5 Take Away Points 2016 National Work Comp & Disability Conf – Part 2

Top 5 Take Away Points 2016 National Work Comp & Disability Conf – Part 3

 

Hello, Michael Stack here with Amaxx. So I just got back from New Orleans, Louisiana… I want to talk to you about my top five take-away implementation points from the sessions that I attended. Continued from Part 2…

 

 

Take Away Point #4: Diagnostic Imaging Awareness

 

Point number four. This comes from Dr. Jacob Lazarovic and Stuart Colburn’s presentation on leveraging a medical expert to not get burned on causation. Dr. Lazarovic was talking about this stat of really reading these diagnostic images, and here’s the figures and here’s the really startling statistics when you’re looking at really reading and diagnosing from a MRI image, for example. 30% of the time, given the same image, given to two different doctors, those two different doctors are going to disagree on the diagnosis. 30% of the time, three out of 10 times, those two doctors are going to disagree on the diagnosis from reading that image.

 

 

Here’s the most telling and most interesting stat. Same doctor, given the same image, one week apart without any further identifying information, the doctor reads it one way on day one and reads it a different way on day seven. So the same doctor’s going to disagree with himself or herself 25% of the time and given to two different doctors they’re going to disagree with each other 30% of the time. The take-away point here is just this recognition that it’s not an absolute diagnosis when you get that from the doctor. Have a second opinion ready to go, have this understanding that just one diagnosis is not always the right diagnosis. Those are just bonus take-away from that session, that same session, Stuart Colburn made the point when talking about the selection of your doctor and the defense of your case, he has to question, “Are you selecting the doctor because of the opinion that him or her is going to give you? Or are you selecting a doctor to win the case?” Very important distinction, really, in the selection of those medical providers.

 

 

Take Away Point #5: Jumper Claims

 

Okay, last take-away point here is from Bill Zachry’s presentation. He was talking about jumper claims. Going back and sort of really relating to that same concept that Marcos Iglesias was talking about in his presentation with his bio-cycle social factors. Bill Zachry got into some more of these statistics of what this actually means in terms of cost. We see this as a national trend, but we’re talking specifically about Albertsons when he was the risk manager there. 3% of their claims represented 60% of those claims’ costs. 3% of their claims represented 60% of the claims’ costs. A very small percentage of claims representing a very large percentage of the costs.

 

 

We see this nationally that figure is 5% of claims representing 80% of the costs, but specifically for Albertsons this is how it worked and here were his numbers. He wanted to bring this down in half, cut this 3% in half, effect a very small percentage, 1 1/2% of those claims to bring down the costs in their program by 30%. So all these things that we’re talking about from these take-aways, these weekly meetings, having those medical provider relationships at the start, being able to bring in particularly in these weekly meetings, identifying some of those bio-cycle social factors early in the claim to bring in the resources necessary to influence the outcome of those claims.

 

 

Those were my five key take-away points. A lot of, of course, other information was discussed, but hopefully you’ll review your notes and you work towards implementing at least just one of these points to start to see a dramatic result in your program. Now if you’re watching this video somewhere other than reduceyourworkerscomp.com, go ahead and go to that website, sign up to receive a lot more free information on how to control and reduce your workers’ comp costs. To take it just one step further you can go to workerscompclub.com/livesstreamtraining to join me on my next livestream training. Again, I’m Michael Stack with Amaxx. Remember, your success in workers’ compensation is defined by your integrity, so be great.

 

 

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/

 

 

Cal/OSHA Reacts to Death of Farmworker

Cal/OSHA Chief Juliann Sum recently commented on Cal/OSHA’s ongoing investigation into a July farmworker death in Bakersfield, Ca.

 
According to Sum, “Cal/OSHA is investigating the tragic death of a farmworker reported last week in Bakersfield. In light of recent high temperatures, Cal/OSHA’s maximum enforcement of its Heat Illness Prevention Standard included 597 inspections of agriculture, construction, landscaping and other outdoor worksites this June and July. So far this year, we have issued 994 citations to 742 employers for heat-related violations which require corrective action to protect workers from heat illness.

 

“Cal/OSHA is also continuing its outreach, consultation and training for workers and employers on the importance of heat illness prevention.”

 

 

 

Author Kori Shafer-Stack, Editor, Amaxx Risk Solutions, Inc. is an expert in post-injury response procedures and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. www.reduceyourworkerscomp.com.  Contact: kstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

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Top 5 Take Away Points 2016 National Work Comp & Disability Conf – Part 2

Top 5 Take Away Points 2016 National Work Comp & Disability Conf – Part 1

Top 5 Take Away Points 2016 National Work Comp & Disability Conf – Part 2

Top 5 Take Away Points 2016 National Work Comp & Disability Conf – Part 3

 

Hello, Michael Stack here with Amaxx. So I just got back from New Orleans, Louisiana… I want to talk to you about my top five take-away implementation points from the sessions that I attended. Continued from Part 1…

 

 

Take Away Point #2: Occupational Doctor Relationships

 

Take-away point number two is occupational doctor relationships, so occupational doctor relationships. This was a very dramatic point and dramatic example given by Laurie English from Excela Health, another Teddy Award-winning presentation. So obviously they’re a healthcare provider. The biggest challenge that they had was all their injured workers going to the emergency room to see non-occupational doctors. They had a relationship often times, they knew who the doctor was, the doctor would say, “Okay, Jane, you’ve got an injury. Here’s a script, you’ve got four days off work,” and then all the problems that start to come with that.

 

So a very dramatic example, and here’s what they did. they took those ER  doctors, those non-occupational doctors that weren’t trained in workers’ compensation, weren’t trained in occupational medicine, off their panel. They took them off the even possibility to go see them, and if an injured worker does go see them, it costs them $100 co-pay. So they had to do this very dramatically. Not necessarily an easy process to change that culture, but they have done it successfully and seen dramatic results. Now those injured workers go to occupationally medicine-trained nurses who will facilitate their care, and they’ve seen significant results, so very dramatic example in a healthcare situation.

 

Now fast-forward to the return to work presentation given by Anne-Marie Amiel, from the city of Columbus in Georgia, very different type of workforce, public workforce. They don’t have the internal doctors that the employers are going to, very different than a healthcare situation, but the statement she made that I thought was very telling of the success of their program, the success of their return to work program. She said the first six months on the job she went to go personally and visit every one of the providers that they work with. Doctors, physical therapists, etc., talk to them about their program, talk to them about the expectations, talked about how they can work together as a partner to return those injured employees back to work to heal rather than keeping them off to heal before they return to work, that dramatic mindset. That was done by those face-to-face individual meetings, she spent that first six months on the job and then they saw that dramatic success and those dramatic results.

 

 

Take Away Point #3: Weekly Claims Meetings

 

So now let’s talk about the third take-away point, and this is an interesting point, because this is one that was also mentioned when I did my top five take-away points last year. Caryl Russo from Barnabas Health, Jennifer Saddy from American Airlines, both mentioned this concept of weekly meetings, weekly claims meetings as a key to success in their programs, Teddy Award winners. Danielle Hill from Hampton Road Transit, Jennifer Massey from Harder Mechanical Contractors, and Laurie English from Excela Health all talked about this idea of regular claims meetings.

 

 

Here’s the take-away. If all these award-winning programs are using and leveraging this concept, to win these awards, probably something to think about implementing in your program or refining in your program if it’s something that you’re doing or maybe just not doing as well as you possibly could. Here’s the take-away here of really how to get this started. If weekly sounds way too often and that’s something that you could never possibly do, start with quarterly. Start to have some success. Move that then up to monthly, then move that up to weekly. You’re talking about in these meetings where these claims are, how to work together towards a positive outcome and a positive resolution in each one of these individual claims. As the great Zig Zigler said, you don’t have to be great to start, but you do have to start to be great.

 

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/

 

Ohio BWC Nets Seven June Comp Fraud Convictions

The Ohio Bureau of Workers Compensation recently reported that it netted seven convictions in June in criminal cases related to workers comp fraud.

 
Those convicted include child care center operators, skilled tradesmen and others who had lapsed policies, forged certificates of coverage or worked while receiving injured worker’s benefits.

 

As of June 30, BWC’s Special Investigations Department had secured 55 convictions this calendar year. June convictions include:

 

  • Walter Dappert, (Butler County) – The owner of Dappert Masonry Construction pleaded guilty June 8 to one count of workers compensation fraud, a fifth-degree felony. Investigators found he had forged a BWC certificate of coverage to show he had active coverage when, in fact, the policy had lapsed in 2010. A judge sentenced Dappert to three years community control, 40 hours of community service and restitution to BWC in the amount of $1,507. Dappert brought his BWC policy into compliance prior to sentencing.
  • Terry Shaver (Franklin County) – The Grove City man pleaded guilty June 8 to one count of workers compensation fraud, a first-degree misdemeanor, after investigators found him working for a pest control company while receiving injured worker’s benefits. A judge sentenced Shaver to 12 months’ probation and ordered him to pay $5,000 restitution to BWC by May 2017.
  • Karon Jones (Cuyahoga County) – The Cleveland-area child care center owner pleaded guilty June 13 in the Cuyahoga County Court of Common Pleas to a first-degree misdemeanor count of Attempted Obstructing Official Business after investigators found her coverage had lapsed from Jan. 1, 2010 through June 30, 2015. A judge ordered Jones to pay BWC $33,985 in restitution.
  • Tenora Edwards-Jones (Cuyahoga County) – The child care center owner pleaded guilty June 14 in Cuyahoga County Court of Common Pleas to one count of Failure to Comply with the Law, a second-degree misdemeanor. Edwards-Jones had lapsed coverage at two day care centers in Cleveland Heights. Prior to her sentencing, she paid BWC $28,514 to bring both policies current.
  • Angelique Braxton (Franklin County) – The home health aide pleaded guilty June 15 in the Franklin County Court of Common Pleas to a misdemeanor count of workers compensation fraud after she was found working for 20 months while collecting BWC benefits. She paid BWC $1,902 for its investigation and $37,962 in restitution.
  • Gary Miller (Fairfield County) – The Columbus area painter pleaded guilty June 23 to one count of workers compensation fraud, a first-degree misdemeanor, after investigators found he had forged a BWC certificate of coverage after his policy had lapsed. A judge in Fairfield County Municipal Court sentenced Miller to two years’ probation and ordered him to pay $732 in fines and restitution.
  • Brian DuVernay (Allen County) – The Lima-area man, owner of A Better Way Contracting, pleaded guilty June 24 to one count of Failure to Comply, a second-degree misdemeanor, after investigators found he hadn’t submitted payroll reports, causing his BWC policy to lapse. The Lima Municipal Court fined DuVernay $150 and warned that he would be jailed and face additional charges if he did not come into full compliance with BWC.

 

Additionally, a Northwest Ohio woman entered into a Hardin County Diversion Program in June in lieu of conviction after investigators found she had altered several BWC certificates of coverage to make them look current after they had lapsed.

 

Kathy S. Detwiler, owner of Detwiler Enterprises Inc., must participate in the program for one year, complete at least 160 hours of community service and abide by all regulations concerning BWC. Once completed, all charges will be dropped.

 

 

 

Author Kori Shafer-Stack, Editor, Amaxx Risk Solutions, Inc. is an expert in post-injury response procedures and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. www.reduceyourworkerscomp.com.  Contact: kstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

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Top 5 Take Away Points 2016 National Work Comp & Disability Conf – Part 1

Top 5 Take Away Points 2016 National Work Comp & Disability Conf – Part 1

Top 5 Take Away Points 2016 National Work Comp & Disability Conf – Part 2

Top 5 Take Away Points 2016 National Work Comp & Disability Conf – Part 3

 

Hello, Michael Stack here with Amaxx. So I just got back from New Orleans, Louisiana; I might be too much of a Northerner to pull off that pronunciation, but nevertheless it was a great time and very valuable time spent at the National Work Comp and Disability Conference last week.

 

 

It’s Not The Time Spent At The Conference, It’s What You Do With That Time

 

We spent a lot of time and we spent a lot of money to attend this conference. Very valuable networking, very valuable meetings, very valuable sessions, but it’s not about the time spent there, it’s about what you do with that time that was spent there, whether it’s follow-up appointments, whether it’s follow-up conversations, or whether it’s taking some of the information from the sessions and now implementing that in your program.

 

 

Take Away Point #1: Return To Work To Heal

 

So I want to talk to you about my top five take-away implementation points from the sessions that I attended. The first point then came from Marcos Iglesias, the medical director at The Hartford. He talked about this idea through his presentation. It was all about really this understanding of the culture of return to work in a program. He talked about return to work to heal, not heal to return to work. So return to work to heal, not heal to return to work. That mindset, that methodology through the workforce, though the medical providers, and through the culture of a company, huge take-away point. Transfer now to the Teddy Award winning presentations.

 

 

Jennifer Massey from Harder Mechanical Contractors. She talked about this idea, and it was very much in the regards to this challenge that a lot of employers have to say, “Well, we don’t have any transitional duty. There’s nothing that we have available for our guys. We would return them to work but we just don’t have any jobs available.” So she took that job, and their company is very unique in that they’re very specialized, highly-skilled, union contractors. Some would say that’s an impossible scenario to deal with, but they’ve had 17 million hours without a lost time plan, very significant stat.

 

 

Here’s how they do it. They engage their workforce to work together to define and create meaningful transitional duty jobs. So if you look at their work force, very skilled labor, maybe they have a highly trained skill in Skill A. But maybe they also have a skill in Skill B or Skill C, and they can work together to engage their workforce, there’s a high level of trust, they have this idea embedded in their culture that return to work to heal for the benefit of the employee and the benefit of the company.

 

 

Both sides get it and both sides are engaged in this creative process to engage the workforce, understand what their skill set is, match them up with a need in the company that’s meaningful for the company and meaningful for the individual to now get that person returning to work so that they can heal. So very significant take-away point in really that mindset, and then action of how you do that in a program.

 

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/

 

Saskatchewan WCB Notes Nearly $282M Surplus

Recently, the Saskatchewan (Canada) Workers Compensation Board (WCB) announced a $281.5 million surplus will be distributed to employers in 2016 as part of the 2015 surplus announced at its annual general meeting in May.

 
At the WCB’s 2015 year end, the funded position was 144.7 percent, which exceeded the 105 to 120 percent funding policy target range resulting in a surplus of $281.5 million. The surplus was slated to be distributed to eligible employers in two installments in July and December of 2016.

 

Chairperson Gordon Dobrowolsky said after seeking input from both worker and employer representatives, and weighing several factors, the Board made the decision to distribute 50 percent of the 2015 surplus to employers in July and the remaining 50 percent by the end of the year.

 

“As a Board, we are legislated to ensure the present and future financial security of the compensation system in our province,” Dobrowolsky said. “We carefully weighed our decision on behalf of both employers and injured workers by considering market uncertainties and investment return volatility, a funding policy review, cash flow requirements, economic uncertainty, and changes in accounting and actuarial standards as well as the potential impacts of the Committee of Review recommendations.”

 

Investment Income Plays Big Role

 

Dobrowolsky said the increase in the 2015 funded position is substantially due to investment income.

 
“We are pleased to see that there will be a distribution to employers, which will help grow the economy,” said Don Morgan, Minister of Labor Relations and Workplace Safety and Minister Responsible for the Workers Compensation Board. “WCB has done an excellent job managing their investments and we thank them for the work they do on behalf of the working women and men of Saskatchewan.”

 

Employers are eligible for the 2016 distribution if their net premiums were greater than their claims costs over the three-year period from 2012 to 2014. A three-year period was chosen to ensure employers were not disqualified based on one or two years of higher claim costs. The amount of the distribution that each eligible firm receives was determined based on their 2014 base premiums because 2014 is the most current year of assessed actual payroll.

 

The WCB’s funded position is impacted by the WCB’s investment performance, which fluctuates depending on world economic activity. The last similar surplus distribution from the WCB was in 2015 based on the 2014 funded position.

 

 

 

Author Kori Shafer-Stack, Editor, Amaxx Risk Solutions, Inc. is an expert in post-injury response procedures and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. www.reduceyourworkerscomp.com.  Contact: kstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

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Understand The Work Comp Heart Attack Presumption

fire-fire-fighter-brand-delete-feuerloeschuebungThe grand bargain of the workers’ compensation system requires employees who allege work injuries or conditions to prove compensability of their claim.  This includes the initial threshold question that it “arose out of” and occurred within the “course of” their employment activities.  While this threshold question applies to all employees equally, there are various presumptions that allow firefighters, police officers and other emergency personal to obtain compensation for heart attacks or other exposures with a lesser degree of evidence.  This is known as the “heart attack presumption,” and is something all members of the claims management team should understand.  They should also be aware as to how to deal with these cases and rebut the presumption when appropriate.

 

 

Origins of the Heart Attack Presumption

 

Employees that work in emergency situations deal with a constant flow of stressful situations during the course of every workday.  This includes rushing to various emergencies, working prolonged and abnormal hours and being subject to constant peril.  The result was a recognition in multiple jurisdictions that these professionals should receive additional protections that while rebuttable, allow them to peruse legitimate claims without having to prove issues of causation to the extent that other employees are required.

 

 

Application of the Presumption

 

It is important to note that the occurrence of a heart attack by a firefighter, police officer or other emergency responders does not automatically trigger compensability.  In order for the presumption to be successful, there is typically a requirement of “an absence of contrary or conflicting evidence on the point and the circumstances which form the basis of the presumption must be of sufficient strength from which the only rational inference to be drawn….”[1]  In other words:

 

  • The employee must fall into the “protected class” given their employment;

 

  • There must be some medical evidence that demonstrates a connection between the heart attack and the employee’s work activity; and

 

  • The connection must be rational or reasonable.

 

In all jurisdictions that have such statutory presumptions, the employer/insurer are able to rebut it with evidence to the contrary.  Other jurisdictions have imposed pre-employment physical requirements and limited the applicable qualifying conditions.

 

 

Rebutting the Heart Attack Presumption

 

When reviewing any workers’ compensation claims, members of the claims management team have a duty to their insured to investigate fully the allegations made before rendering an opinion on compensability.  This includes instances where a qualifying employee suffers a heart attack.  In those instances, the ability to rebut the presumption is defined in statute or interpreting case law.  Examples of the presumption rebuttal include:

 

  • Proof of causation that a non-work related event took place at the same time as the heart attack and was manifested itself in the alleged condition;

 

  • Contemporaneous medical evidence that demonstrates the existing of a condition, which was not related to the employment and resulted in the heart attack; or

 

  • Evidence that the employee died from a condition other than a heart attack, and the death was not related to one’s employment.

 

 

Practice Tips and Pointers

 

Any workers’ compensation investigation should be ethical and diligent.  In instances of a heart attack, the following additional steps should be taken:

 

  • Obtain a complete medical history and set of medical records for the claimant;

 

  • Obtain complete pharmacy records for the claimant. The use of medications for high blood pressure, cholesterol or other conditions are important to the claims investigation; and

 

  • Schedule an independent medical examination with a board certified cardiologist to determine issues of causation. In instances of death, an autopsy may be necessary.

 

 

Conclusions

 

The existence of a heart attack presumption is part of the grand bargain to ensure fairness in compensation for emergency workers.  While this may result in the payment of a claim under a lesser standard of scrutiny, it is important for members of the claim management team to understand how it works and rebut the presumption when evidence suggests non-work related factors were the real result of the condition or death from a heart condition.

[1] Hopson v. Hungerford Coal Co., 187 Va. 299, 305, 46 S.E.2d 392, 395 (1948).

 

 

 

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/

 

 

©2016 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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