The Workers Compensation  Research Institute (WCRI) reports a reduction in medical costs per claim in Tennessee as a result of reforms in 2004 introducing a medical fee schedule for the state’s workers’ compensation system.
Monitoring the Impact  of the Tennessee Fee Schedules: CompScope^TM Medical Benchmarks, 9th Edition, showed, on average in 2006/2007, (18 months post-fee schedule) Tennessee’s employers paid $1,300 less for medical cost per case than prior to pre-reform years,  reflecting  the impact of the new fee schedule.  The new schedule  addressed fees for a wide range of services provided by physicians, chiropractors, physical/occupational therapists, hospitals, and outpatient ambulatory surgery centers.

On average  Tennessee experiences relatively higher rates compared to other states.  However, the new fee schedule led to a significant drop in the average prices paid to non-hospital providers.

Decreases Reported in 2006:

1. 9%    Major surgery (arthroscopic knee and shoulder, laminotomy, carpal tunnel).
2. 12%  Physical medicine (modalities and procedures) decreased 12 percent.
3. 5%    Major radiology (MRI, CT scan).
4. 15%  Minor radiology (X rays) decreased 15 percent.

Decreases for hospital outpatient services

1. 23%   Physical medicine services.
2. 34%   Major radiology.
3. 43%   Minor radiology.

In contrast  prices paid for non-hospital evaluation and office visits services increased 9%, as expected, due to higher fee schedule rates in comparison to the average prices paid prior to the fee schedule.

The study pointed out that having such substantial changes in prices paid may lead to changes in utilization of medical services.

1.   In 2006/2007,  the study found growing utilization among non-hospital providers and decreasing utilization among hospital outpatient services. Before the fee schedule regulations, utilization among all types of providers in Tennessee was relatively stable for a period of four years.

2.  Utilization of medical  services among non-hospital providers grew 5% in 2006/2007, driven by an increase in the number of services per visit when surgery was performed and a somewhat larger volume of billed services among all other non-hospital services.

3.  The number of services  per claim among hospital outpatient services declined 16%, especially for services delivered at the operating/treatment/recovery room.

However, the study said,  the current trend in utilization in the post-fee schedule period should be analyzed in light of the typical use of medical services among non-hospital providers and lower use of services rendered in a hospital outpatient setting.

Tennessee’s fee schedule  also focused on hospital inpatient cost. The inpatient fee schedule may have helped to reduce the hospital inpatient payments per episode. Before the regulations, Tennessee had higher hospital inpatient payments per episode.

Based on claims  with 12 months of experience in the post-fee schedule period, hospital inpatient payment per claim was typical of the study states, driven by typical payment per episode with surgery.  workersxzcompxzkit)

In 2004/2005,  prior to regulations, the average total hospital payment per episode was 13% higher than the median study state.

To order this report, go to the WCRI Web site: www.wcrinet.org.

Author:  Robert Elliott, J.D.

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The risk manager  is responsible for a broad array of risk-related duties, including overseeing the injury coordinator as the workers’ compensation management program is implemented. As a risk manager your key responsibility is oversight of the workers’ compensation injury management program. Cost reduction requires close monitoring.

The risk manager follows these guidelines:

1. Determine what  type of claims administration arrangement your company has.
2. Ensure the  adjuster-to-claim ratio is appropriate for adjusters responding to your claims to get your workers back to productive employment faster.
3. Consider  whether claims volume requires dedicated staff to provide oversight and input about how you want your claims handled and to implement your injury management program.
4. Familiarize  yourself with claims administration best practices to better comprehend the role of the adjuster.
5. The claim  handling process should go smoothly. If it doesn’t you want to be sure you have realistic expectations about how your claims are handles. Don’t assume you are the one who is wrong!
6. Make sure  claims handling personnel are trained in injury management concepts so they grasp the issues affecting your claims.
7. Visit  an adjuster claims handing location to see how your adjuster handles your files, and view their claims operations first hand.
8. An on-site  visit is an opportunity to develop a positive relationship with adjuster and clarify expectations, procedural issues, special handling instructions, etc.
9. Attend association seminars and meet with other industries to observe how other organizations address workers’ compensation issues in today’s labor market. (workersxzcompxzkit).
10. Maintain benchmarks  for your profession showing how potential savings generated by an effective Injury Management Program far outweigh the initial costs of staffing.

Author: Robert Elliott, J.D.

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It is important  to document workers’ compensation claims throughout the injury process. As your employee heals, or even worsens, you need to have this process documented.

It’s a good idea  to follow up with your adjuster by using a form designed to gather information from and follow up with your adjuster.  In some cases, you may want to use the form for a live interview, rather than having the adjuster fill it out. This allows you both to sign off on the document.

Gathering Information

1. Include all the basics, even if documented elsewhere. Be sure to include:

a-Employee social security number
b-Date of injury
c-Your company name

2. Ask about current condition  and whether the injury requires physical therapy or surgery.

3. Ask about the employee’s  medical history  may affect the injury and what a typical timeline for recovery may be.

4. Ask about the relationship  with the doctor and whether through communication is being provided.

5. Document if there  is any question to the validity of the claim and about the employee’s attitude.

6. Give a deadline,  no more than 24 hours in advance for the adjuster’s suggestions to rapidly resolve the case. (workersxzcompxzkit).

Consistency is another factor to consider. If you develop or purchase a regulated form, you will remember to ask all appropriate questions in every case. You will also be using the same language each time you have a workers’ compensation claim thus removing personality from what should strictly be a professional arrangement,  since everyone wants the employee to heal and get back to work.

Author: Robert Elliott, J.D.

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Looking to Protect Employers, Workers During Summer Months

Attention to workplace  safety by employers and workers is more important than ever during the summer months, considering the typical spike in workplace injuries and workplace deaths according to The Department of Labor & Industries (L&I).  Historically, July and August are the most dangerous and deadly months for workers in Washington state.

“There are a variety  of reasons injuries, illnesses and even deaths go up in the summer, but that doesn’t mean we have to accept it year after year,” said Steve Cant, L&I’s assistant director for safety and health. “We’re trying to raise awareness to summertime dangers so employers and employees can work together to improve safety on the job.”

The number of  workers’ compensation claims from 2004-2008 showed a jump to nearly 14,000 a month in July and August each year, compared with a low of fewer than 11,000 a month in December.

Cant cited several things contributing to a summertime spike in workplace injuries and deaths.

1. Young  workers entering the workforce may lack experience and training.
2. Increased road  construction raises risk for workers and drivers alike.
3. More people  on the road lead to more risks of motor vehicle accidents.
4. Increased  activity in all sectors, e.g., construction, agriculture, manufacturing.

To combat the injury  and death increases seen during the summer, L&I is offering a number of resources to make workplaces safer. (workersxzcompxzkit)

This year the department is running an advertising campaign, co-sponsored by four business and labor organizations, to increase awareness that if you work safe, you go home safe.

More information  about the campaign and workplace safety is available at  http://www.worksafe.lni.wa.gov/

Author:  Robert Elliott, J.D.

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According to a  report from the San Francisco Chronicle, a California  sheriff’s correctional officer is in custody on suspicion of workers’ compensation fraud, booked on eight counts of insurance fraud.

It is alleged  the individual made a workers’ compensation claim to the county stating he injured himself while fighting with an inmate.

An investigation determined the man’s version of how the injury happened was false, according to a statement released by the local sheriff and district attorney. (workersxzcompxzkit)

Authorities report  the man was treated for the same injury by his personal doctor two days prior to the reported the workers’ comp claim to the county.

Author:  Robert Elliott, J.D.

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New Jersey Teacher’s Claim for Occupational Asthma Fails Due to Lack of Objective Evidence

Here’s What Happened
Thomas was  employed by the school system from 1984 until 2000, initially as a substitute teacher and subsequently as a full-time teacher and staff developer. In 1974, at the age of thirty, she developed problems with asthma. From 1974 until 1987, Thomas stated  her asthma “wasn’t bad.” 

Sometime in 1987,  Thomas began to have problem with her asthma.  She stopped working in December 1999, attempted to come back to work a few months later, but was unable to finish even one complete day of work. Thomas indicated when she worked in certain parts of the school building, she noticed fumes that “smelled like gasoline or a furnace smell,” that the ceilings in some rooms of the school building would occasionally leak, causing damage to some of the boxes in which she stored her belongings, that those rooms were “damp and moldy,” and stated  she was exposed to those areas approximately once a week.  She also stated  she generally felt better when not at work on the weekends.

Thomas’ condition  deteriorated rapidly after she left her employment in February 2000.  In March, she was admitted to the intensive care unit of a local hospital. At the time of her workers’ compensation hearing in 2007, she was taking eleven medications daily and using oxygen.  She also weighed 255 pounds, having gained some 30 pounds after she stopped working. 

The school building  was inspected in June 2000.  Increased levels of carbon dioxide were found, as was some evidence of water-damaged materials that could cause mold. 

One expert,  a pulmonary specialist, diagnosed Thomas with chronic occupational asthmatic bronchitis, and opined further she met the criteria for chronic obstructive pulmonary disease (COPD), resulting in a sixty-five percent total lung disability.

The expert  indicated  Thomas’ exposure to numerous inhalants such as dirt, fumes, poor ventilation or in her classroom where she taught and other poor irritants that Thomas mentioned to him during the evaluation played a role in the development of her chronic airways disease.

The employer’s  pulmonary expert attributed Thomas’ asthma problems with the normal aging process, with smoking by Thomas’ spouse, with Thomas’ obesity, and other factors not related to the employment.

The trial judge  found Thomas’ claims lacked credibility, that if her condition had been caused by her employment, her condition would have improved after her departure from the work force, that instead, her condition deteriorated, and that she had not met her burden of proof that her condition arose out of and in the course of her employment.  (workersxzcompxzkit)

Here’s How the Court Ruled
In Thomas v. Newark Public Schs. Sys.,  2009 N.J. Super. Unpub. LEXIS 1860 (July 16, 2009), the Superior Court of New Jersey, Appellate Division, affirmed.  The appellate court agreed with the trial court that Thomas’ expert had based his opinion totally on information supplied by Thomas, rather than on objective quantifiable evidence.  There was no evidence as to the nature or extent of any inhalants in Thomas’ work environment, other than Thomas’ own subjective statements.  The trial judge’s acceptance of the opinion of the employer’s expert was within the judge’s discretion in determining the weight to be given the evidence.  The appellate court reiterated that a decision in an occupational exposure case must be based on some objective quantifiable evidence. It could not be based on the claimant’s subjective characterization of the workplace environment.

See generally  Larson’s Workers’ Compensation Law, §§ 52.03, 52.06.
Tom Robinson, J.D. is the primary upkeep writer for Larson’s Workers’ Compensation Law (LexisNexis) and Larson’s Workers’ Compensation, Desk Edition (LexisNexis). He is a contributing writer for California Compensation Cases (LexisNexis) and Benefits Review Board – Longshore Reporter(LexisNexis), and is a contributing author to New York Workers’ Compensation Handbook(LexisNexis). Mr. Robinson is an authority in the area of workers’ compensation and we are happy to have him as a Guest Contributor to Workers’ Comp Kit Blog. Tom can be reached at: compwriter@gmail.com.
http://law.lexisnexis.com/practiceareas/Workers-Compensation

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The U.S. Department  of Labor reported it paid more than $5 billion in compensation and medical benefits to more than 52,600 claimants nationwide under the “Energy Employees Occupational Illness Compensation Program Act” (EEOICPA).

This milestone  coincides with the eighth anniversary of the Labor Department’s administration of the EEOICPA, providing compensation and medical benefits to employees who became ill while working in the nuclear weapons industry.

The Labor Department  began administering Part B of the EEOICPA on July 31, 2001. Part B covers current or former workers who diagnosed with cancers, beryllium disease or silicosis, and whose illness was caused by exposure to radiation, beryllium or silica while working directly for the U.S. Department of Energy, that department’s contractors or subcontractors, designated Atomic Weapons Employers or beryllium vendors.

The EEOICPA  also provides additional compensation to uranium workers who worked at Section 5 uranium mines, uranium mills and ore buying stations covered under the Radiation Exposure Compensation Act. Certain survivors of nuclear weapons industry workers are also eligible for benefits under Parts B and  E.

Since 2001,  the Labor Department delivered compensation to more than 37,200 claimants under the Act’s Part B provisions.

Part E,  created by an amendment to the Act on October 28, 2004, provides federal compensation and medical benefits to contractors and subcontractors of the Department of Energy who worked at covered facilities and sustained an illness as a result of exposure to toxic substances. Under the Labor Department’s administration, the Part E benefit payout has exceeded $1.6 billion.

During fiscal year 2009,  the Labor Department continued to assist the nuclear weapons community by expanding its claimant services and outreach initiatives across the country.

The department’s Traveling Resource Center was in Washington, Pa., last week to inform workers and their survivors about new special exposure cohorts at Vitro Manufacturing and Westinghouse Atomic Power Development Plant.

The Traveling Resource Center  goes monthly to Kayenta, Ariz., and Shiprock, N.M., to assist individuals filing claims under the EEOICPA. Eleven stationary resource centers continue to play an active role in outreach efforts and provide personal assistance to claimants with filing claims, conducting occupational health interviews and answering questions concerning medical bills.  (workersxzcompxzkit)

For additional information  about how to file a claim under the EEOICPA, call 866-888-3322 toll-free.

Author:  Robert Elliott, J.D.

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Eight Steps for Managing an EMERGENCY Injury in a post loss injury program.

As is well known,  the keys to managing your workers’ compensation costs are documentation and following procedures.

1. The supervisor makes the decision about obtaining medical care, such as on-the-spot first aid, when a subordinate is injured on the job.

2. Follow your location’s procedures for notifying emergency services such as an ambulance.

3. Remain with the employee until medical professionals arrive and you are satisfied the employee is receiving adequate care.

4. Obtain the name of the contact person at the medical facility to contact about the employee’s condition over the next few hours/days.

5. Obtain the name and address of the medical facility treating the employee.

6. The supervisor must have ready and give the employee a copy of your company’s Injury Instructions, Workers’ Compensation Brochure, and Work Ability Form.

7. Supervisor also sends the Work Ability Form directly to the medical provider with instructions to complete and return to the supervisor within 24 hours of treatment.

8. Supervisor faxes report package (Work Ability Form and Employee Report; Supervisor Report and Witness Report) to injury coordinator.

When an Injury is NOT an Emergency

Seven Steps To Follow When Emergency Services Are Not Required

Even if emergency services  are not required following an on-the-job injury, your company is not off the hook. You are still responsible for treating the employee fairly.

However, as always,  procedures put in place before work-related injuries occur,  aid  supervisors in following and properly documenting the chain of events.

1. Direct the employee to preferred medical providers where statutorily permitted.

2. Work Ability Form (WAF) must accompany the employee.

3. The treating physician must sign and return WAF to the supervisor within 24 hours of treatment.

4. The employee also brings the Transitional Assignment Form (TAF) to the physician.

5. Physician must complete and sign TAF.

6. Employee must return TAF to supervisor within 24 hours of treatment. (workersxzcompxzkit)

7. The supervisor then faxes TAF to injury coordinator and works with injury coordinator to assign an appropriate transitional duty position to injured worker.

Author:  Robert Elliott, J.D.

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Training ALL Employees

Training ALL your employees  to know injury procedures  before  a work-related injury occurs – just as you would plan a fire drill – is instrumental in holding down your company’s workers’ compensation costs.

Six Training Guidelines to Follow   

1. Implement a training seminar, lasting one hour, to introduce and reinforce injury management program concepts to your management and to distribute new workers’ compensation materials. The goal is to inform management of workers’ compensation concepts and how workers’ compensation costs are affecting the company.

2. Schedule an in-service training session for supervisors to train them in correct post-injury responses in the event of a work-related injury.

3. Like fire drills, when a work-related injury occurs, every supervisor and employee must be able to demonstrate exactly what to do, where to go, and how to obtain help.

4. Convene small-group employee training sessions to discuss post-injury response training and integrate new roles and responsibilities into the work culture.

5. Training includes instructing employees on who to notify when a work-related injury occurs and what their responsibilities are if they witness a work-related injury.

6. Have employees sign an in-service acknowledgement indicating they have received post-injury response training. (workersxzcompxzkit)

Author:  Robert Elliott, J.D.

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Causality: When Diagnosed Injury was Pre-existing

Following a  work-related incident, a good employer makes sure the injured employee is seen by medical professionals; often more than one type; and often over an extended period of time.

Since it is  common practice for people to delay going to the doctor for symptoms they are experiencing, there are times a condition is diagnosed for the first time following a work-related accident.

For example,  an MRI following a head injury could turn up a tumor – clearly the tumor is not a result of the work accident and, therefore, not part of the obligation of your workers’ compensation program.

Determining causality  can be cleared up in an email from the injury coordinator to the adjustor.

When a physician  reviews the file and speaks to the employee’s treating specialist, the two doctors can discuss the medical issues peer-to-peer. The result is very credible evidence the injury is or is not related to work.

Workers’ Comp Kit suggests the following email communication:

1. Be sure  to include claim number and all relevant addresses and contact information on the letter.
2. Explain   the company’s medical advisor has reviewed the employee’s medical records.
3. Explain  the accident as well as the recently diagnosed condition.
4. Show how  physicians determined  one is not the result of the other.
5. Let the  adjustor know these physicians’ findings will arrive soon. (workersxzcompxzkit)
6. Explain  you will contact the adjustor once they have time to review the notes to be sure you have sufficient evidence to deny the claim.

Author:  Robert Elliott, J.D.

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