A final rule requiring federal contractors and subcontractors to provide notice to their employees of their rights under the National Labor Relations Act (NLRA) has been published in the Federal Register. The final rule implements Executive Order 13496, signed by the President in the beginning of 2009.
The final rule mandates all covered federal contractors and subcontractors to post a notice in their workplaces to ensure their workers are aware of their rights under the NLRA. Notices must be visible, posted in the workplace even if also distributed via e-mail, and depending on the language spoken by employees, translated notices must also be posted.
The required employee notice, released by the Department of Labor:
1. Lists employees' rights under the NLRA to form, join, and assist a union, and to bargain collectively with their employer.
2. Gives examples of unlawful employer and union conduct interfering with those rights.
3. Provides instructions to workers on how they can contact the NLRB with questions or complaints.
The Office of Labor-Management Standard (OLMS) and the Office of Federal Contract Compliance Programs (OFCCP) are responsible for administering and enforcing the rule's requirements. (workersxzcompxzkit)
Contractors violating the requirements of the regulations may be subject to sanctions, including suspension or cancellation of the contract.
\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, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact him: Robert_Elliott@ReduceYourWorkersComp.com or 860-553-6604.
FREE WC IQ Test: http://www.workerscompkit.com/intro/
WC Books: http://www.reduceyourworkerscomp.com/workers-comp-books-manuals.php
WC Calculator: http://www.reduceyourworkerscomp.com/calculator.php
TD Calculator: http://www.reduceyourworkerscomp.com/transitional-duty-cost-calculator.php
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.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
Small changes in your workers’ compensation program lead up to large cost savings. Your company’s central job is to find where to make those little changes. Find problems while you can still fix them.
Assess your current state:
- Claims are reactive so management needs to stop waiting for things to happen.
- Assess your corporate best practices.
- Assess consistency across all locations or business units.
So how do we find these TONS of little things we can do better?
A retroactive review of claims is a good place to find trends, but it’s more waiting! Consider doing an Early Satisfaction (or Dissatisfaction) Survey by calling employees 10-14 days after the injury to get feedback on their experience. You will use carefully scripted questions, and have professional interviewers. By doing an EARLY ASSESSMENT you find out problems while you can still correct the situation.
Meaning, you will be waiting until a problem costs you money in order to find it in a loss run.
So, assess practices as an organization across the whole organization. Then dig down into business units or specific workers’ comp. coordinators to find out if you are consistently following best practices.
Follow these steps:
- Audit.
- Assess.
- Educate.
Look at the following analytics:
- Data Benchmarks (can be retroactive which means more waiting).
- TPA practices.
- Operational best practices.
TPA practices are critical and they tend to lead to the topic of your role as the employer in the process. One way to find out the impact your TPA has on the overall process is to ask the employees. (workersxzcompxzkit)
To effectively assess your operation’s internal practices related to injured workers, focus support efforts in the right places:
- Give incentive for honesty.
- Get your arms around the truth.
- Get the most bang out of your efforts.
Claim/policy budget allocations and bonus structures are for incentive and punitive process. Your best practice survey must not be perceived as either. In order to get to the root of your challenges, it will be important to make this process neutral. The objective is to give your staff in the field the opportunity to identify where they need help.
\Author Rebecca Shafer, J.D. Consultant/President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact her: RShafer@ReduceYourWorkersComp.com or 860-553-6604.
FREE WC IQ Test: http://www.workerscompkit.com/intro/
WC Books: http://www.reduceyourworkerscomp.com/workers-comp-books-manuals.php
WC Calculator: http://www.reduceyourworkerscomp.com/calculator.php
TD Calculator: http://www.reduceyourworkerscomp.com/transitional-duty-cost-calculator.php
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.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
If you self-administer your own claims, you already know hiring the best workers' compensation adjuster(s) is a necessity. The challenge is in knowing what job skills and personal characteristics to look for in an adjuster beyond the normal experience and education job interview you may ask.
JOB SKILLS
If you ask an adjuster candidate if s/he knows how to handle a work comp file, you will get an obvious answer like “I handled an open inventory of approximately 125 claims at any one time during my 5 years at XYZ Company.” The answer by the adjuster candidate assumes s/he was doing the job correctly, but is that true?
Before you interview adjuster candidates, take time to create a fictional test claim customized to the statutes within your state, with a partial investigation completed. The purpose of a “test claim” is to test the candidates’ technical competence and real knowledge of file handling.
Include in the fictional test claim information:
1. the facts of the accident, with the supervisor's name and the names of witnesses
2. information on the injury (make it a burn or a fractured limb with the need for surgical repair, or other complicated injury)
3. the Employer's First Report of an Accident form for your state (with wage information but no mention of the employee's second part-time job)
4. have facts (like horseplay or intoxication) that create questions in regards to compensability
5. have facts (like sub-contractor or seasonal worker) that create questions in regards to coverage,
6. the employee treating at an unapproved medical provider
Following a review of the fictional claim by the candidate, ask the person:
1. opinion as to coverage for the claim
2. opinion as to compensability for the claim,
3. to outline the investigation steps to take (interview the employee, the supervisor, and witnesses? contact the medical provider?)
4. provide a reserve calculation sheet showing how reserves will be set for the claim,
5. show his/her calculations of the average weekly wage
6. list the state forms needing to be filed, and when
7. handle the medical treatment at the unapproved medical provider
In your review of the adjuster candidate's answers to the questions on the “test claim” determine if s/he missed any key points like coverage and compensability. Verify the investigative steps are correct, that s/he know how to properly establish the average weekly wage and to set reserves. Be sure the appropriate state forms would be filed and s/he knows and understands all state specific statutes. [If you are unsure as to the quality of the adjuster's answers your claims manager or defense attorney can review the answers].
PERSONAL CHARACTERISTICS
The personal characteristics of the workers’ comp adjuster candidate are very important. Being a workers’ comp adjuster is not easy. It takes a person with many personal characteristics beyond the job skills.
Personal characteristics include:
1. Self-stress management as the workers’ comp adjuster position can involve difficult people, deadlines, conflicting demands, pressure from both outside and inside the organization, and frequent change.
2. Reasoning to understand relationships between facts, information from various sources and to data.
3. Creative thinking as the facts and issues vary from one claim to the next.
4. Problem solving ability to analyze the facts and use proper reasoning to solve the problem when confronted with both relevant and irrelevant facts.
5. Oral communication ability to obtain information from various sources and to convey information in a clear and precise manner.
6. Written communication skills to convey information in a well organized manner
7. Interpersonal skills to deal with people who are injured, difficult, or even hostile.
8. Self-motivation to set personal goals and to take the initiative to accomplish personal objectives and company goals.
9. Honesty and integrity in all aspects of her interactions with everyone.
10. People skills including tactfulness, empathy, understanding, and concern.
11. Planning ability to set priorities, organize work, to achieve short term and long term goals.
12. Customer service skills to maintain rapport with employers and provide guidance and assistance to them.
13. Self esteem to maintain a positive image of self and the company and to display it in a professional manner.
14. Mathematical ability in establishing indemnity benefits and reserves.
15. Conscientious about the details of the work.
16. Plays well with others and encourage cooperation, commitment, and company loyalty.
If you are unsure how to measure or evaluate the personal characteristics of the adjuster job candidate, there are various personality testing services and forms available. (workersxzcompxzkit)
The list of technical job skills and personal characteristics could be extended several more pages for the selection of the best adjuster candidate for your self-administered claims program. The skills and characteristics outlined here will assist you in weeding out unqualified or inappropriate adjuster job candidates. While testing of the technical competency and personal characteristics of the adjuster candidates takes more time and expense, it is well worth the investment of your goal in hiring the best qualified adjuster.
Author Rebecca Shafer, J.D., Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact: RShafer@ReduceYourWorkersComp.com or 860-553-6604.
FREE WC IQ Test: http://www.workerscompkit.com/intro/
WC Books: http://www.reduceyourworkerscomp.com/workers-comp-books-manuals.php
WC Calculator: http://www.reduceyourworkerscomp.com/calculator.php
TD Calculator: http://www.reduceyourworkerscomp.com/transitional-duty-cost-calculator.php
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.
©2010 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 U.S. Supreme Court recently decided in a 9-0 ruling that the African-American plaintiffs in Lewis v. Chicago did not wait too long to sue the city of Chicago, and can proceed with their case. The plaintiffs are a class of African-Americans alleging the Chicago Fire Department’s use of a written entry-level exam to decide hiring pools discriminated against African-Americans. In 1995, more than 26,000 people applied for a position with the Chicago Fire Department by taking a written test.
In January 1996, the City stated applicants whose score fell into the “well-qualified” range, 89 to 100, were chosen randomly to proceed in the hiring process. Those scoring below 65 were told they failed and would not be considered at the time of hiring.
Applicants scoring between 65 and 88 were looked upon as “qualified” but were informed it was unlikely they would become employed. However, they were told their applications would remain on file in the event the “well-qualified” applicant pool was ever used up in the future hiring rounds.
In 1997, Crawford Smith and five other African-Americans whose scores were in the “qualified” range but were not selected for a possible firefighter position, filed a discrimination charge with the EEOC. The EEOC issued them right-to sue letters.
Not long after, they filed a civil action against the City, claiming that “the practice of selecting for advancement only applicants who scored 89 or above led to a disparate impact on African-Americans in violation of Title VII.” The District Court certified a class of over 6,000 African-Americans who took the 1995 exam, received a “qualified” score, and were not selected to advance in the hiring stage.
The City did not contest the fact the scoring system had a “severe disparate impact against African Americans,” but claimed it was a business necessity. The business necessity defense was rejected by the District Court.
Next, the Seventh Circuit Court reversed the decision, stating that the petitioners’ suit was filed more than 300 days after the discriminatory act — the sorting of the scores –and therefore was untimely.
The case was eventually brought to the Supreme Court who ruled in favor of the petitioners, saying their suit was brought in a timely manner. They found that “for disparate-treatment claims — which require discriminatory intent — the plaintiff must demonstrate deliberate discrimination within the limitations period. But no such demonstration is needed for claims, such as this one, that do not require discriminatory intent.” (workersxzcompxzkit)
The Supreme Court also noted that their opinion may cause problems for employers and employees when the situation is reversed, such as in Ricci v. DeStefano where the Supreme Court sided with white firefighters in a bias case.
\
\Author Rebecca Shjafer, J.D. President, Amaxx Risks Solutions , Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact her: RShafer@ReduceYourWorkersComp.com or 860-553-6604.
FREE WC IQ Test: http://www.workerscompkit.com/intro/
WC Books: http://www.reduceyourworkerscomp.com/workers-comp-books-manuals.php
WC Calculator: http://www.reduceyourworkerscomp.com/calculator.php
TD Calculator: http://www.reduceyourworkerscomp.com/transitional-duty-cost-calculator.php
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.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
Telecommuting (not to be confused with independent contractors) is a work arrangement where workers (employees) perform all or part of their jobs outside the employer’s usual place of work. Also known as telework or e-work, telecommuting relies on the use of computer and communication technology to perform work from home or other remote locations.
Telecommuting workers may be covered under workers’ compensation, according to Workers’ Compensation Board (WCB) Alberta, Canada.
When coverage is in effect, employers’ responsibilities under workers’ comp legislation (including recording and reporting accidents) apply even though the work is performed from the worker’s home or another remote location.
Telecommuting arrangements may be temporary or permanent. Temporary arrangements include carrying out a time-limited project at home. Permanent arrangements include workers who perform all or part of their duties out of their homes on a regular basis. For example a medical typist who types medical reports, a distance learning instructor working for a post-secondary institution, or an auditor employed by a public institution.
Telecommuting does not cover occasional situations when an employee brings work home on his or her own initiative, even with the employer’s knowledge (for example to complete a project in time for a deadline).
Workers Comp Issues Arising Out of Telecommuting
Recording and Reporting
Because injuries or illnesses arising from telecommuting may be work-related, employers are required to record and report these injuries and illnesses.
The Workspace
When an employer authorizes telecommuting, as a general rule, coverage is confined to the defined workspace unless the worker is engaged in an activity directly related to the telecommuting work.
For example, injuries occurring in a basement bedroom specifically designated as a work office may be covered. There may also be circumstances when injuries occurring outside the designated area are covered. The following section lists the key factors WCB-Alberta considers in determining entitlement.
Entitlement
Taking into consideration the individual circumstances of each claim, WCB-Alberta looks at the following factors, and possibly others, to determine whether a telecommuting injury is work-related and therefore covered:
1. Was the activity on work time?
2. Was the activity for the employer’s benefit?
3. Was the worker paid for the time?
4. Was the worker in that time and place due to employment reasons?
5. Was the work arrangement authorized by the employer?
6. Did the injury occur in the course of using equipment or materials supplied by the employer?
Travel
Travel at the direction of the employer is covered. This includes situations when a telecommuting worker travels from his or her home to the employer’s office or another site to attend a work-related meeting. It may also include travel to pick up supplies for the worker’s home office being used in the performance of his or her work duties.
Employers need to exercise caution when authorizing telecommuting. Even though some hazards in a telecommuting arrangement may not be under their control, employers still have a legal obligation under occupational health and safety legislation to provide a safe and healthy workplace. (workersxzcompxzkit)
A written policy or agreement clarifies the arrangement for the worker and employer, as well as helping WCB-Alberta in the adjudication of claims arising from telecommuting.
\Author Rebecca Shafer, Consultant, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact at: RShafer@ReduceYourWorkersComp.com or 860-553-6604.
FREE WC IQ Test: http://www.workerscompkit.com/intro/
WC Books: http://www.reduceyourworkerscomp.com/workers-comp-books-manuals.php
WC Calculator: http://www.reduceyourworkerscomp.com/calculator.php
TD Calculator: http://www.reduceyourworkerscomp.com/transitional-duty-cost-calculator.php
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.
©2010 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 It Got Started
In 1999, the manager of the casualty claims supervisory office of a large national third-party administrator (TPA) was dismayed at the poor quality of claim file handling in the field branches. In 1995 the same manager was a part of the team who established the Best Practices for the TPA to use nationally. While the Best Practices were provided to the branch offices, most of the branches were still doing it their own way.
The manager made a recommendation to senior management in the Home Office for an on-site file inspection at some of the worst performing offices. The idea was simple, identify and correct the claim handling errors before the clients saw them. The recommendation was declined. The senior management attempted to correct the branch offices quality problems by sending memos out to the branches to do better.
By early 2000 several large self-insureds, Fortune 500 companies, complained to the TPA's senior management about the poor quality claim service and threatened to take their claims elsewhere. Several of the Fortune 500 companies plus two major insurance companies hired independent claim auditors or sent their own staff auditors, who all confirmed the poor quality of claim handling.
After a multi-million dollar account walked out the door, senior management sent more memos to the branches marked “urgent.” After a second Fortune 500 company left, the Senior Vice President of Claims finally realized memos, no matter how urgent, were not going to correct the problems. The Senior VP contacted the manager who had the idea of doing internal file inspections to identify the problems in the field. The manager was promoted to Quality Assurance Manager and given the responsibility of performing internal file audits.
How To Do Internal File Audits
The new Quality Assurance Manager spent a week in each of the three offices expected to have the worst file quality. The initial report on each office reflected coverage was not being verified, initial contacts were not being made, file investigations were incomplete or even nonexistent, and claim settlements were usually initiated by the claimants.
While the already known poor quality was confirmed, a way of quantifying the results was needed.
Using samples from the external auditors audit sheets, the Quality Assurance Manager created his own audit sheet.
Using the Best Practices created five years earlier, an audit score sheet was designed to reflect whether or not the Best Practices were being used for coverage verification, initial contacts, investigation, data accuracy, indexing, settlement evaluation, etc. A number of points were given to each category with the total points for all categories equaling 100 points or 100 percent. A computer program was created to compile the scores from each claim file audit sheet into an overall score in each category, and an overall score for the entire audit.
The First Internal File Audits
The Quality Assurance Manager quickly realized one auditor was not going to be enough to audit all the branch offices on an annual basis. The Quality Assurance Department quickly grew from the one Quality Assurance Manager in 2000 to six auditors in early 2001.
The auditors, individually and as teams, performed claim quality audits on each of the branches. As the word got around that the Home Office was now serious about improving file quality, some of the branch managers started working with their claim staffs to improve claim-handling quality. Some of the branch managers continued to ignore claim-handling quality.
Each audit gave a percentage score and the score was given to the branch, the regional claims management and to the senior staff. After the first round of branch audits, there were a few branches scoring in the 95+ percentile, and there were several branches scoring in the 50+ percentiles. A score in the 50+ percentile reflects only about half of the work that should have been done on the claim files was actually done.
Who Needs Quality?
Due to the poor quality of claim file handling by the branch offices, by 2001 national and regional accounts were abandoning theTPA almost every day. Revenue for the corporation was declining rapidly and the stock market price for the corporation declined even faster.
With clients leaving due to the poor quality service, the number of new claim files coming in also sharply declined. Instead of working to improve the file quality on the new claims being received, the company took a different approach. In a very short-sighted effort to improve the financial bottom line, the TPA started laying off staff. In April, May and June, 2001, over 250 employees including branch managers, adjusters and clerical were terminated.
The Quality Assurance Manager and the entire Quality Assurance Department was terminated.
Turmoil Sets In
One of the large offices for the TPA promoted a woman from financial clerk, where she issued clients checks in payment of medical bills and claim settlements, to the position of adjuster trainee. The manager left the new adjuster trainee with the ability to continue to issues checks so she could be a back-up to the new financial clerk.
An adjuster able to request the issuance of a check and issue the check was a clear breach of the TPA's check handling guidelines. Sure enough, the new adjuster was soon issuing client's checks to her family and friends. It did not take long before a national account noticed the unauthorized payment of a phony claim.
The Quality Assurance Manager who was terminated on a Friday in June, 2001 received a call from his former employer's Legal Department, the following Tuesday. The Legal Department hired the former QA Manager as an outside consultant to audit the office of the adjuster issuing the unauthorized checks. Two months and two thousand files later, the TPA was able to identify all unauthorized payments made by the former adjuster and reimburse the clients' accounts. This incident reinforced the need within the TPA for an internal file auditing system.
The Second Round of Internal File Audits
The former QA Manager worked as a consultant for his former employer until January of 2002 when the TPA realized they still needed to deal with the issue of poor claim file quality. He was then rehired and the internal auditing of the branch files was reestablished.
The internal file audits of 2002 reflected the same poor quality of claim handling as the internal audits of 2000 and 2001. The same adjusters (those surviving the mass layoff) producing poor quality in 2000/2001 were still producing poor quality in 2002. The same offices that were poor performers in 2000/2001 were still poor performers in 2002.
The Toothless Tiger
From the audits done in 2002 it became clear to the auditors that just doing an annual file quality audit was not going to change the behavior of poor performing adjusters and poor performing branches. It was now up to the senior management of the TPA to take actions as internal file audits without consequences were not changing the behavior of the poor performers — the file quality was still poor. The TPA's internal file audits had become “a toothless tiger”. . . a lot of roar but no bite.
The Tiger Gets Teeth
In 2004, the TPA's senior management questioned the need to continue to do the internal audits if nothing was improving. The Quality Assurance Department convinced senior management to incorporate the internal file audit scores into the performance evaluations of the branch managers, branch supervisors and adjusters. This entailed an expansion of the number of internal auditors, but every branch and every adjuster was now being audited and graded on their work product by the Quality Assurance Department.
As soon as the quality of the work product was the largest part of the performance evaluations and tied to pay raises (and bonuses earned by management), the quality of the claim handling started improving. The improvements in quality were so dramatic that in 2005 only two branch offices out of over 300 offices had a performance grade under 80%. (workersxzcompxzkit)
Summary
The quest for superior quality continues at the TPAs of the world. The internal file audit process is firmly established. While the internal file audit process is not a cure-all for all the problems facing any large claim organization, it has made a tremendous difference in the claim handling file quality at the TPA discussed above.
Author Rebecca Shafer, J.D., 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. She can be contacted at:
RShafer@ReduceYourWorkersComp.com or 860-553-6604.
A chiropractor, a medical doctor and a billing employee at a clinic owned by a chiropractor in Illinois were indicted on federal healthcare fraud charges, federal law enforcement officials announced.
The defendants allegedly illegally submitted false claims totaling more than $1 million to obtain payments from workers’ compensation and other insurers for services not provided and for inflated claims for provided services. The physician signed false documents and the chiropractor forged doctors’ signatures on documents supporting the false claims, according to an 18-count indictment returned by a federal grand jury.
Most of the patients of the clinic, the Spine and Joint Rehabilitation Center, were United States Postal Service employees who were eligible for benefits from the United States Labor Department’s Office of Workers’ Compensation Program.
Scott Caspall, special agent-in-charge of the Great Lakes Field Office of the U.S. Postal Service Office of Inspector General, noted, "Workers’ Compensation is a valuable healthcare program that provides a safety net to hardworking people injured on the job. This investigation is an effort to dismantle a group of medical providers and billers who the indictment alleges were abusing that program. In an age when individuals, businesses and the federal government are paying more for healthcare, this case is a prime example of the excellent results that come from combining the forces of federal law enforcement agencies."
According to the indictment, the defendants and others intentionally created and submitted false claims and information to the federal Workers’ Comp office and other health care insurers to obtain payment for the clinic and for patients. The false claims and information related to patients’ work-related injuries, including medical, diagnostic, and physical therapy services not provided or they inflated provided services.
As part of the scheme, the defendant allegedly forged and caused others to forge physicians’ signatures on various documents falsely representing services, treatment, physical therapy and/or testing were provided, ordered or supervised by medical doctors.
The defendant allegedly forged the doctors’ signatures, and caused them to sign reports without doing patient exams, knowing that Workers’ Comp would not accept a chiropractor’s opinions or reports as medical evidence to support patients’ claims.
Under the Federal Employees’ Compensation Act, chiropractors are not qualified physicians and their opinions did not constitute medical evidence except in very limited cases involving specific spine problems.
The defendant also falsely told patients he was qualified to prepare impairment rating reports and to order and provide testing and treatment. He failed to disclose that Workers’ Comp would not pay for services provided by a chiropractor except in very limited circumstances. The other defendant, et al allegedly signed false documents making it appear the physician or another licensed physician had examined or treated patients.
The two defendants and others allegedly prepared false progress notes and fee sheets showing patient services were rendered when, in fact, they were not. One defendant allegedly forged physicians’ signatures on claim forms certifying they were accurate, even though he knew many were false, including whether the services were provided and by whom.
He also prepared false itemized billing statements in personal injury cases to support payments to the clinic and patients. In addition, the two double-billed Workers’ Comp for disability exams the physician performed for which he received payment from every patient pay, so the clinic was paid twice for the same service, the indictment alleges. (workersxzcompxzkit)
Each count of health care fraud carries a maximum penalty of 10 years in prison and a $250,000 fine. If convicted, however, the Court would determine a reasonable sentence to impose under the United States Sentencing Guidelines advisory.
\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, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact him: Robert_Elliott@ReduceYourWorkersComp.com or 860-553-6604.
FREE WC IQ Test: http://www.workerscompkit.com/intro/
WC Books: http://www.reduceyourworkerscomp.com/workers-comp-books-manuals.php
WC Calculator: http://www.reduceyourworkerscomp.com/calculator.php
TD Calculator: http://www.reduceyourworkerscomp.com/transitional-duty-cost-calculator.php
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.
©2010 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 term “settlement authority” is often heard in discussions about the resolution of workers' compensation claims. Settlement authority is often thought of in dollar amounts as in “the adjuster has a $10,000 settlement authority.” I learned the term after the insurance company settled a claim out from under me! I learned the hard way — after it was too late (on that claim.)
Settlement authority is, in reality, the control of financial decision-making allowed to a lower level in the claims management hierarchy by a higher level in the hierarchy.
Settlement authority can be granted for all claims as a group and/or settlement authority can be extended for a single claim.
For example: the workers’ comp adjuster with $10,000 settlement authority is allowed make a decision as to the dollar amount to settle any claim an employee is willing to settle, as long as the cost to settle the claim does not exceed $10,000.
If the adjuster has a claim with a settlement value of $20,000, the adjuster reviews the claim with the workers’ comp claims supervisor and if the supervisor agrees on the value of the claim, the supervisor would grant settlement authority of $20,000 on that single claim.
It should be noted settlement authority is the maximum amount an adjuster is allowed to spend to resolve a workers’ comp claim. It is always understood, whenever possible, claims settle for the least amount.
Settlement authority ultimately lies with the insurance company, as they are the ones taking the risk, up to their level of retention. If the workers' compensation insurance company has a reinsurer, the ultimate settlement authority rests with the reinsurer on claims over and above the retention level of the primary carrier.
Multiple levels of settlement authority exist within every claim management hierarchy. The purpose of the multiple layers is to maintain control over the cost of claims. It is based on the assumption that the higher the person is within the corporate hierarchy, the better the decision-making skills.
The granting of settlement authority within an insurance company and the granting of settlement authority to a third party administrator (TPA) differs in some facets. Within an insurance company, settlement authority level generally follows the corporate hierarchy level. Within a TPA, the settlement authority process depends upon the relationship between the insurer (or self-insured) and the TPA.
How settlement authority might work within an insurance company.
The vice president of claims for an insurance company has settlement authority granted by the president of the insurance company to settle claims for any amount up to the maximum level of insurance coverage.
The vice president of claims grants the regional managers for the company settlement authority up to $250,000 with any claim greater than $250,000 being approved by the vice president of claims.
The regional managers grant the claim managers of each claims office settlement authority up to $100,000 with any claim greater than $100,000 being approved by the regional manager.
The claim manager grants settlement authority to the claim supervisor to settle any claim up to $25,000 with any claim greater than $25,000 being by the claim manager.
The claim supervisor grants the workers’ comp adjuster settlement authority up to $10,000 with any claim greater than $10,000 being approved by the claim supervisor.
(Note: These dollar levels are used for illustration purposes only. The settlement authority dollar levels will be determined by each insurance company as they see fit).
Settlement authority and the TPA.
Before settlement authority is granted to a TPA, the insurance company first establishes a comfort level with the financial decision-making ability of the TPA. If the insurance company has worked with the TPA previously and has a good feel for the claims decision making of the TPA, the insurance company is then willing to grant a higher settlement authority amount to the TPA than it would with a TPA it has not business with before.
When an insurance company is determining the level of settlement authority to grant to a TPA, it basically determining how much control over its claims that it is willing to relinquish to the TPA. The lower the amount of settlement authority granted to the TPA, the higher level of control over settlements the insurance company will have. If the insurance company does not trust the TPA's financial decision-making, they can exercise more control by lowering the settlement authority amount. Of course, with the higher control level comes a higher level of involvement in the claims by the insurance company.
With a new TPA the insurance company might extend $50,000 settlement authority to the TPA. The TPA then is free to handle and resolve any claim reporting to them evaluated by the TPA as worth $50,000 or less. When a workers’ comp claim exceeds $50,000, the insurance company requires regular reporting from the TPA. The insurance company reviews the details of the claim, and if satisfied with the way the claim is being handled, grants the TPA settlement authority up to a specific dollar for the single claim in question.
After being granted settlement authority by the insurance company, the TPA handles the claim the same way the insurance company handles a claim. The TPA grants the claim office manager $50,000 settlement authority, the supervisor would be granted $25,000 settlement authority, and the adjuster $10,000 settlement authority.
Settlement authority can be extended from the insurer or TPA to a representative, the defense attorney for claim resolution. In the jurisdictions mandating mediation or arbitration of workers’ comp cases before they can be adjudicated by the workers’ comp board or the courts, it is often required defense counsel be extended settlement authority. The workers’ comp adjuster and the defense attorney discuss what they think the workers’ comp claim is worth. The adjuster then requests the settlement authority with the request going upward through the claim management hierarchy until it reaches the level of approval and authority is granted for settlement of the individual claim. Then the settlement authority is granted to the defense attorney. (workersxzcompxzkit)
Settlement authority levels allow the management of an insurance company to retain some control over how their money is spent. The level of control drops as the dollar value of claims drops. This provides the insurance company with significant control over the large claims likely to have a bigger impact on the company's financial soundness.
Author Rebecca Shafer, J.D., 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. She can be contacted at: RShafer@ReduceYourWorkersComp.com or 860-553-6604.
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
AXIOM: The sooner an employee returns to work from a workers' compensation injury, the lower the overall cost of the workers’ comp claim will be.
Numerous documented studies show there is a definite correlation between time off work due to a work related injury and the employee's chances of continuing employment with your company.
Per U.S. Bureau of Labor Statistics
An employee who has been off work for 6 months has a 50% chance of ever returning to work.
An employee who been off work for a year has a 25% chance of returning to work.
Employees off work for more than 2 years rarely ever return to work.
However, employees who return to work in less than 7 days have almost a 100% chance of continuing their employment.
A well-managed modified duty return-to-work program can have a sizable impact on the cost of your workers' compensation program. These short-term programs expedite the employee's return to work by facilitating limited duty or modified duty for employees with a temporary condition preventing them from performing their regular duties.
A common myth is: Employees are reluctant to return to work on modified duty. While this may be true in a few cases, much more often it is the employer who is the reluctant one when it comes to having a modified duty program.
Supervisors who are not educated about the benefits of a return-to-work program or the true cost of workers' compensation often see modified duty as an inconvenience to themselves. Also, supervisors and managers often have a conflict between their productivity goals and the return-to-work program. If their own performance evaluation or year-end bonus is tied to their production goal, they (often subconsciously) place their own well being ahead of what is best for the company — the employee's return to work on modified duty.
What is an Off-Site Return-to-Work Program?
The solution for the employee, the employee, and the supervisor is the off-site return-to-work program. An aggressive off-site return-to-work program provides temporary job placements at a non-profit organization when the employee's medical restrictions cannot be accommodated by the employer. With an off-site return-to-work program, the supervisor or manager no longer has the conflict between the productivity goals and the return-to-work program, nor do they see an off-site return-to-work program as an inconvenience to themselves.
Some employers place employees in charity jobs, others use jobs at another job and still others use "cross-divisional" placements. National Job Finders at www.NationalJobFinders.com and Soar Research www.SoarResearch.com both place employees in alternate jobs at employers with realistic alternative jobs. Their call centers makes phone calls looking for openings at local employers. They first learn the employees medical restrictions then make phone calls to locate matching jobs. They then monitor the job seeking efforts. If the employees intentionally "blow" the job interview, the callers document these issues and eventually the false job seeking attempts may be used to discontinue the claims in some states.
An example of an off-site return to work program
A third party administrator who was handling the workers’ comp claims for both a national trucking company and nationwide charity arranged for truck drivers to return to work on modified duty at the charity's thrift stores. The truck drivers, often with musculoskeletal injuries, often had weight lifting, standing, and sitting restrictions. The truck drivers instead of reporting to their truck terminal for modified duty would be given off-site work at the charity's thrift stores. The truck drivers sorted donated clothing. They were allowed to sort clothes seated at a table, or stand or walk, as they needed, to accommodate their restrictions from their medical provider. (workersxzcompxzkit)
When an employee is unable to return to work full time for the employer and the employer is unable to provide appropriate modified duty work, the off-site return to work program becomes an attractive option to the employee. An off-site return-to-work program provides several benefits to the employee that the employee would not get if forced to stay home from work.
Author Rebecca Shafer, J.D. Consultant, President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. She can be contacted at: RShafer@ ReduceYourWorkersComp.com or 860-553-6604.
Podcast: KNOW the New OSHA Recordkeeping Rules — OR Risk Fines and Criminal Penalties. Click Here: http://www.workerscompkit.com/gallagher/podcast/Non_Compliance_with_Recordkeeping_Standards/
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
Work-related stress is one of the biggest health and safety challenges individuals and companies face in Europe according to the European Agency for Safety and Health at Work. (Section 1.01).
Nearly one in four workers is affected by stress and studies suggest between 50% and 60% of all lost working days are stress related, representing a huge cost in terms of both human distress and impaired economic performance.
Stress at work can affect anyone at any level. It can happen in any sector and in any size of organization. Stress affects the health and safety of individuals, but also the health of organizations and national economies.
Stress is the second most reported work-related health problem, affecting 22% of workers from EU 27 (in 2005). And the number of people suffering from stress-related conditions caused or made worse by work is likely to increase.
The changing world of work is making increased demands on workers, through downsizing and outsourcing, the greater need for flexibility in terms of function and skills, increasing use of temporary contracts, increased job insecurity and work intensification (with higher workload and more pressure), and poor work-life balance.
Stress compromises workplace safety, and contributes to other work-related health problems, such as musculoskeletal disorders. And stress significantly affects an organization’s bottom line. In addition, workplace stress carries over into stress at home, which, in turn, carries over into the workplace, setting up a vicious cycle.
Reducing work-related stress and psychosocial risks is not only a moral, but also legal imperative. There’s a strong business case as well. In 2002, the annual economic cost of work-related stress in the EU-15 was estimated at 20 billion Euros. (That’s almost 29 billion in U.S. dollars.) (workersxzcompxzkit)
The good news is that work-related stress can be dealt with in the same logical and systematic way as other health and safety issues. There is a wealth of practical examples of dealing with it across the EU. With the right approach, workers can be kept safe from stress.
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, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He can be contacted at: Robert_Elliott@ ReduceYourWorkersComp.com or 860-553-6604.
Podcast: KNOW the New OSHA Recordkeeping Rules — OR Risk Fines and Criminal Penalties. Click Here: http://www.workerscompkit.com/gallagher/podcast/Non_Compliance_with_Recordkeeping_Standards/
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
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