3 Times to Consider the ADA in Workers’ Compensation

Workers’ compensation claims professionals and other interested stakeholders face many challenges in their programs.  One important challenge is running a program that is consistent with the applicable workers’ compensation act and not conflicting with the Americans With Disabilities (ADA) Act.  Failing to understand this matter can result in serious legal consequences and impact your bottom line.

 

 

What is the ADA?

 

The ADA is codified under 42 U.S.C. §12101, and is an important civil rights law that prohibits discrimination based on disability.  It was enacted in 1990 and laid the groundwork for greater inclusion of persons with disabilities in American society, which includes those suffering from a work-related injury.

 

There are many legal nuances to this law, so it is important to consult an attorney if you have questions.  Areas of concern as outlined by the U.S. Equal Employment Opportunity Commission (EEOC) include:

 

  • Whether a person with an occupational injury has a disability as defined by the ADA;

 

  • Disability-related questions and medical examinations relating to occupational injury and workers’ compensation claims;

 

  • Hiring practices concerning a person with a history of occupational injury, return to work of persons with occupational injury, and application of the direct threat standard;

 

  • Reasonable accommodation for persons with disability-related occupational injuries;

 

  • Light duty issues; and

 

  • Exclusive remedy provisions in workers’ compensation laws.

 

 

3 Times to Consider the ADA in Workers’ Compensation

 

Employers and other interested stakeholders need to understand the value anyone with a disability has and how it can impact the work environment in a positive manner.  Contrary to popular belief, people who may be disabled want to work as it provides a number of intangibles that benefit morale and self-worth.

 

Keeping this in mind, employers need to consider the following touchpoints in their hiring and workers’ compensation programs:

 

 

Pre-employment:

 

All hiring polices need to comply with the ADA and its mandate of non-discrimination.  Asking potential new hires about disabilities or work restrictions many result in legal action.  It is also important to keep in mind that a disability is not limited to physical barriers.  Various mental health conditions can qualified as a covered disability under the Act.

 

Issues concerning drug testing also come into play under the ADA.  As a general rule, employers can ask all applicants to submit to a drug test as part of the pre-employment process.

 

 

Post-work injury:

 

Employee’s suffering from a work injury can also be covered under the ADA.  A common misconception is the ADA only applies when an employee reaches MMI, this is incorrect. A person injured at work can immediately be considered a “qualified individual with a disability”. At the time of injury a referral to HR and a discussion, referred to as the “interactive process” regarding reasonable accommodations must occur.

 

Additional areas of concern include job search requirements, return-to-work/employment transitions and light duty.  Employers should work with various professionals within their organization when crafting a return-to-work plan and requires modified job duties or positions.  Additional considerations should also be given to time off from work to attend medical appointments, etc.

 

 

Post-injury Termination of Employment:

 

Problems also arise following a work injury when the employee’s position is eliminated or that individual is terminated.  It is important to document all steps that are taken and involve legal counsel.  Employers should also involve specialized counsel if they are requesting a global settlement of a workers’ compensation claim that involves a voluntary resignation of employment and release of all claims.  Issues to consider include a separate employment release and monetary consideration beyond what is paid for workers’ compensation benefits.

 

 

Conclusions

 

Workers’ compensation claims are complex and require an understanding of the law.  The ADA is an important consideration for those involved in handling claims and the myriad of associated issues.

 

 

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 & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©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.

Impact of OSHA’s New Electronic Recordkeeping Rule On Employers & Their TPAs

 

This Interview with Broadspire’s CEO Danielle Lisenbey was originally published in Crawford’s On the FrontLine Magazine – Spring 2017

 

The Occupational Safety and Health Administration (OSHA) implemented a final rule in 2017 requiring employers that must record workplace injuries and illnesses for OSHA to submit reports of such incidents electronically. For the first time, OSHA will post on its website establishment-specific data, rather than only aggregated industry data. The goal is to encourage employers to identify workplace hazards and improve their safety records. We ask Broadspire’s Danielle Lisenbey for her views.

 

 

What does OSHA’s new rule mean for employers and TPAs?

 

OSHA has long required employers to keep a log of certain workplace incidents that result in injury or illness. That basic recordkeeping requirement is not new, but what is new is that OSHA is now asking employers to submit certain forms electronically. That will greatly facilitate the administration’s ability to make employer specific data publicly available. Employers and their third-party administrators (TPAs), including Broadspire, will work closely to make sure the appropriate data is submitted to comply with all applicable OSHA rules. Our mantra as a TPA is “early reporting and early intervention lead to better outcomes.” The new OSHA rule ultimately ties into that.

 

 

Which industries are primarily affected by the new electronic tracking rule?

 

The new recordkeeping rule applies to a significant number of  employers. Under the final rule, employers with 250 or more employees that are required to maintain OSHA injury and illness records must submit their logs, summaries of injuries and illnesses, and  incident reports.

 

Employers with 20 to 249 employees in industries classified as having high rates of occupational injuries and illnesses must submit an electronic summary report. Industries on OSHA’s list include construction, manufacturing, healthcare, transportation and others – all of which are important sources of employment and productivity.

 

Industries that OSHA considers to have lower injury rates, which include insurance and financial services, and some retail businesses, are partially exempt from such reporting. The reality is, however, that OSHA’s new rule will cover a large number of U.S. employers and their workers.

 

 

How does Broadspire see this new rule benefiting employers and workers?

 

The intent of OSHA’s new final rule is to increase workplace safety and motivate employers to reduce injury and illness  for  their workers.  That is a noble goal and we not only support it; it is at the heart of our business.

 

Broadspire exists to help employers reduce claims frequency and severity. We believe that the more data an employer has, the better it can plan ahead and mitigate situations that can cause injury or illness. OSHA’s new rule will make more workplace data accessible, which will encourage employers to focus more attention on the causes of occupational injuries and illnesses. That’s a positive thing for  all concerned.

 

Workers will benefit because they will be healthier and safer. Employers will benefit from reduced downtime and increased productivity, which in turn will benefit communities through economic growth. Truly, improving workplace safety pays big dividends, well beyond an employer’s door.

 

 

What are the downsides or unintended consequences of the new OSHA rule?

 

Some observers have expressed concern that online publication of employer-specific reports could create cyber exposures, increase litigation and might even discourage some employers from tracking minor incidents to artificially improve their safety results. While public disclosure may not be the preferred method to motivate employers to improve safety, greater transparency and competitiveness are likely to accelerate changes.

 

It is our belief that the vast majority of employers required to report to OSHA will submit injury and illness reports fully and accurately. We also believe that the general population of employers will see the data points as helpful to keeping them focused on the big picture, which is to make workplaces safer. We certainly hope that OSHA has considered the implications of this final rule and will swiftly address any problems should they arise.

 

 

What is Broadspire doing to help prepare its clients to comply with the rule?

 

Broadspire is deeply invested in helping employers to improve their claim outcomes and to reduce the costs of workplace injury, illness and disability. Early access to data is key, and TPAs can step up and help employers build out their data sets.

 

Between the data and benchmarking that we provide, and the reports that OSHA intends to make available, the ultimate objective is to reduce loss costs for the employer and improve the care of the injured worker. It’s a win-win for both employer and employee. Compliance is a big part of what we do every day for our clients, and we are having ongoing conversations with our clients to ensure they submit the appropriate data to OSHA by the July 1, 2017, deadline.

 

Read more On the FrontLine Magazine.

 

 

Danielle Lisenbey, Broadspire President & CEO. As president and CEO, Lisenbey’s goal is to make Broadspire the number one choice for companies seeking claim, disability and medical management services to help increase their employee productivity and contain costs. On the road to excellence, however, Lisenbey knows you don’t have to sacrifice integrity for achievement. She believes in always doing the right thing. Although tough when called for, she prides herself on being fair and demonstrating integrity in everything that she does.  https://choosebroadspire.com/us/

Avoid Ethical and Legal Pitfalls In Workers’ Comp Surveillance

Surveillance can be an effective tool to reduce costs in a workers’ compensation program.  While many service providers can show “injured” employees doing some crazy activities, it comes with a price and often does not produce the desired results.  Before hiring a service provider to engage in surveillance activities, claims handlers and their managers should understand how to use it in an effective manner.

 

 

Use of Surveillance in the Right Case

 

The sheer volume of workers’ compensation claims coupled with the cost of surveillance limits the amount of cases that can use this discovery tool.  A proactive claims management team must set parameters on when it is to be used and for the length of time to conduct surveillance on a suspect employee following a work injury.  Cases that are prime for using surveillance often include:

 

  • Cases where the claimant is likely to or has made a claim for permanent total disability cases. It is understood that these are the cases with the most exposure.  This can also include catastrophic work injuries and their resulting complex claims;

 

  • Instances where you receive a report of possible fraud or other information the employee may be engaging in suspicious activity that exceeds their stated limitations or abilities. Tips should obviously be carefully vetted.  This is especially the case where the tip is anonymous.  Always consider the source; and

 

  • Instances where the information being reported by the employee does not coincide with verifiable information.

 

 

Avoiding Ethical and Legal Pitfalls

 

There are ethical and legal implications to surveillance that may impact your cases.  It is important to act within the confines of the law and other regulations governing a workers’ compensation act.  This also applies to the service providers you hire.

 

Before hiring a service provider, it is important to do your homework.  Before hire them, it is important to verify the company has the requisite licenses or permits to engage in surveillance activities, if applicable.  It is also important to verify the people conducting work on your behalf know the law and follow them.  Checking with state agencies or business bureaus regarding complaints or infractions is a necessary step.

 

 

Practice Pointers and Effective Techniques

 

Given the costs of most surveillance activities, it is important for claims handlers to do their homework in advance.  They should know when the claimant will be in public and report that information to the service provider.  Key events can include:

 

  • When the employee has a doctor appointments or will be seen by an independent medical examiner;

 

  • Civic groups or organizations they belong to and when certain events they may attend will take place; and

 

  • Other activities they like to do outdoors such as exercising or even if they get the mail, go to the grocery store or visit a local coffee shop.

 

 

Selecting the Right Private Eye

 

Other tips for effective surveillance include:

 

  • Selecting a service provider with a track record or proven results; and

 

  • Authorizing a service provider to conduct surveillance activities for at least two to three days in a row. It is also important to allow the investigator to work for at least eight to 10 hours per day to maximize the chance of better results.

 

 

Conclusions

 

Surveillance can be an effective tool to resolve workers’ compensation claims in a timely manner.  It is costly so it is important to use this tool wisely and within the bounds of the law.

 

 

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 & lead trainer of Amaxx Workers’ Comp Training Center. .

 

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.

6 Ways to Avoid Ransomware

Imagine walking into your office, turning on your computer, and seeing nothing but a message demanding bitcoins in return for unlocking all your company’s files. The nightmare known as ‘Ransomware’ recently became all too real for more than 200,000 computers in more than 150 countries, bringing some hospitals and other organizations to a halt. While those affected were primarily outside the U.S., experts say the perpetrators are ramping up their efforts and they warn all businesses to take steps to prepare.

 

The information typically available within the workers’ compensation system — social security numbers, personal health information, etc., — makes it a must for the industry to take notice of the situation. The good news is there are ways to shield and prevent such attacks from infiltrating your company.

 

 

What Is Ransomware

 

Ransomware takes the idea of hacking to a whole new level. Those spearheading the efforts are not necessarily interested in stealing your data, they really just want to hold it hostage until you pay up — hence the term.

 

Businesses large and small may be equally at risk. In fact, small businesses may be even more at risk than larger ones because of their often more relaxed attitude about cyber security.

 

Ransomware is sophisticated malware that blocks access to a computer by encrypting the data or system until it is unlocked. ‘WannaCry,’ the malware used in the recent incident, is not the only ransomware out there and, in fact, there are even copycat versions of WannaCry now available on the black market.

 

The wrongdoers look for the easiest way to infect a system or network and use it as a means to spread the malicious content. Often, it is through an unwitting employee. Phishing is one of the main ways of accessing a computer, where someone sends emails that that appear to be from legit companies, but are not.

 

Another method is for someone to send a fraudulent email that appears to come from a high-ranking company official seeking sensitive information or money transfers. Lost devices, such as laptops, phones and physical files are another way to break in to a company’s network.

 

 

Ransomware Preventive Measures

 

  • Back it up – twice. An external hard drive should be used for backing up all your files and data; then it should be disconnected from the computer. The cloud may be used for a second backup, such as Dropbox, Google Drive, or OneDrive. However, the cloud application should not be turned on except once per day to sync the data. Another backup source can be an ‘air gapped’ computer or server, that is secure and isolated from other networks.

 

  • Train employees. Unfortunately, unwitting employees may be the most vulnerable part of your cyber security. It’s imperative they understand and are kept up to date on what and how cyber-attacks and ransomware occur and how to prevent them. You can then periodically test employees with mock phishing emails. The training should be ongoing and should include the following:

 

– Review emails closely to make sure they are from a trusted and known sender before links or attachments are opened.

– Never download attachments from spam or suspicious emails.

– Bring Your Own Device (BYOD) training to highlight the risks in downloading suspicious apps on them. On smartphones, only official materials should be downloaded.

– Don’t store important data on the PC, if possible.

 

  • Update software. Computers and software that are outdated are more likely to crash and face cyberattacks. Security updates for Microsoft and other operating systems should be applied immediately, including any patches released to combat WannaCry or malware. Antivirus and anti-spam filters should also be kept current.

 

  • Implement/update security policies. Passwords should be strong; meaning they should contain upper and lowercase letters as well as numbers and symbols; and they should be changed at least every 90 days. A companywide password policy should be strictly enforced. Computer browsers’ security and privacy settings should be adjusted for better protection. Outdated plugins and add-ons should be removed from the browser. An ad blocker should be used to prevent potentially malicious ads.

 

  • Check your policy. If your company does not have a cyber policy, explore the idea of getting one. These typically cover the cost of notifying those whose data has been affected, and even hiring a public relations firm to combat reputational damage. If you have a policy it’s vital to inform the insurer if and when a breach occurs. Other policies that may include coverage are kidnap and ransom, or property policies. In the event of a breach these may help pay for legal costs, data restoration, business interruption and the ransom, if paid.

 

  • Incident response plan. Your company should consider forming an action plan that would kick into effect in the event of a security breach, to help limit costs and damages. It should guide personnel at all levels to help manage the breach. Once implemented, you can run simulated attacks to test your company’s level of preparedness.

 

 

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 & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©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.

Express Scripts & myMatrixx Combine to Offer Best In Class Pharmacy Services

ST. LOUIS, May 17, 2017 /PRNewswire/ — Express Scripts (NASDAQ: ESRX) today announced it is taking an important step in expanding its customized workers’ compensation pharmacy solutions by acquiring myMatrixx, a pharmacy benefit solutions provider for the workers’ compensation industry. The companies will merge core capabilities to deliver best-in-class clinical expertise, advanced analytics, and customized client experiences to serve workers’ compensation clients and injured patients.

 

Express Scripts, St. Louis, Missouri. (PRNewsFoto/Express Scripts)

 

Terms of the transaction were not disclosed. Bryan Cave LLP and Skadden, Arps, Slate, Meagher & Flom LLP served as legal counsel to Express Scripts. SunTrust Robinson Humphrey acted as myMatrixx’s exclusive financial advisor and Akerman LLP served as myMatrixx’s legal counsel.

 

The combination of Express Scripts and myMatrixx will make enhanced pharmacy services offerings available to current and prospective workers’ compensation clients. The combined workers’ compensation team will be led by Artemis Emslie, currently Chief Executive Officer of myMatrixx.

 

“We are proud to create best-in-class pharmacy services for workers’ compensation programs by combining our deep expertise with the market-leading myMatrixx customer experience and technology,” said Express Scripts President & CEO Tim Wentworth. “We are well-equipped to address our clients’ evolving needs. Our unique combination of scale, technology, and a customized client experience sets the standard for workers’ compensation programs.”

 

“myMatrixx’s industry knowledge, technology and client experience have put us at the forefront of pharmacy services for workers’ compensation programs,” said Ms. Emslie, myMatrixx CEO. “With the demand for customized pharmacy solutions only growing, now is the right time to partner with Express Scripts and leverage the size and scale of the nation’s largest PBM to benefit our clients.”

 

With more than 83 million members, Express Scripts brings an ability to invest resources into advanced analytics. Express Scripts will leverage its clinical expertise innovation, client services, and strong marketplace footprint on behalf of its workers’ compensation program. myMatrixx’s strong reputation in the market for client services and agility will generate new growth opportunities and the combination will create more customer value.

 

Underlining the growing need for novel workers’ compensation solutions, earlier this month, Express Scripts released new data finding that the company’s innovative solutions lowered prescription drug spending for workers’ compensation payers overall by 7.6 percent in 2016. Much of this reduction can be ascribed to a sixth consecutive year of decline in overall opioid trend. In 2016, opioid trend decreased 13.4 percent due to a combination of Express Scripts’ clinical solutions, aggressive client management, and state and federal opioid regulatory trends.

 

 

About Express Scripts

 

Express Scripts puts medicine within reach of tens of millions of people by aligning with plan sponsors, taking bold action and delivering patient-centered care to make better health more affordable and accessible.

 

Headquartered in St. Louis, Express Scripts provides integrated pharmacy benefit management services, including network-pharmacy claims processing, home delivery pharmacy care, specialty pharmacy care, specialty benefit management, benefit-design consultation, drug utilization review, formulary management, and medical and drug data analysis services. Express Scripts also distributes a full range of biopharmaceutical products and provides extensive cost-management and patient-care services.

 

For more information, visit Lab.Express-Scripts.com or follow @ExpressScripts on Twitter.

 

About myMatrixx

 

myMatrixx® is a full-service workers compensation pharmacy benefit management company focused on patient advocacy. By combining agile technology, clinical expertise, and advanced business analytics, myMatrixx simplifies workers’ compensation claims management while providing safer medication therapy management. Located in Tampa, Florida, myMatrixx has positioned itself as a thought leader in the workers’ compensation industry.

 

Media Contact:

Ellen Drazen

(314) 684-5355

evdrazen@express-scripts.com

 

To view the original version on PR Newswire, visit:http://www.prnewswire.com/news-releases/express-scripts-and-mymatrixx-combine-to-offer-best-in-class-pharmacy-services-for-workers-compensation-programs-300459277.html – See more at: http://phx.corporate-ir.net/phoenix.zhtml?c=69641&p=irol-newsArticle&ID=2273690#sthash.1V3b2ynl.dpuf

10 Requirements For Employees Injured At Work

We tend to think of workers’ compensation cost containment programs as an endeavor best left to the employer, and while the employer must design the program, the employee has a role also.

 

 

10 Requirements For Employees Injured At Work

 

  1. Know what to do if they are injured on the job
  2. Sign an acknowledgement of these responsibilities
  3. Seek medical care from the employers medical provider (or their own primary treating physician if allowed by law)
  4. Keep the employer informed and updated of their condition/status
  5. Complete forms required by the employer truthfully.
  6. Attend weekly meetings to keep the employer informed of their condition and any obstacles to return to work full duty
  7. Participate in transitional duty (this must be a condition of employment).
  8. Attend all medical and rehabilitation appointments.
  9. Return to work in either transitional duty or full duty as soon as medically able.
  10. Other tasks as required by the employer and allowable by law such. Each state is different.

 

Remember, communication is the most powerful to gain buy-in and bring employees on board with participation in your workers’ comp management program.

 

 

Main Communication Message

 

“Our employees are our greatest asset, we are sorry one of our employees was injured, and we need your help getting them back to work.”

 

 

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 & lead trainer of Amaxx Workers’ Comp Training Center. .

 

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.

Denied Claim Zero MSAs: Still Available, But Put Through Wringer by CMS

In October 2016, CMS made an unannounced policy change which effectively eliminated the ability to obtain a Zero MSA approval from CMS based upon a complete denial of the claim, without a supporting judicial decision. After only a couple weeks, CMS withdrew this policy change and again allowed for approval of Zero MSAs based solely upon a complete claim denial. Nonetheless, these Zero MSAs reviews are placed through the proverbial wringer by CMS such that it is important to understand when a case meets the criteria for a Denied Claim Zero MSA and the documentation required to obtain CMS approval.

 

 

Denied Claim Zero MSA Approval Criteria

 

A Denied Claim Zero MSA (or Legal Zero MSA) approval from CMS is available when the claim has been completely denied with no medical or indemnity payments having been made with the exception of medical payments made for non-treatment purposes such as IMEs, case management and medical records copies (Note, in certain limited situations a Zero MSA may be approved with medical treatment payments having been made. Please consult with Tower MSA).

 

Importantly, CMS will not approve a Denied Claim Zero MSA if settlement is made final and/or a settlement payment or any medical or indemnity payment is made prior to CMS approval of the Zero MSA. A tentative or agreed to settlement is allowable, but please do not make the settlement final or make indemnity or medical payments prior to CMS approval of the Zero MSA.

 

If the case meets this criteria, then CMS has strict documentation requirements which must be adhered to or the Zero MSA will be rejected. Notably, since the policy change and rollback occurred in October 2016, CMS has added a requirement to provide claim reserve documentation. The requirement for claim reserve documentation, as well as all other supporting documentation, is detailed below.

 

 

Denied Claim Zero MSA Documentation Requirements

 

The following documents are required by CMS to obtain approval of a Zero MSA based upon a complete claim denial:

 

1. Claim Payment History

 

  • A claim payment history printout, even if blank, representing payments since the inception of the claim. All payments must be itemized.
  • Printout must be divided into categories for medical, indemnity and expenses with subtotals for each category and a grand total listed. Print or run date listed on the printout.
  • Date range for listed payments – Must be since inception of claim.
  • If the Claim Payment History does not meet the above requirements, then the following rules apply:

 

Provide a copy of the available Claim Payment History with the following statement inserted, signed and dated in the document:
This document provides a complete representation of all payments made on the life of the claim (including medical of $0* and indemnity of $0)

 

Signed:
Date:

*If medical payments were made, provide the invoices or reports, i.e. IME report, associated with those payments and see below Financial Detail and Denial Letter requirement.

 

  • Letter providing an explanation why a Claim Payment History meeting CMS’s requirements is not available (See below Financial Detail and Denial Letter)

 

2. Claim Reserves

 

  • A Claim Reserves printout divided into categories for medical, indemnity and expenses with subtotals for each category and a grand total.
  • Print or run date listed on the printout.
  • If there is a legal argument for claiming the reserve information is privileged then the legal argument, including citations to statute or case law must be provided along with a copy of a redacted (reserve information blacked out) version of the Claim Reserves printout.
  • If no reserves were placed on the claim, then a statement regarding the same.

 

3. Draft or final settlement documents and court orders or rulings or a statement that no such documents exist
(See below Financial Detail and Denial Letter).

 

4. First Report of Injury or a statement that no such document exists (See below Financial Detail and Denial Letter).

 

5. Financial Detail and Denial Letter – Tower MSA will provide draft letter upon request for submission of the Zero MSA to CMS

 

  • A statement indicating the claim was completely or fully denied with no medical or indemnity payments having been made.
  • If medical payments have been made for non-treatment purposes, i.e. IME, case management, medical records requests, then if the Claim Payment History does not properly explain the purpose of these payments, then provide an explanation for the payments.
  • If the available Claim Payment History does not meet the requirements under #1, then state that the carrier’s claim system does not have the ability to provide a Claim Payment History printout with the information requested by CMS, i.e. print date, subtotals for medical, indemnity and expenses.
  • If Claim Payment History did not meet the requirements under #1, then insert the requested information into the letter, i.e.list categories for medical, indemnity and expenses with subtotals for each category and a grand total.
  • If there are no draft or final settlement documents and no court orders or rulings, then a statement regarding the same.
  • If there is no First Report of Injury, then a statement regarding the same.
  • Letter must be placed on letterhead and hand signed.

 


6. Consent to Release form executed by claimant

 

While CMS places Zero MSA submissions based upon a complete denial through the wringer, these approvals remain available for workers’ compensation cases meeting the applicable criteria.

 

 

Author Rita Wilson, CEO, Tower MSA Partners, LLC. Rita serves as CEO of Tower MSA Partners, LLC. With more than 20 years in leadership positions in pharmacy software development and workers’ compensation managed care, Rita brings a wealth of expertise in information technology solutions and performance metric evaluation. Contact Tower MSA Partners at referrals@towermsa.com or (888) 331-4941

11 Simple Ways to Make Return to Work Part of Corporate Culture

It is critically important that management makes return-to-work programs part of the corporate culture. The employee’s expectations should be that if/when they go out on workers’ compensation, they will return to work immediately in some form of transitional work capacity. What are a few of the tools that can be used to make return to work part of the culture?

 

 

 

11 Simple Ways to Make Return to Work Part of Corporate Culture

 

  1. Talk about RTW in a positive way- never badmouth the jobs, the participants or the concept.
  2. Make RTW a positive experienceby finding productive tasks or jobs. Never have transitional duty jobs be punitive.
  3. Demonstrate the costof NOT doing it, and the savings OF doing it by showing it to employees in terms they understand and management in terms understood by executives.
  4. Incorporate RTW in all policies and procedures such asMedical Policy and/or Leave of Absence Policy, Wellness Policy. 
  5. Make it amandatory requirement of employment – so all employees expect to be treated in a similar fair manner.
  6. Holdweekly meetings to discuss obstacles to return to work – keeps employees “connected” and employers stay on top of the worker’s abilities.
  7. Send Get Well Cards for colleagues that are injured. Perhaps include a gift card to Papa Johns’s or a local restaurant or one that delivers with the card.
  8. Maintain the rules strictly and make them standardized.
  9. Show supervisors the cost savings and benefits (they have less retraining, for example).
  10. Don’t hesitate to use vendors that do on-site work hardening and RTW coaching.
  11. Include them in workplace activitieswhile they are recovering. Don’t forget to include them in meetings, events while they are injured. Once they are out of work they can easily become alienated and lose social contacts, so continue to include them in workplace activities even if they are doing a partial schedule while they work toward full duty.

 

These are just a few ways to make RTW part of your corporate culture. Start now, and take small steps. Stick with the program and gradually it will be accepted.

 

 

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 & lead trainer of Amaxx Workers’ Comp Training Center. .

 

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.

 

8 Categories To Define Winning Workers’ Comp Litigation Strategy

Legal fees in litigated workers compensation claims can quickly become a significant part of the overall claim cost.  Fortunately, there are some very good ways to control legal cost without having a negative impact on the overall claim settlement.  The best time to establish control over legal fees is when the defense attorney is first employed; however, the best time to control the overall strategy of the litigation is before counsel is even hired.

 

Prior to hiring counsel, a fast track defense strategy should be established to ensure that appropriate actions are taken immediately upon notification of a claim. [The individual components of a fast track strategy are beyond the scope of this article.] The establishment of some basic ground rules for the legal fee billing before the attorney goes to work on the workers compensation claim will result in a measure of cost control without sacrificing the best possible settlement of the claim.

 

Litigation cost control is much more than negotiating the hourly rate and whether or not you will be charged for postage.  There are Best Practices for Litigation Management that should be utilized as a major part of your legal cost control.  The Litigation Management Best Practices can be broken down into easy to measure performance goals.  The following questions will assist you in determining if your current litigation program is controlling cost fully.

 

 

Defense Counsel Selection:

  • Is the defense counsel on your company’s list of approved counsel?
  • Is the defense counsel selected a law firm, or a specific attorney (preferably), within the law firm? Many carriers have an “approved list” of attorneys they use; this doesn’t necessarily mean those are the best attorneys or the most knowledgeable for your purposes, so consider their qualifications carefully and if you have another attorney you wish to use, discuss adding him/her to the list of approved counsel.
  • If the defense attorney is new to representing your company, has the attorney been provided the terms and conditions of the assignment?
  • Have they visited your operations, seen your products and know the basic requirements of the jobs within your workplace?
  • Have the reporting requirements been clearly stated?
  • Was a litigation budget request incorporated into, or attached to, the assignment letter?

 

The Answer:

  • Did the workers compensation adjuster refer the matter to defense counsel timely when an answer must be filed?
  • Does the employer provide the complete facts of the injury immediately such as how the injury occurred, photographs of the accident, information about weight of objects lifted, the employee’s application for employment, information about any prior injuries, prior claims, or prior medical absences. Having the employment file is very helpful.
  • Does the defense attorney have everything needed to complete ALL blanks on the First Report of Injury. Does he have the OSHA Report?
  • Does the defense attorney offer arbitration or mediation as an alternative to protracted litigation?

 

Initial Legal File Handling:

  • Are all medical and/or indemnity issues covered by the workers compensation policy?
  • Is the potential exposure on the claim evaluated correctly?
  • Is there an economic justification for a quick disposition of the claim?
  • Are there any statute defenses that need to be addressed?
  • Are there any unique aspects of the claim that could alter the outcome favorably or unfavorably?
  • Are all potential third parties noted?

 

Defense Counsel Acceptance:

  • Does the defense counsel send an acknowledgment of the assignment to both the workers compensation adjuster and to your workers compensation coordinator?
  • Does the defense counsel provide an initial review and evaluation report within the first 30 day?
  • Does the initial review offer alternative courses of action and the probable outcomes?
  • Does the defense counsel provide a detailed budget plan within the first 30 days?

 

Defense Counsel Staffing:

  • With the acceptance of the assignment, did the defense counsel specify who will be working on the claim?  (Unless the claim is extremely complex, the defense attorney, possibly one junior associate and one paralegal are all of the law firm that should be involved.  Multiple associate attorneys and multiple paralegals will add time [cost] learning the claim before being able to proceed with an activity).
  • Is the hourly rate for each of the law firm members clearly stated?
  • Does the attorney do work that should be done by the paralegal?

 

Budget:

  • Is the budget completely itemized?
  • Is research time included only for extraordinary issues?
  • Does the budget include the cost of any experts that will be retained?

 

Claim Handling:

  • Does the defense counsel make recommendations for any additional adjuster work that should be done?  (Defense attorneys are notorious about having the paralegals do the adjuster’s job of obtaining medical records and other documentation).
  • Does the defense attorney have the adjuster hire other vendors (surveillance, nurse case managers, vocational rehabilitation, etc.) or does the defense attorney complete the adjuster’s work?

 

Actions of Defense Counsel:

  • Is defense counsel avoiding the expenses of depositions and other discovery if it is the intent to settle the claim? Often, some discovery prior to settlement can reduce the amount of the ultimate settlement.
  • Is the defense counsel requesting only necessary depositions?
  • Is the defense counsel reporting significant developments timely?
  • Is the defense counsel reporting the progress of the claim at least every 90 days if the case is moving slowly?
  • Do the reports from defense counsel cover all pertinent information without repeating prior reports?
  • Does each report include an action plan to move the claim forward?

 

Hearings / Trials:

  • Is the hearing / trial date reported as soon as it is known?
  • Does the defense attorney provide a pre-hearing / pre-trial report at least 30 days ahead of hearing / trial?
  • Does the defense attorney provide a strategy for the hearing / trial?
  • Does the defense attorney timely request additional settlement authority when needed?
  • Does the defense attorney provide a timely update or report on the hearing / trial?

 

Legal Bills:

  • Is the amount billed for each activity appropriate?
  • Are the bills properly itemized with each activity being billed separately?  (As opposed to block billing where several activities are lumped together and one charge is given for all work done).
  • Do the legal bills follow the defense attorney stated course of action?
  • Are the legal bills in compliance with the litigation budget?

 

If you are uncomfortable trying to control the litigation cost or feel you need an expert to review the litigated workers compensation claims, please contact us for assistance.

 

 

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 & lead trainer of Amaxx Workers’ Comp Training Center. .

 

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.

5 Reasons Your Employee WANTS to Return to Work

There can often be a negative connotation for those that are injured at work.  After dealing with thousands of claims adjusters can get jaded that claimants are up to no good and are only looking for a free paycheck.

 

A handful of bad apples can ruin it for everyone, but for the most part people just want to get back to their normal routine.  When injured, workers are usually in pain, receiving less money than they are used to, and traveling back and forth to doctor offices for examinations and therapy.  A revolving statistic may state that up to 10% of claims filed are not necessarily legitimate.  That leaves 90% just looking to heal and get back to pre-injury status.  Some injured workers even heal or return to work quicker than expected.  But why?  It seems obvious, but let’s explore some of the reasons in more detail:

 

 

  1. Loss of income

 

The biggest factor for an injured worker wanting to go back to regular duty is the income they receive.  There aren’t many people out there than can get rich off of receiving work comp pay.  Typically they receive a percentage of the income they are used to receiving, ranging from 60% to 80% of their net income.

 

Even in dual income families, this loss of income can be substantial, especially those that are living from paycheck to paycheck.  Do not be surprised when your injured worker is in a rush to get back to normal.  As long as a qualified doctor releases them to work with no medical restrictions, then you should be all set.  Of course this will vary on the injury.  I have handled cases when the claimant is adamant about making the doctor return them to work, and the physician will indicate in the notes that they are just retuning the patient back to full duty because that is what the patient requests.  You have to be very careful in this situation to avoid further injury, so if this should happen review it on a case by case basis.

 

 

  1. The claimant is bored if they are totally out of work and sitting at home

 

Sitting at home in an empty house with nothing to do can be even worse than light duty.  There is only so much daytime TV one can stomach.  It is no coincidence that most plaintiff law firm commercials run during the morning and afternoon, when injured workers would be home while disabled from work.

The vast majority of workers like working, or at least need to work for income, and even though sitting at home for weeks sounds great it is indeed not so great after a while.  It’s not like they can do whatever they want.  In fact this is what will land most workers in trouble, because once boredom creeps in they start to get outside and do something to take their mind off of being at home, and if you have surveillance on that certain day this can land a person’s case in suspension or denial due to them breaking their medical restrictions, whether it be on purpose or not.  I have seen a lot of injured workers say they just cannot sit at home any longer, and want to return to work.

 

 

  1. The claimant hates being involved with the adjuster and the carrier/TPA

 

Most claimants are new to being on work comp.  They have no idea what they are supposed to do, they do not like treating with the occupational doctor, and they hate sitting around and waiting on a paycheck to come in the mail that may take weeks to come once the investigation is complete.  In fact, I have had some workers that have had a legitimate work injury decline filing a claim under work comp, and choose to cover the bills from their medical care another way.  This is especially true if they have had a messy comp case in their past.  They are so jaded about how the process works that they will avoid it at all cost.  This is not necessarily the right thing to do, but the overall choice is up to the worker.  Realistically the carrier is not going to try and talk the injured worker into filing the claim.

 

 

  1. They think that a work comp case is going to be a litigation nightmare

 

Taking this one step further, some workers have heard horror stories about being on work comp, and being embroiled in a years-long litigation battle, with mounting attorney fees and a life filled with misery.  Sure this could be true sometimes, but not as much as the general public thinks.  Despite what the adjuster may tell them, we can’t make the worker pull the trigger and file the claim.

 

 

  1. The worker just heals faster than expected

 

Some people just heal better and quicker than others.  This is due to conditioning, genetics, the type of injury, the location of the injury, the severity of the injury, and so on.  If the adjuster thinks that it can take 6-8 weeks to heal from a back strain, and the worker is released to full duty in 2 weeks, this doesn’t mean that they are just in a rush to get back to gainful employment.  If the medical checks out, and the treating doctor signs off on it, then so be it.  Full duty is full duty. Adjusters should not hold this against a person just because they heal better or quicker than we thought they would.

 

 

Summary

 

There are many more factors to add to this article, but in my opinion the 5 above are the most tangible. This should prove that all claims shouldn’t be placed in the “bad” category.  Put yourself in the shoes of your injured worker.  Their money is not the same, they are in some sort of pain, their job tasks have changed, they are dealing with the adjuster and the carrier/TPA, etc.  They are in uncertain waters.  The common response to that is to get back to whatever they think is their normal life as soon as possible, so they can put this all behind them.

 

 

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 & lead trainer of Amaxx Workers’ Comp Training Center. .

 

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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