Using various databases, your company can find investigative leads to follow according to Arthur J. Gallagher Risk Management Services, Inc. Looking for problems in the research you pull up could help you find holes in injury claims.
Often injuries are legitimate and certainly something a good company wants to take responsibility for. But occasionally red flags come up that prompt further investigation. In our modern age of information, there are some amazing resources available that can help investigate the veracity of a claim.
Ten Databases to Look Into When You Suspect Fraud
1. Use local, state and federal databases.
2. Go to regional courthouses to look for information that might mitigate the claim.
3. Work with claims handlers to establish what would add value to the file.
4. Research using databases to determine past injuries or pre-existing claims.
5. Does the claimant have Uniform Commercial Code filings? This means the claimant is borrowing money for a business. For example if the claimant cites a workplace burn injury but also owns a pizza parlor, this could encourage additional investigation.
6. Does the address history provide additional leads that could turn up previous claims from this employee?
7. Remember that almost everything is available on the internet such as EBay stores.
8. Look at www.pipl.com, www.spokeo.com or www.dirtsearch.org and other multiple search engines to help check many sites on one name, for example.
9. www.Bowl.com shows who is involved in bowling – if someone has a great bowling record but is supposed to be home due to injury, this site can be very helpful. (workersxzcompxzkit)
10. Use state fraud bureaus to access information and to help in prosecution.
"FRAUD PREVENTION" PODCAST click here: http://www.workerscompkit.com/gallagher/mp3 By: Private investigator with 25 years experience.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agen about workers' comp issues. ©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
Safety is a message that needs to be communicated consistently and continually.
Five suggested communication methods:
1. Employee safety meetings (for all shifts).
2. Posters and bulletins.
3. Newsletters.
4. A safety suggestion box.
5. “Tool box” safety talks conducted informally by supervisors with their employees.
Training records must be kept, and you should refer to federal and state regulations for the requirements. Training must also be bi-lingual, if appropriate, and there are a variety of resources and products available to help you with your program.
Before developing a Safety Recognition Program, consider the following:
1. You cannot “buy” safety, but you can expect safe behavior and recognize employees who deliver.
2. Keep it simple, and change it every occasionally to keep it fresh.
3. Concentrate on results (i.e., fewer injuries) AND on behaviors (i.e., use of personal protective equipment, safety inspection scores).
4. Establish clear, measureable goals for both results and behaviors.
5. Employees should know that there will be serious consequences for not reporting accidents.
6. Awards should have true value and be more than just cash (something tangible to remind the employee why they won the award, and presented by senior management during an employee celebration (pizza party, for example). (workersxzcompxzkit)
7. Senior management must completely support the Safety Recognition Program and be visible in the process.
8. Consider rewarding individuals for safe behaviors and groups for safety results.
“FRAUD PREVENTION” PODCAST click here: http://www.workerscompkit.com/gallagher/mp3
By: Private investigator with 25 years experience.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker about workers’ comp issues.
©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
Great Britain’s Health and Safety Executive (HSE) website recently released is full and finalized offshore health and safety statistics for 2008/2009. The detailed report follows the release of “headline” statistics in August (09) and contains figures on injury, ill health, and dangerous occurrences, including hydrocarbon releases, between April 1, 2008 and March 31, 2009.
1. No workers were killed while working offshore during 2008/2009 – the second consecutive year with no fatalities – and there was a fall in reported major injuries (30), a fall of 14 compared with 2007/2008 figures.
2. The combined fatal and major injury rate dropped to 106 per 100,000 workers in 2008/2009 compared with 156 in 2007/2008 and 146 in 2006/2007. The highest number of injuries occurred during maintenance and construction work.
3. The number of major and significant hydrocarbon releases, regarded as potential precursors to a major incident, also showed marked improvement with 61 in 2008/2009 compared with 74 in 2007/2008.
4. The three-day injury rate in 2008/2009 experienced a small decrease with 496 workers per 100,000 reporting an injury, bucking the broadly flat trend over the previous seven years.
Steve Walker, HSE’s head of offshore, noted, “Though these figures suggest the sector is getting safer, with both the combined fatal and major injury rate and major hydrocarbon releases at their lowest since HSE began regulating the industry, they cannot be taken in isolation. The tragic loss on April 1, 2009 of 17 workers in two separate air transport and maritime incidents – areas not regulated by HSE – is a stark reminder of the hazards of working offshore and the need to ensure they are carefully managed. (workersxzcompxzkit)
”However, while continuing to work to minimize the potential for large-scale incidents, the offshore industry must not forget the risks to workers from every day activities such as lifting and carrying and maintenance work which were responsible for the vast majority of all offshore injuries during 2008/2009,” he added.
The offshore injury, ill health, and incident statistics report 2008/09 can be downloaded free from the HSE at www.hse.gov.uk/offshore/statistics.htm
Author Robert Elliott, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, health care, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He can be contacted at: Robert_Elliott@ReduceYourWorkersComp.com or 860-553-6604.
“FRAUD PREVENTION” PODCAST click here: http://www.workerscompkit.com/gallagher/mp3
By: Private investigator with 25 years experience.
Employers who have experienced a long string of seemingly exaggerated claims with anomalously long and expensive periods of disability learn, the hard way, to recognize patterns. First, the names of the doctors are repetitive. Second, the same attorneys always seem to have the claims.
The associations are not pure coincidence. The clustering of certain lawyers and certain doctors is associated with production of work comp claims in a bulk process. Litigation, one claim at a time before the comp board, is seldom productive. In fact, if it were the assembly line of claims would soon come to a halt.
There is a Remedy – Subrogation
An employer, or its carrier, can take over a worker’s right to sue a third party in a procedure known as “subrogation.” Usually, this remedy is found in motor vehicle accidents where the comp carrier sues the other vehicle when the employee has little interest, since much or all of the recovery is paid to the comp carrier, which has a lien.
What is less known is the employer can sue the worker’s doctor for medical malpractice that made a comp injury worse, even if the worker refuses to sue. Provisions for how this is done are contained in Sect. 29 of the New York Workers’ Compensation Law. Persons looking for quick answers are cautioned that this section is not light reading.
Such suits are very rare, but they do occur, among the first being “Parchefsky v. Kroll,” in 1935.
However, for many the largest surprise is that such suits can be brought, by the employer, for legal malpractice against the employee’s comp attorney where the handling of the claim resulted in disability created solely to enhance the value of a claim.
Such suits are not reported because the mere threat of such a suit being underway causes a claim mill to collapse. Doctors, lawyers, and comp boards have marvelous ways of making the abuses vanish when an employer draws a line in the sand and demands that formal courts and attorneys general get involved. It becomes a battle fought, in the words Winston Churchill used to describe covert operations, “in the shadows, in the alleys and in the sewers.” (workersxzcompxzkit)
Such a conflict was fought in New York, in the period beginning in 1993, when anti-fraud units began to take work comp fraud seriously. For every case published, a hundred settled quickly and quietly. For every lawyer and doctor who ran into serious legal problems, dozens opted for a quick change in career goals.
Vigilance, however, must be ongoing. It is the suspicions and the evidence, first provided by employers, that makes the effort worthwhile.
Author: Attorney Theodore Ronca is a practicing lawyer from Aquebogue, NY. He is a frequent writer and speaker, and has represented employers in the areas of workers’ compensation, Social Security disability, employee disability plans, and subrogation for over 30 years. Attorney Ronca can be reached at 631-722-2100.
“FRAUD PREVENTION” PODCAST click here: http://www.workerscompkit.com/gallagher/mp3
By: Private investigator with 25 years experience.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers’ comp issues.
©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
The Federal Employees' Compensation Act (FECA) provides benefits to all federal employees of the United States Government. These civilian employees of the U.S. government include the Departments of Agriculture, Commerce, Defense, Education, Health & Human, Services, Homeland Security, HUD, Justice, Interior, Labor, State, Transportation, Treasury, Veteran's Affairs, Federal Judiciary (Court System), U.S. Postal Service, U.S. Capitol Police, Legislative Branch, TSA, NASA, Forest Service, Border Patrol, National Guard, et al.
FECA is administered by the Office of Workers' Compensation Programs (OWCP), U.S. Department of Labor, with 12 District Offices located across the United States. FECA is financed by the Employees' Compensation Fund, appropriated by Congress directly and indirectly through a chargeback system.
FECA can be found on the U.S. Department of Labor, Employment Standards Administration, Office of Workers' Compensation Programs website, http://www.dol.gov/esa/owcp_org.htm or at http://reduceyourworkerscomp.com/workers-compensation-laws-and-regulations-federal.php and by reviewing "The Federal Employee's Compensation Procedure Manual," and the 20 Code of Federal Regulations (C.F.R.) Part 700 to 799.
FECA's law provides payment of benefits, including loss wage compensation, schedule awards, medical benefits, and vocational rehabilitation services for employment-related injuries and occupational disease sustained in the performance of duty by civilian employees.
FECA also provides payment of monetary compensation to specified survivors of an employee whose death resulted in a work-related injury with payments of certain burial expenses subject to the provisions of 5 U.S.C. § 8134. FECA, however, is not a retirement system.
FECA, passed in 1916, is remedial in nature and non-adversarial. It is the sole remedy since a federal employee or surviving dependent is not entitled to sue the U.S. Federal Government or recover damages for injury or death under any other law.
There are four (4) types of claims: 1. Traumatic Injury 2. Occupational Disease/Illness 3. Recurrences 4. Death
Five (5) Conditions of Coverage must be met: 1. Time 2. Civilian Employee 3. Fact of injury 4. Performance of Duty 5. Causal Relationship
The employee is responsible for establishing the essential elements of the claim. Office of Workers' Compensation Program (OWCP) will help the employee to meet this responsibility, termed "burden of proof," by requesting evidence needed to establish these elements if such information is not included with the original submittal. This assistance does not relieve the employee of his or her burden of proof. Agencies are required by law to provide medical and factual evidence requested by OWCP to adjudicate a claim. To minimize delays in the adjudication of claims, OWCP gives the employee and agency a specific period to submit required evidence in claim.
One of the biggest challenges facing federal employers under the FECA is reemployment when medical evidence shows disability has ended. Agencies are encouraged to reemploy, regardless of how long the injured worker (IW) has received compensation. The IW is expected to return eventually to work within medical restrictions when light duty is offered, pending full recover. If residuals of the injury prohibit the IW from returning to the position held at the time of injury, and IW has received compensation for more than one year, agencies can return IW to (1) the position held at time of injury with modifications to accommodate the IW's limitations; (2) employment in another position at the same salary as the position held at time of injury; or, (3) employment in another position at a lower salary than the position held at the time of injury. If any loss of wages incur due to return to work in lower position, OWCP compensates the difference in pay.
One of the many services FECA provides is vocational rehabilitation services to assist IW in returning to gainful employment. One such service is "Assisted Reemployment." OWCP may reimburse an employer who was not the employer at the time of injury for part of the salary of the reemployed IW. This wage subsidy is intended to assist in reemploying workers who are found to be difficult to place with their former employers. It is also available to other Federal employers as well as to State and local governments and the private sector. (workersxzcompxzkit)
Federal agencies continue to partnership with local government and the private sector to accomplish this agreement within agencies and do the right thing by working together as a community to reemploy those who are not totally disabled, by Protecting Our Workers and Ensuring Reemployment.
WorkCompRoundup Blog welcomes our newest guest writer, Sue Wetherington…
Author: Sue Wetherington has served as President and CEO of GS&S and Associates, Inc., St. Augustine, Florida since September 1999. GS&S, founded in 1999, is comprised of experts with over 120 years of combined experience with all laws and regulations governing workers' compensation for federal employees and helps control escalating program costs and assist in returning injured workers to productive employment. Services include but are not limited to Workers' Compensation Program diagnostics, roll reduction, development of automated claims filing and tracking systems, and formulation of policy letters and job offers. Contact her at sue@gss-compsolutions.com; gss-compsolutions.com. Or (904) 461-5520
We accept articles about WC cost containment. Contact us at: Info@WorkersCompKit.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers' comp issues.
©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
For not obeying the laws prohibiting disability discrimination this employer ended up with these sanctions:
1. $142,500 in back pay and compensatory damages.
2. Payment to employee’s attorney.
3. A 26-month consent decree prohibiting further discrimination and retaliatory behavior.
4. Maintenance and distribution of procedures for responding to accommodation requests.
5. Anti-discrimination training for employees, managers, and the hospital’s human resources department.
6. Monitoring and reporting.
7. Posting a notice about EEOC and the lawsuit.
“This problem, like so many others, could have been avoided if this employer had simply fulfilled its legal obligation to work with the employee to find a reasonable accommodation,” said EEOC Acting Chairman Stuart Ishimaru.
Here’s What Happened
Hudson Valley Hospital Center Inc. must pay $142,500 to a former nurse to settle a disability discrimination lawsuit brought by the U.S. Equal Employment Opportunity Commission (EEOC). The EEOC’s lawsuit charged the hospital discriminated against the nurse on the basis of her disability, Type I “brittle” diabetes, after she experienced a diabetic coma for which she was treated at Hudson Valley.
The lawsuit charged the hospital failed to grant Romano a reasonable accommodation to permit her to modify her part-time work schedule as an employee health nurse so she could work three days in a row rather than alternate workdays. The nurse’s treating doctor submitted documentation stating she needed a more consistent schedule to enable her to gain better control over her diabetes.
Although the hospital initially granted the request for schedule modification, and the nurse had previously worked a similar schedule without problems, the EEOC said, the hospital withdrew the schedule accommodation, stating it unduly disrupted the hospital’s business operations. The EEOC charged that the hospital endangered the nurse’s physical health and effectively terminated her employment by refusing to accommodate her request to work the modified part-time schedule. (workersxzcompxzkit)
The EEOC said the hospital’s failure to grant a reasonable accommodation, and the employee’s resulting termination of employment, violated the Americans With Disabilities Act (ADA), prohibiting employment discrimination based on disability. The EEOC filed suit after first attempting to reach a voluntary settlement out of court.
Author Robert Elliott, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, health care, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He can be contacted at: Robert_Elliott@ReduceYourWorkersComp.com or 860-553-6604.
“FRAUD PREVENTION” PODCAST click here: http://www.workerscompkit.com/gallagher/mp3
By: Private investigator with 25 years experience.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or broker about workers’ comp issues.
©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
The Washington Department of Labor & Industries announced Nov. 30 that workers’ compensation premiums will increase by an average of 7.6% next year. Individual employers could watch their rates go up or down, depending on their recent claims history and any changes in the frequency and cost of claims in their industry.
According to Robert Malooly, assistant director for L&I’s Insurance Services Division, the agency has intensified its efforts to decrease operational costs of managing the system while protecting benefits that injured workers obtain. “We’re examining all of our costs and all of our processes to identify any potential additional savings that we can squeeze out of the system,” he said in a statement.
Over the last five years, L&I, rate changes ranged from a drop of 2% in 2007 to a 3.2% gain last year. Over the past 15 years, rates have gone up an average of 2.1% annually. Two of the biggest factors influencing next year’s rate increase are health care inflation, up 8.5%, and wage inflation, up 3.4% last year, according to the agency. (workersxzcompxzkit)
The 7.6% rate increase is an average for all Washington employers. Average premiums will rise by approximately four cents per hour worked.
“FRAUD PREVENTION” PODCAST click here: http://www.workerscompkit.com/gallagher/mp3
By: Private investigator with 25 years experience.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker about workers’ comp issues.
©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
How Would You Decide: Florida Worker’s Refusal of “Sheltered Employment” Was Not Reasonable
Here’s What Happened:
Claimant, a commercial housekeeper, suffered a compensable injury to her right (dominant) shoulder, underwent surgery, and was placed on no-work status for approximately one week. Subsequently, claimant’s authorized orthopedist returned claimant to work with significant restrictions relative and recommended three weeks of physical therapy.
The employer, as part of its return-to-work program, offered claimant a light-duty job — dusting with only the left hand. Claimant advised the employer that she would not return to work until she received the recommended physical therapy, that she was still in pain, and that she could not perform the job because it was too difficult. Thereafter the employer terminated claimant’s employment, citing claimant’s failure to show up for work or call. Claimant underwent physical therapy and eventually found other employment.
The JCC found the modified position was a legitimate offer of suitable employment made pursuant to the employer’s return-to-work program and was not “sheltered employment.” Based on these findings, the JCC denied all requested temporary partial disability benefits due to Claimant’s unjustified refusal of suitable employment. As grounds for reversal, claimant argued the one-arm duster job was “sheltered employment,” because it was light of effort and responsibility and laden with rest and comfort and thus, benefits should have been awarded.
Here’s What The Court Decided:
In Moore v. Servicemaster Commer. Servs., 2009 Fla. App. LEXIS 15556 (Oct. 14, 2009), the First District Court of Appeal of Florida disagreed with Claimant’s argument. The court first indicated it was inconsistent for Claimant to contend, on the one hand, that the job was laden with rest and comfort and, on the other, to argue that it was too difficult to perform.
The appellate court acknowledged that under appropriate circumstances, such as when an employer had created a job merely as a litigation tactic, such a job might not be considered “gainful employment” that would defeat a PTD claim. Here the situation appeared to be different, however. The court indicated that claimant’s concept of “sheltered employment” was antithetical to the intent of the legislature that the Workers’ Compensation Law should be interpreted to facilitate the worker’s return to gainful reemployment at a reasonable cost to the employer. Her sheltered employment concept was also at odds with the affirmative defense provided for in § 440.15(6), Fla. Stat.
The court stated that to the extent that a temporary offer of employment was perceived to be the result of “gamesmanship on the part of the employer,” § 440.15(6) allowed a JCC to excuse an injured worker from accepting such an offer. There was no reason, however, to resort to the common-law concept of “sheltered employment” in such situations. The court concluded that because the JCC failed to make any findings with regard to Claimant’s entitlement to TPD benefits after Claimant’s refusal of employment ceased, and before she returned to work, the decision was reversed. (workersxzcompxzkit)
On remand, the JCC should determine whether Claimant proved, based on the evidence presented, entitlement to TPD benefits in accordance with the standards set forth in section 440.15(4), Fla. Stat. (2006).
See generally Larson’s Workers’ Compensation Law, § 81.06.
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). 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
“FRAUD PREVENTION” PODCAST click here: http://www.workerscompkit.com/gallagher/mp3
By: Private investigator with 25 years experience.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker about workers’ comp issues.
©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
While gathering material to write this article I found a wealth of information about workplace injuries documented over the last two or three hundred years. I concluded that, if it were possible to find a history of the world and trace the concept of “workplace” as far back in history as possible, we might find workplace injuries were being sustained in our cave man era. The day the organizer of the hunt had one of his hunter’s shoot himself in the foot with an arrow I’m sure we could label that as a workplace injury.
But since recorded history doesn’t actually go back that far I would like to start the discussion of the ethics of workplace injuries about the turn of the 20th century. If historical documents can be believed it would appear that in America, we went from an agricultural based society to an industrial one at the end of the 1800′s and the beginning of the 1900′s.
This basic economic change magnified the workplace injury concept one thousand fold. Prior to this time workplace injuries occurred one at a time in diverse locations which made counting them statistically difficult, if not impossible. With the advent of a factory setting where hundreds of people were gathered to work together under one roof, workplace injuries became very apparent and the ethical considerations on both the employee and the employer became a critical factor.
In the dictionary I used to look up the word “ethics,” Webster has four (4) basic definitions. First, ethics, a principal of right or good behavior; Second, ethics, a system of moral principals or values; Third, ethics, the study of the general nature of morals and the specific moral choices an individual makes in relating to others; forth, ethics, the rules or standards of conduct governing the members of a profession. These four (4) definitions used singly and incorporated together give us a framework by which to judge the ethical behavior of a number of entities involved in the workplace injury scenario.
Who are these entities that must react ethically to one another? I’m sure employer and employee are two of the first to come to mind. What about the state legislatures? How about the third party administrators and adjusters? How about all of the vendors including doctors, lawyers, investigators, case managers, and vocational rehabilitation professionals?
I would proffer that every entity interacting with a workplace injury and/or the injured worker has an ethical responsibility to the process called “returning the injured worker to gainful employment.” The statement that “workers’ compensation is all about return to work” would seem to be particularly apropos when discussing workplace injury ethics.
We all are aware of the various ways cases are closed. However, the true measure of all closed files is whether or not an injured worker was returned to gainful employment. Lump sum settlements not withstanding, it would appear the entire focus of the workplace injury process is to return the employee to gainful employment with the current employer or an alternative employer, near the injured worker’s place of residence.
The workers’ compensation system in America was designed in the early 1900′s with the express purpose of codifying a standard of ethical behavior between employers and employees, specifically to address the issues of workplace injuries. The workers’ compensation system was designed to redress the quantifiable, ethical abuses perpetrated on the employee by the employer, using the judicial system. The workers’ compensation system was designed to eliminate the need for lawsuits and lawyers.
One only has to open any state statistical date base to receive first hand proof that this element of the workers’ compensation decision certainly is a failure. In many jurisdictions as high as 90% of disputed workers’ compensation claims are being handled by the legal community.
Because of the high incidence of workers ‘ compensation litigation, it would appear that in some measure either the employee or the employer feel the code of ethics surrounding the workers’ compensation laws in their jurisdictions are being compromised or violated. Is this then not the responsibility of the state legislature to define more clearly the code of ethics of both employer and employee when they design the laws that govern the workers’ compensation system?
There is a sad fact that politics runs ramped through the workers’ compensation process and the politics starts in the legislature. A review of legislative decisions, in most jurisdictions, over a long period of time will readily show that, on a cyclical basis, parochial interests are being fostered on either the employer or employee side of the workers’ compensation equation. It is extremely difficult to codify a system of ethical behavior between employer and employee when this behavior is being redefined, on a routine basis, by every State Legislature. It would be nice to blame the legislatures of the various states for all of the workers’ compensation problems however, that is certainly not the intent of this paper. The intent of this paper is to show that the ethical concerns of all participants in the workers’ compensation drama are parochial in the extreme. Use of parochial, in this context, means, “what’s in it for me.”
Having served the workers’ compensation community for the last 35 years, as an expert of both the field of investigations and re-employment, I can testify personally to the prevalence of the “what’s in it for me” attitude displayed by the various entities serving the injured worker. The following statistics gathered form the US Department of Labor, NCCI, Peridime Corporation and Compensa as well as others may shed a little light on the cost of the “what’s in it for me” ethical behavior pattern.
At the time of this writing, there are approximately 5.9 million accidents in the workplace each year for a total cost of $59.6 billion, averaging $10,105 per claim. Three point nine (3.9) million claims are med only, 1.62 million claims are loss time with less than $3,000 paid and 770,000 claims are loss time with greater than $3,000 paid of which 26,000 claims are catastrophic or chronic in nature.
What is particularly interesting in these statistics is that of the 770,000 new lost time claims per year the average cost is over $60,000. These cases represent 13% of all the claims in America today and cost us 80% of the dollars paid. That is, 80% of $59.6 billion are spent on 13% of our workplace injuries. The ethical question is does the “what’s in it for me” attitude make a critical difference in the cost and, if so, how can this be changed and not just changed but measurable change.
As stated at the outset of this discourse, if employers and employees were perceived by on another to be acting in an ethical fashion then all other concerns would be moot. The injured worker would get well as quickly as possible, the employer would accommodate the injured worker in any way possible to facilitate a return to gainful employment, injured worker and defense attorney’s would have to find another line of work because their expertise in this matter would no longer be necessary.
Physicians would focus on the earliest return to work date because that’s what everyone wanted and they could no longer prolong the injury status. Nurse case managers would work around the clock to make sure that the injured worker got the type of treatment needed, as quickly and as economically as possible. The vocational rehabilitation community would focus on return to work at the exclusion of all other aspects of their perceived job duties and the adjuster handling the file could count a case as successful only if the case resolved in an expeditious fashion. And then we would all live “happily ever after.” (workersxzcompxzkit)
The fact that workers’ compensation in America today has become an adversarial process precludes the “live happily ever after” scenario. Employees do malinger, employers do use injuries for their own purposes, physicians don’t return injured workers back to the workplace as quickly as possible and in some cases perform unnecessary procedures. Nurse case managers are not incented, in most instances, to close a case as quickly as possible and our rehabilitation professionals certainly do not focus on reemployment issues to the exclusion of every other way they are able to make money in this process.
All the aforementioned individuals and many more operate in a system that has become know as disability management and, if our statistics are correct, disability management even at it’s “what’s in it for me” worst works effectively 87% of the time. The true abuse of the disability management concept happens monetarily within the 700,000 loss time cases comprising 13% of all case and spend 80% of the workers’ compensation dollar.
Why doesn’t it work, or if it does work, why does it cost so much? What is going on inside the disability management system? Where is its focus and what are its procedures for implementation? These are not only logical questions but they are ethical questions because they focus on how professionals do their job. If it is indeed the professionals function to return the injured worker to gainful employment or to resolve an injury status as quickly as possible, and then they set up a method of payment that, in its very nature, begs for abuse then they are guilty of unethical behavior.
The new millennium must bring with it new methods of operation and new belief systems that reinforce ethical behavior between one another. I submit to you that the new millennium needs a new watchword. In 100 years, we should have grown through the concept of disability management to one with greater insight, one that offers the ability to measure individual entities’ compliance with current ethical standards. This concept is disability intervention. It is no longer possible for us just to manage a file; we now must intervene and bring it to a conclusion.
Disability intervention companies, in the new millennium, will subscribe to a new philosophy and a new code of ethics as related to workplace injuries. Disability intervention entities will place the emphasis on resolution of workplace injuries by subscribing to two basic philosophies. . . flat fee pricing and risk sharing. As we begin to review the practices of our disability management professionals over the next few months and years, society as a whole and the insurance workers’ compensation industry specifically must begin to regard entities that are willing to flat fee price guarantee and risk share with the injured worker, the worker’s representatives, the employer and their representatives as being the only viable source of workplace injury care.
In conclusion, workers’ compensation injury management ethics revolve around three concepts — time, money, and risk. Utilizing new millennium companies that can be measured on how they handle these three criteria will substantially lower workers’ compensation costs. They will also have an enormous impact on the lives of the injured worker’s and their families as they are encouraged and aided in the process of returning to gainful employment. “Workers’ compensation IS all about return to work.” (workersxzcompxzkit)
Author: Gordon R. Butler, BA, MA, CWCP is a national authority/consultant on employability & wage capacity in workers’ comp, liability, PIP and LTD Claims. He can be reached at 321-377-1164 (cell) or email gbutler@gbutlerconsult.com or www.gbutlerconsult.com
“FRAUD PREVENTION” PODCAST click here: http://www.workerscompkit.com/gallagher/mp3
By: Private investigator with 25 years experience.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers’ comp issues.
©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
Safety Program Documentation/Injury & Illness Record Keeping: Develop Written Policies, Procedures and Programs To establish consistency and creditability, and to comply with applicable federal (OSHA) and state regulations (Cal/OSHA, for example), it is important to document what you are doing. The written policies, procedures and programs should be posted for all employees to see, and can be distributed via your company's intranet. A safety manual is one method of compiling all of your safety policies, procedures and programs. To remain effective, all policies, procedures and programs should be reviewed annually. Remember to stay current on all federal and state regulations and requirements. An Accident Investigation Program is a CRITICAL tool in preventing new accidents. It is always a key part of an effective safety process. All accidents, near misses and incidents should be thoroughly investigated. The investigation should be documented and provide answers to Who, What, When, Where, Why, and How. Review all accident, near-misses and incident investigations during your safety committee meetings. Also, consider linking an electronic accident reporting form to an Accident Evaluation form so that the information automatically flows from one form to the other. Training for Employees, Supervisors and Managers – It is Essential! It is imperative, and often a regulatory requirement, that everyone in the workplace be properly trained, including contractors, part-time employees and temporary employees. Employees must know how to do their jobs safely, how to recognize hazards and how to prevent injuries and illnesses. No employee should be expected to do a job until he has been trained to do it safety and is authorized to perform it! Employees need to know: 1. The success of the safety and health program depends on everyone's actions. 2. Safe work procedures are required for every job. 3. When, and how, to use personal protective equipment (PPE). 4. What to do when an emergency occurs. Training and instruction should be provided: 1. To all employees when your program is first established, and annually, thereafter. 2. To all NEW employees, as part of their orientation. 3. To all employees given new job assignments for which they were not previously trained. 4. Whenever new substances, processes, procedures or equipment are introduced into the workplace. 5. To ALL supervisors. Safety is a message needing to be communicated continually and consistently. Some suggested communication methods include employee safety meetings (for all shifts), posters and bulletins, newsletters, safety suggestion box and "tool box" safety talks conducted informally by supervisors with their employees. (workersxzcompxzkit) Training records must be kept, and you should refer to federal and state regulations for the requirements. Training must also be bi-lingual, if appropriate, and there are a variety of resources and products available to help you with your program. All elements of your safety program should be documented, reviewed annually, and updated, if appropriate. See Safety Resources http://reduceyourworkerscomp.com/resources.php for specific regulations. "FRAUD PREVENTION" PODCAST click here: http://www.workerscompkit.com/gallagher/mp3 By: Private investigator with 25 years experience.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker about workers' comp issues. ©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
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