Nova Scotia Canada Leading the Pack in Workplaces Becoming Safer

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Posted in Canada Workers Comp, Safety and Loss Control, WC in Other Countries (International), Wellness Programs and WC |

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Canadian Government Helping Disabled with Job Preparation

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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.

Posted in Canada Workers Comp, Communication with Employees, Employment Law Issues |

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New York Employer Floored with Workers Comp Fraud Charge

New York Employer Floored with Workers’ Comp Fraud Charge

The 28-year-old owner of a Bayshore, New York flooring company faces a charge of workers’ compensation fraud for allegedly cheating the New York State Insurance Fund out of $33,000 in unpaid premium.

The Suffolk County District Attorney’s Insurance Crime Bureau arrested the man recently, charging him with fraudulent practices in violation of Section 114 of the New York State Workers’ Compensation Law, a felony.

The man’s arrest followed a joint investigation by Suffolk County DA Thomas Spota’s Office, the New York State Insurance Department Frauds Bureau and NYSIF’s Division of Confidential Investigations.

Investigators said the man, owner of North Star Flooring in Bayshore, N.Y., carried workers’ comp insurance for his company with NYSIF, but allegedly underreported his payroll to lower his premium.

According to investigators, the defendant allegedly failed to report approximately $700,000 in sales from 2008 to 2009, resulting in a lower cost for workers’ comp insurance during that period. (workersxzcompxzkit)

By allegedly falsifying his payroll reporting, the man underpaid his NYSIF premium by $33,000, investigators said.

WC Calculator:   http://www.reduceyourworkerscomp.com/calculator.php

Posted in Fraud and Abuse, NY Workers Comp Issues |

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Tips When Considering a Performance Guarantee with your TPA

If your Third Party Administrator (TPA) is not living up to the promises made when you signed up with them to handle your workers' compensation claims, or if the quality of service is less than you expected, you need to incorporate a performance guarantee into your service contract.  A performance guarantee goes back to the old adage “What gets measured gets done.”  By implementing a performance guarantee with your vendors, the vendors have a better understanding of how they will be evaluated and they have a bigger stake in the quality of service provided.

 In a performance guarantee, the TPA guarantees they will meet pre-determined levels of performance in their claims handling and claims administration.  If the TPA exceeds the guaranteed performance level, they receive a bonus payment over and above their contractual service fee amount.  On the other hand, if the TPA fails to meet the guaranteed performance level, they will incur a penalty reduction in their contractual amount. 

The performance level is stated as a percentage of a measurable activity and the bonus or penalty must be stated in the same format with an explanation of how it will be measured.   For example “The TPA will meet or exceed the servicing standards 90% of the time.”  “The TPA will be paid 1% of the contractual amount for each percentage point the TPA exceeds 90% and the contractual amount will be reduced by 1% for each percentage point the TPA falls short of the 90% goal.”   “The performance will be measured by an annual claim file audit of the established goals.”

Performance guarantees with TPAs have been shown to improve service quality, reduce administrative and data errors, and reduce workers compensation claim cost through higher quality claims handling.  When the difference between the TPA making a profit, a bigger profit, or suffering a loss is the quality of service provided, it is in the best interest of the TPA to strive to provide the best service/quality possible.   

To properly construct a performance guarantee, you need to determine the criteria that will be used to measure performance of the vendor.  With a TPA, a common criterion is compliance with the Best Practices in their claim handling service standards.  The broad categories often used are:

1.         Investigations

2.         Reporting & compliance with the client instructions

3.         Reserving

4.         Medical Management

5.         Litigation Management

Each of these categories will have sub-categories that should be listed in the performance guarantee.

The weakness in performance guarantees comes when they are understood differently by the self-insured and the TPA.   For instance the performance guarantee would include timely three-point contact with the employer, employee, and medical provider as part of the criteria for Investigations.   If the adjuster thinks three-point contact within 24 hours means sending out a form letter to the employer and employee the first day of an assignment, while the risk manager expects voice-to- voice contact with information exchanged between the adjuster and each party, the differences in interpretation will lead to disagreement between the TPA and the self-insured company. 

For a performance guarantee to work, the criteria that will be measured has to be spelled out in detail.  Instead of stating the TPA will complete three-point contact, the performance guaranteed should state, “The TPA will contact the employer, the employee and the medical provider by telephone, or in person on severe claims, and obtain all available information from each party within 24 hours of the claim being transmitted to the claims office.”   Note the time measurement starts from the time the claim is assigned to the claims office, not from the time the claim lands on the adjuster's desk.  This prevents the adjuster from making the excuse “the claim was held up by the clerical staff.”

With a new TPA, Best Practices should be used as the standard by which the TPA will be measured.  If the self-insured has been using a TPA for a period of time and is satisfied with the quality of the TPA's performance in some areas but not satisfied in other areas, the performance guarantee can be customized to address those areas needing improvement.  By benchmarking the areas of unsatisfactory performance, the TPA and the self-insured can work together to improve the areas of poor performance.  A claims audit would be used to measure the results.

As the performance guarantee can have a substantial impact on the profitability of the TPA handling the claims, it is essential to have an unbiased and unrelated claims auditor to measure the quality of the claim files.  Neither the TPA, nor the broker, nor the self-insured should be the claims auditor as they each have a built-in conflict of interest in the outcome of the audit.  For the claims audit to be accurate, it should be contracted to an out-side claims auditor mutually agreed upon by both the TPA and the self-insured.  (workersxzcompxzkit)

If you need assistance in designing a performance guarantee for your new TPA contract, or assistance in creating a performance guarantee to address specific problems with your current TPA, our experienced consultants will be glad to assist you. If you already have a performance guarantee in place, we will be glad to arrange for a highly experience claims consultant to perform the claims audit for you.  Please feel contact us with all your performance guarantee questions.

Author R. Shafer, J.D. 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/   

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Posted in TPA and Claims Administration |

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Things to Know About Texas Workers Compensation: How it is Unique

When it comes to workers' compensation, Texas is unique in several ways.  The following is a basic primer for people outside of Texas who may be involved in a Texas workers' compensation claim. 

Texas has four types of work comp benefits.  They are: 

1.       Income benefits – replaces a portion of the wages an employee loses because of a work-related injury or illness

2.       Medical benefits – pays for the necessary medical care due to a work-related injury or illness

3.       Burial benefits – pays some of the cost of employee's funeral to the person who paid the funeral expenses

4.       Death benefits – replaces a portion of lost family income for family members of employees who die as a result of a work-related injury or illness

The average weekly wage (AWW) in Texas is calculated based on the 13 weeks prior to the date of injury for full time workers (30 hours or more per week).   If the employer does not continue to pay for health insurance while the employee is off work due to a work comp injury or illness, the cost of health insurance is also added to the wages.  If the employee has multiple jobs, the income reportable for federal tax purposes at the second job is added to calculations to determine the AWW.  (School district employees have their own separate calculation system for AWW, which is not included here.)  The Division of Workers' Compensation establishes each year a cap or maximum amount that can be paid per week.  The minimum amount that can be paid for an AWW is 15% of the maximum amount.

INCOME BENEFITS

While Texas has Income Benefits, the indemnity benefits do not use the same names as income benefits in other states.  The Income Benefits in Texas are designated as follows:

1.    Temporary Income Benefits (TIBs) – TIBs are calculated  by multiplying the AWW by 70 percent.  The maximum TIBs that can currently be paid is $539.00 per week, but it changes each year.   The employee is paid TIBs if the employee is off work for more than 7 days due to a work-related injury or illness.  Benefits start on the eighth day off work.  If the employee is off work more than 14 days, TIBs are retroactive back to the first day missed from work.  TIBs end on the date the employee is physically able to earn the same wages he was earning before the injury, OR, on the date the medical provider determines the employee has reached maximum medical improvement (MMI), OR, at the end of 104 weeks (which makes Texas among just a few jurisdictions which place a two year time limit on temporary benefits).

2.    Impairment Income Benefits (IIBs – pronounced “ibs”) –  IIBs are paid when the employee suffers a permanent impairment from a work-related injury or illness.  IIBs start the day after an employee has reached MMI.  If the employee has not reached MMI before 104 weeks after the date of work-related injury or illness begin, the Texas law states the employee is declared at MMI and can start receiving IIBs for his injury.  A doctor certified by the Texas Division of Workers' Compensation is required to examine the employee and access an impairment rating to the body as a whole.  For each one percent of disability, the employee is paid 3 weeks of benefits at 70 percent of his average weekly wage, not to exceed $377.00 per week.  For example, if the employee is given a ten percent impairment rating, the employee will receive 30 weeks of IIBs (10 x 3 weeks for each one percent).

3.    Supplemental Income Benefits (SIBs) – SIBs have to be approved by the Division of Workers' Compensation for the first quarter year (3 months) they are paid.  SIBS are income benefits paid monthly to employees who meet the entitlement requirements of:

·      has an impairment rating of 15% or higher,

·      has not returned to work because of the impairment, or has returned to work at a reduced wage and is earning less than 80% of the AWW at the time of the injury,

·      has made a good faith effort to find job that can matches his ability to work, and

·      did not take his IIBs in a lump sum payment.

SIBs have their own unique way of being calculated.  The employee is paid 80% of the difference between 80% of the AWW (earned prior to the injury) and the AWW earned after the work related injury.  [Why they don't just say 64% of the difference between your old wage and what you make now, I don't know].  Each month the employee will receive one check for 4.34821 weeks of the SIBs.  The employee has to apply for SIBs every three months and provide proof that he has:

·      has looked for work each week of the prior three months,

·      has current medical documentation that his work-related injury or illness keeps him from working at the level he was prior to the injury, and

·      has provided full cooperation with the Texas Department of Assistive & Rehabilitative Services, or a private provider of vocational assistance.

After the first three months, the SIBs application is sent each quarter to the insurer or self-insured by the employee, confirming to the insurer or self-insured that the employee has looked for work, is unable to work or has not found work that matches his disabilities, and is pursuing vocational rehabilitation.  The SIBs can continue for 401weeks.

4.    Lifetime Income Benefits (LIBs) – There are some specific work-related injuries that entitle an employee to LIBs.  They are:

·  Loss of both feet at or above the ankle

·  Loss of both hands at or above the wrist

·  Loss of one foot at or above the ankle and loss of one hand at or above the wrist

·  Total and permanent loss of sight in both eyes

·      A spinal injury that results in permanent and complete paralysis of both arms, or both legs, or one arm and one leg

·  A traumatic brain injury that results in incurable insanity or imbecility

·  Third degree burns over at least 40% of the body that require skin grafting

·  Third degree burns covering the majority of both hands or one hand and the face.

    LIBs are paid at 75% of the AWW but cannot exceed the TIBs rate, currently $539.00 per week.  LIBs begin when the medical provider certifies to the Division of Workers' Compensation that one of these eight conditions have been meet and will continue until the end of the employee's life.

MEDICAL BENEFITS

Medical Benefits in Texas are the same as in other jurisdictions.  The necessary cost of medical care is paid by the insurer or self-insured to the medical provider.  It covers only the work-related injury or illness and does not pay for any non-work related medical care, even if it provided at the same time as the medical care for the injury.

The employee selects the choice of doctors in Texas if the employer is not a member of a certified workers' compensation health care network.  If the employer is a member of a certified network, the employee must obtain his medical care through medical providers within the network, if the employee lives in the area covered by the certified network.  If the employee is not employed by an employer who has joined a certified network, the employee selects his own physician but it cannot be a physician who has not been admitted to, or who has been removed from, the Division of Workers' Compensation Approved Doctor list.  Once an employee has selected a medical provider, either in a network or approved by the Division, the employee cannot change medical provider without approval from the Division of Workers' Compensation. 

DEATH BENEFITS

Death Benefits are paid to the surviving spouse, minor children, dependent grandchildren or other dependents of the deceased employee.  If there are no dependents of a deceased employee, the death benefits are paid to the deceased non-dependent parents or siblings.  The death benefit is 75% of the deceased employee's average weekly wage, but cannot exceed the state weekly wage maximum.

The death benefits start the day after the employee dies.  A surviving spouse will receive death benefits for the remainder of the spouse's life unless the spouse remarries. If the deceased employee has both a surviving spouse and dependent children, the surviving spouse gets one-half of the death benefit and the second half of the death benefit is divided among the dependent children.  Children remain eligible for the death benefit until they are 18 years old, or until age 25 if they are enrolled full time at an accredited educational institution. Children with physical or mental disabilities remain eligible for death benefits until they die or no longer have the disability.

Other family members who are dependent upon the deceased employee such as siblings, parents and grandparents can collect death benefits if there are no eligible spouse, children or grandchildren.  These family members can collect death benefits for 364 weeks.   If there are no dependents of the deceased employee, the non-dependent parents of the employee can collect death benefits for 104 weeks.  If there are no eligible beneficiaries for death benefits, or if the eligibility of the beneficiaries ends in less than 364 weeks, the remaining death benefits are paid to the Subsequent Injury Fund. (workersxzcompxzkit)

While Texas workers compensation has it oddities, it can be understood by the non-Texan with a little effort. 

Author R. Shafer, 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. She can be contacted at: RShafer@ReduceYourWorkersComp.com or 860-553-6604.

Free Podcast: KNOW the new OSHA recordkeeping rules – or risk fines and criminal penalties.
Click Here: http://208.106.129.109/gallagher/podcast/Non_Compliance_with_Recordkeeping_Standards/
 

Posted in Buying Workmans Comp |

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Wisconsin Physicians Using More Generics Than Most States Lower Costs

The cost per claim of prescription drugs used to treat injured workers in Wisconsin was significantly lower than in most study states, according to a new report by the Workers’ Compensation Research Institute (WCRI).

The 16-state study by the Cambridge, MA-based WCRI reports  the average payment per claim for prescription drugs in the Wisconsin workers’ compensation system was $288 – 30% lower than the median of the study states.

The main reasons for the lower prescription costs in Wisconsin include lower prices paid to pharmacies for most common drugs, more frequent use of less expensive generic drugs, and fewer prescriptions per claim, especially for some commonly used narcotics.

The WCRI study, Prescription Benchmarks for Wisconsin, found the average price paid to pharmacies in Wisconsin was 15% lower than in the median state. The average prices paid to pharmacies in Wisconsin were lower for some common drugs, but fairly typical for other common drugs.

Wisconsin physicians more often prescribed generics to substitute for more expensive brand name drugs. Brand name medications accounted for 11% of all prescriptions, compared with 15%  in the median state, according to the study.

The study also reported  the utilization of prescription drugs in Wisconsin was lower compared to most study states.

The average number of prescriptions per claim in Wisconsin was 14% lower while the average number of pills per claim was 12% lower than the 16-state median. This was mainly because Wisconsin physicians wrote and workers filled fewer prescriptions per claim, especially for common drugs such as the painkillers Vicodin^®, OxyContin^® and Darvoset-N^®.

Finally, the report noted some Wisconsin physicians wrote and dispensed medications directly to the patient. (workersxzcompxzkit)

Physician-dispensed prescriptions accounted for only 7% of all prescriptions in Wisconsin. Physician dispensing prescription drugs did not appear to be a cost driver of prescription drugs for Wisconsin, according to the study. 

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.

Posted in Medical Cost Containment & Managed Care |

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GREAT BRITAIN Surveying Effective Asbestos Work Helps Manage Risks

Asbestos surveys are only effective if competent surveyors are employed to do them. That is one of the key messages being promoted at road shows around Great Britain to help explain new guidance devised for those responsible for managing the risks from asbestos.

Asbestos: The survey guide (Ref: HSG264) published by the Health and Safety Executive (HSE) in January is aimed at those who commission asbestos surveys, the surveyors who carry them out and those who use them, such as architects and demolition or removal contractors. 

A number of successful road shows, attended by surveyors and health and safety professionals have already taken place with further events scheduled for Cardiff (May 19), Birmingham (June 16) and London (June 30).
 

The new guide stipulates that clients and duty holders only engage a competent surveying organization. This can be demonstrated either through the organization being accredited and/or individual surveyors having their own certification.
 

The guide strongly recommends the use of UKAS accredited or ABICS certified surveyors for asbestos surveys.

Dr. Martin Gibson, author of the guide and a principal specialist inspector for HSE, noted, "Ensuring that contractors are competent to do asbestos surveys should be a top priority for those responsible for managing the risks from asbestos. Those organizations or individuals without accreditation and/or certification will find it more difficult to demonstrate that they are competent, so by employing a contractor with accreditation and/or certification, duty holders can better meet their legal requirements."
 

Rob Bettinson of UKAS added, "UKAS accreditation for surveying companies is a well established scheme. Accredited organizations can demonstrate that not only do they have competent surveyors but they are also working within a well defined management system that provides confidence in the surveying procedures that are used. Clients can have confidence that accredited surveyors will provide a quality service." (workersxzcompxzkit)

The road shows are organized by the British Occupational Hygiene Society (BOHS) and Asbestos Testing and Consultancy (ATaC).

Podcast: KNOW the new OSHA recordkeeping rules – or risk fines and criminal penalties.
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Posted in Risk Management, Safety and Loss Control, WC in Other Countries (International) |

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Twelve Things You Should Know About Subsequent Injury Funds and Disabled Workers

If your state has a SIF it would be in your best interest to get acquainted with the details of how it operates. It can be a major source of funding for severe claims where the employee had a prior disability. If you have questions about your SIF, please contact us.

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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.

Posted in ADA (Americans with Disabilities Act), Integrated Disability Management, Medical Cost Containment & Managed Care, Medical Issues |

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Movie Theater Owners May Be Showing New Picture

The owners of movie theaters may find it necessary to install special equipment for patrons with
hearing and visual impairments under the Americans with Disabilities Act as a result of a federal
appeals court ruling that is viewed as groundbreaking.

The April 30 decision by the 9th U.S. Circuit Court of Appeals in San Francisco in State of Arizona vs. Harkins Amusement Enterprises Inc. et al. largely overturned a lower court’s dismissal of the case brought by Frederick Lindstrom, who has severe hearing loss, and Larry Wanger who is blind in one eye and has trouble seeing out of the other.

The two filed suit alleging Scottsdale, Ariz.-based Harkins Amusement, which operates 21 theaters in Arizona, violated the ADA and state law when they could not see or hear a movie five years ago due to their respective disabilities.

For those battling hearing impairments, two out of Harkins Amusement’s 262 theaters have open captions on the screen, but it has no theaters with descriptive narration for the visually impaired. Another option for the hearing impaired is closed captioning, which employs a device connected to a seat, according to court papers.

A district court determined that neither the ADA nor the Arizonans with Disabilities Act requires movie theaters “to alter the content of their services.”

However, a unanimous three-judge appeals court panel did not agree.

“Because closed captioning and audio descriptions are correctly classified as 'auxiliary aids and services’ that a movie theater may be required to provide under the ADA, we conclude the district court erred in finding that these services are foreclosed as a matter of law,” the appeals court stated in remanding the case for additional action.

The 9th Circuit panel, however, did concur with the lower court that the ADA does not require open captioning.

“Our holding doesn’t necessarily mean that plaintiffs will be entitled to closed captioning and descriptive narration in Harkins's theaters,” the appeals court stated.

“Harkins may still be able to avail itself of a number of defenses, like the contention that the devices would fundamentally change the nature of its services or constitute an undue burden.” (workersxzcompxzkit)

In a statement, Arizona Attorney General Terry Goddard claimed the decision is groundbreaking due to the fact this is the first time an appeals court has ruled on this matter.

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.

Posted in ADA (Americans with Disabilities Act) |

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Judge Oregon Company Broke Law in Firing Workers

Altogether, Local 296 accused BrucePac of firing 17 union supporters and attempting to mask the firings in a 42-worker mass layoff.

Agents of the National Labor Relations Board (NLRB)  deemed there wasn’t enough evidence to pursue charges in 13 of the firings, but issued a complaint in four, and held a trial in front of administrative law judge Lana Parke. It’s against federal law for a company to fire a worker for union activity.

At BrucePac, firings took place at both Oregon plants, on every shift, in every department — operations, sanitation, maintenance, quality assurance, accounting.

In a workplace of approximately 350, the employer laid off 42 workers  — one month after a union campaign began.

Local 296 came out against the firings, placed pickets outside BrucePac, and filed 18 charges with the NLRB.

BrucePac informed NLRB agents it didn’t know the terminated workers were union supporters, so it couldn’t have fired them for being union supporters.

In her written decision, Parke ordered BrucePac to halt interrogating employees about union activities, threatening employees with unspecified reprisals for backing the union, and terminating employees for engaging in union activities. She also ordered the company to offer reinstatement and back pay to three of the fired workers, and post a notice in the workplace detailing all her instructions and letting workers know of their right to form a union. (workersxzcompxzkit)

BrucePac reportedly failed to reinstate within the judge’s timeline, meaning it may have been planning to appeal her ruling to the next level: the National Labor Relations Board in Washington, D.C.  

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.

Posted in Employment Law Issues, Union Issues |

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