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Tips to Uncover Fraud with Social Networking


 
Good old Google may be an insurance investigator’s best friend. Routinely looking for claimants’ profiles can yield as much information as expensive and common video surveillance techniques used by insurance companies and defense counsel.
 
Sometimes photos or status updates can yield information that indicates a fraudulent claim, demonstrating a claimant is capable of physical activity beyond whatever grave condition he or she is claiming. It is wise for plaintiff’s attorneys to ask clients if they maintain profiles on any of the many popular sites.(WCxKit)
 
 
Another investigative use of Facebook has a New York woman discussing her salary on-line though she claimed she was unable to work. Even when employees set privacy to make this information untenable to the entire public, it can be subpoenaed or requested by defense counsel by demonstrating relevance. Many state courts have allowed counsel to acquire on-line e-mails, journals, diaries, and communications – or even the passwords to the employee’s social media sites. Many social networking sites include in the privacy policy users agree to when opening an account that some tailored court-ordered requests are one area where privacy cannot be guaranteed. Further, some information may be accessible through the claimant’s friends’ pages.
 
 
Regardless, it seems that searching unprotected information on-line is comparable to public video surveillance as long as neither defense counsel nor their investigators initiate contact with the opposing party – for example, by “friending” them. Non-attorney investigators and insurance company representatives are not regulated by the attorney codes of professional responsibility and, if not associated with an attorney, may have a little more freedom when interacting with claimants. However, it is advisable to proceed with extreme caution under these circumstances, even if the claim has not yet been referred to an attorney.
 
 
Once you have received court permission, if the claimant refuses to turn over records or deletes information, it is possible to contact the social networking site operators to attain the information. Two defenses site operators have in refusing to offer the information are the Stored Communications Act (SCA) and violation of privacy. An exception can be made for the SCA if the claimant authorizes the disclosure. Privacy claims are unlikely to hold up in court because the very nature of social networking implies the user has given access to at least some members of the general public.(WCxKit)
 
 
In summary, the workers compensation industry will increasingly face discovery, privacy, and professional responsibility issues that arise when dealing with social networking information. Attorneys, insurance companies, and investigators should familiarize themselves with these networking technologies to take a bigger step toward combating insurance fraud.
 
 
About the authors:
Gregory M. Duhl is an Associate Professor of Law at the William Mitchell College of Law in St. Paul, Minn., as well as the executive editor of The Business Lawyer, the flagship publication of the ABA Section of Business Law. He received a B.A. summa cum laude from Yale University, a J.D. cum laude from Harvard Law School, and an LL.M. in Legal Education from the Temple University James E. Beasley School of Law. He can be reached at gregory.duhl@wmitchell.edu.
 
Jaclyn S. Millner is an in-house attorney for Liberty Mutual in Minneapolis, Minn., practicing workers compensation and insurance litigation. She is licensed to practice law in Wisconsin and Minnesota. She has a B.A. from the University of Michigan and a J.D. magna cum laude from the William Mitchell College of Law in St. Paul, Minn. She was an editor of the William Mitchell Law Review. She can be reached at jaclyn.millner@libertymutual.com.

Our WC Book:  http://www.wcmanual.com

WORK COMP CALCULATOR: http://www
.LowerWC.com/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.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Posted in Fraud and Abuse, Legal Doctrines |


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75 Retired NFL Players Sue Over Concealment of Concussions


Seventy-five retired National Football League players are suing the NFL citing mismanagement of concussions and willful concealment of evidence of the long-term effects of head injuries which led to the players’ current brain damage.
 
 
Studies on brain trauma led the National Football League to change its rule regarding concussions in 2009. The change required any player suffering severe concussion symptoms to not return to the field that day. A medical committee had been formed to study the effects of concussions in 1994 and literature was given to players in 2007 essentially telling them concussions, when properly treated, will not hamper their continued playing.(WCxKit)
 
 
Previously, players had been allowed back on the field once symptoms had subsided, going against recommendations from industry experts for several of the previous years. Further studies have indicated a higher level of dementia in retired players – possible result of lifelong brain trauma. Depression, vision issues, and memory impairment have all been linked to multiple head injuries.
 
 
According to a Oct. 21 New York Times article (part of an exploratory series on the NFL and brain injuries), “Contrary to popular belief, a concussion is not a bruise to the brain caused by hitting a hard surface. Indeed, no physical swelling or bleeding is usually seen on radiological scans. The injury generally occurs when the head either accelerates rapidly and then is stopped, or is spun rapidly. This violent shaking causes the brain cells to become depolarized and fire all their neurotransmitters at once in an unhealthy cascade, flooding the brain with chemicals and deadening certain receptors linked to learning and memory. The results often include confusion, blurred vision, memory loss, nausea and, sometimes, unconsciousness. Neurologists say once a person suffers a concussion, he is as much as four times more likely to sustain a second one. Moreover, after several concussions, it takes less of a blow to cause the injury and requires more time to recover.”
 
 
The article goes on to say, “A 2000 study surveyed 1,090 former N.F.L. players and found more than 60 percent had suffered at least one concussion in their careers and 26 percent had had three or more. Those who had had concussions reported more problems with memory, concentration, speech impediments, headaches and other neurological problems than those who had not, the survey found.”(WCxKit)
 
 
The suit, filed in Superior Court in Los Angeles seeks an unspecified amount of damages above the jurisdictional minimum of $25,000.

Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.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.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Posted in Medical Issues |


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Eight Clues You Need To Call a Special Investigation Unit


According to the Coalition Against Insurance Fraud, fraudulent workers compensation claims cost employers $6 billion a year and is a significant part of the $30 billion a year insurance fraud problem. Per one estimate, 25 percent of all workers compensation claims entail some element of fraud. Workers compensation fraud runs the gamut from the totally bogus claim to the employee who extends his time off work “a few extra days” to take care of personal errands or other personal issues. Workers compensation insurance fraud is any intentional act of falsifying or exaggerating a work place accident for the purpose of obtaining medical and/or indemnity benefits that would not otherwise be owed.
 
 
Most larger workers compensation insurers will have a “special investigation unit” (SIU) whose purpose is to defeat the totally bogus claims and to stop the work comp claims that have a significant element of fraud. Many smaller insurers will have membership in groups like the National Insurance Crime Bureau (NICB) whose purpose is to identify and prosecute fraud and will utilize the NICB as their SIU. There are also SIU companies that sell their services to insurers, third party administrators, and self-insured employers.(WCxKit)
 
 
The SIU goal is to reduce the amount of losses due to workers compensation insurance fraud and to prosecute the employees who commit work comp fraud. To achieve these goals, SIU units have become “high tech.” The days of SIU being “Jim Rockford” or “Magnum PI” have been replaced by the use of technology and data mining to identify fraudulent aspects of each work comp fraud. Most SIU investigators either have a law degree, a forensic accounting background or have worked in law enforcement before joining the SIU.
 
 
Handling each fraud is different. The SIU, upon learning of a potential fraudulent or a definitely fraudulent, claim can take one or several actions including:
 
5 Ways SIUs Investigate Fraud
1.      In-depth analysis of the claim.
2.      Extensive interviews.
3.      Field investigation.
4.      Background investigation.
5.      Work with the state and local law enforcement agencies.
 
 
The question employers often ask is, “When should a claim be turned over to a SIU for further investigation?” The answer is simple – any time the employer suspects a work comp claim is not what it is claimed to be.
 
 
There are also some “red flags” that should tell the employer it is time to request SIU involvement in the claim including:
 
8 Red Flags of Fraud – Time for SIU
1.      Excessive medical treatment for a minor injury.
2.      Attorneys who refer all their clients to the same doctor.
3.      Medical billing errors – for example, two medical providers in different locations seeing the employee at the same time, or medical providers seeing the employee when the employee's time card shows he or she was at work.
4.      Rumor or documentation that the employee is working somewhere else while drawing indemnity benefits.
5.      Co-workers give a different version of the accident than the employee provides.
6.      Co-workers advise the accident happened away from work and it is not work related.
7.      The employee's version of the accident reported to you differs from the employee's version of the accident given to the doctor.
8.      The employee was having serious financial difficulties prior to the injury.
 
 
If you do not initiate the SIU involvement in a workers compensation claim, but are contacted about a work comp claim by an SIU investigator, cooperate fully with the investigator and provide any information or documentation the SIU investigator request. The failure to assist the SIU will allow the employee to defraud the insurance company or your company if you are self-insured. Also, fraud is contagious. Many employees who would not normally consider fraud will be embolden to try it if they see your company as lax in your handling.
 
 
There are proactive measures the employer can take to assist the SIU to reduce their case load. To eliminate many of the fraudulent claims (and the legitimate work comp claims, too), have a strong safety program that reduces the employee's options for creating a fraudulent claim scenario. Also, when confronted with a documented work comp fraud, prosecute fully. Employees who know that fraud is not tolerated and will be prosecuted are less likely to consider committing work comp fraud. (WCxKit)
 
 
If your insurer does not have a SIU, ask why not. Your insurer should be as committed to fighting work comp fraud as you are. If your insurer has a SIU, know they are committed to protecting your company from the cost of workers' compensation fraud.

Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.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.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Posted in Fraud and Abuse |


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Contractor Fined and Qualified for OSHA Severe Violators Enforcement Program


A roofing contractor with a long history of violating workplace safety standards faces nearly $244,000 in proposed fines from the U.S. Department of Labor's Occupational Safety and Health Administration (OSHA) following a December 2010 inspection resulting in citations for alleged egregious, willful, serious, and repeat violations for failing to provide fall protection and having other workplace hazards.
 
 
OSHA previously cited Lessard Brothers Construction Inc. and its predecessor, Lessard Roofing & Siding Inc., 10 times for fall protection violations at various Maine work sites. OSHA inspectors found four Lessard employees exposed to potentially life-threatening falls of 23 feet while working on a steep-pitched roof at a work site. Due to management's knowledge of the hazard and the required safeguards, along with the company's extensive history of violations, Lessard was cited for four egregious, willful violations with $224,000 in proposed fines. (WCxKit)
 
 
Since October 28, 2010, according to Maine's workers compensation insurance verification system, Lessard Brothers Construction has been without workers compensation insurance coverage.
 
 
This employer ignored the law and put workers’ lives at risk,” said Assistant Secretary of Labor for OSHA Dr. David Michaels. “OSHA's commonsense regulations save lives. Employers who ignore these regulations and endanger employees must face the consequences.”
 
 
In addition, Lessard was cited for two serious violations with $10,560 in proposed fines for an electrical hazard and for failing to train workers on electrical hazards and fall protection. The company also was cited for one repeat violation with a proposed fine of $8,800 for a lack of hardhat protection. The repeat citation stems from OSHA citing the company in January 2010 for a similar hazard.
 
 
Falls are the number one killer in construction work,” said Marthe Kent, OSHA's New England regional administrator. “Employees in situations such as this are just one slip, trip or misstep away from a fatal or disabling fall. Responsible employers must ensure that effective fall protection measures are in place and in use every day on every job site.” (WCxKit)
 
 
This significant enforcement action qualifies Lessard Brothers Construction for OSHA's Severe Violators Enforcement Program (SVEP), mandating targeted follow-up inspections to ensure compliance with the law. Initiated in 2010, SVEP focuses on recalcitrant employers who endanger workers by committing willful, repeat or failure-to-abate violations.
 
 
 
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, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact:Info@ReduceYourWorkersComp.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.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Posted in Safety and Loss Control, WC 101 |


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This Week at Workers Compensation Roundtable


This week on LinkedIn’s Workers Compensation Roundtable, the group manager, Bob Wilson, President & CEO of WorkersCompensation.com managed to skip town for a real vacation. Nice going, Bob!

One of our own blogs sparked a discussion – if an employee has a heart attack at home that may be a result of a too-heavy workload, is that the employer’s fault? Kelly Haile, president of Keystone Case Management, posted the blog and asked what others think.

 
 
As though in answer, Mark Walls, assistant vice president of claims at Safety National posts an interesting article from Risk and Insurance magazine titled, “Not All Claims are Created Equal.” The article talks about presumption laws which are available to some employees in 43 states and assume that SOME diseases, such as heart disease, are indeed assumed to be a result of work. It is the employer’s burden to prove otherwise.
 
 
Ginger Benter, Founder & CEO of People Solutions, Inc., asks, “Does anyone know of any employment agencies in California that specialize in Risk Management or other Workers' Compensation positions with employers either temporary or permanent?”
Tom Bielicki from Insurance Recruiting Specialists (IRS) responded saying that his is the only such agency he knows of.
 
 
John Carrington, analyst at Hound Partners, asks, “Does anyone know where I can find the number of workers' compensation claims filed per year in each U.S. state?” His question sparks many in agreement looking for the same information and a few suggestions. Read more here to find some ideas.
 
 
Jack Kanner, COO of P.S.R. Corporation [aka] Professional Safeguard Resources, posts this article, “Insuring Infrastructure Industries: Avoidable Losses in Uncertain Economic Times.”
 
 
 
Celina Allemand, at Louisiana Association of Self Insured Employers, reminds readers the Certified Medicare Secondary Payer Professional CMSP Program in Baltimore, MD is coming up Aug. 5-7, 2011.
 
 
And  Anthony Poston, CEO of ESM Solutions, Inc., offers safety training videos for your company.
 
 
Amy Brown, insurance consultant and WC specialist at DHR posts this article, titled, “Ariz. Court: Workers’ Comp Time Limits on Workers’ Comp Judges Not Mandatory.” It begins, “Arizona law does not prescribe any consequences in cases where administrative law judges do not issue an opinion in workers’ compensation cases with the required 30 days from hearing, a state appeals court ruled.” Brown stresses that it is interesting for both employers and employees to note.
 
 
On the job front, recruiter Debbie Heiman, is looking for an at-home claims adjuster. Follow this link to read more. And LaTesa Williams is looking for an assistant service center manager in workers comp claims for a Tampa Broadspire job. There were a few other jobs posted in the group this week as well.
 
 
Join us at Linkedin's Workers Compensation Roundtable right now and right here! Better yet, invite your friends so they too can become informed on hot topics in the Workers Compensation industry.
 
Workers Compensation Roundtable is jointly managed by people dedicated to the concept that workers compensation is a manageable line on your expense ledger, and that informed professionals are empowered achievers. Workers' compensation is not simply a cost of doing business, it is a cost that can be controlled. Beginning with an assessment of cost drivers, benchmarking data, and integrating the solutions, employers can reduce workers' comp costs 20 to 50 percent. With proper information, professionals managing compensation claims can reduce costs and improve outcomes for all stakeholders in the process. This group is for employers, business owners, risk managers, HR managers, insurance executives, and brokers to discuss the obstacles and strategies to overcome them.(WCxKit)
Posted in Assessment & Diagnostics, Communication with Employees, Professional Development Issues |


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Irish Employers Let Health and Safety Lapse


Two employers were fined as a result of an incident at the Springbank Industrial Estate, Belfast, during the lifting of a hollow core concrete floor slab into one of the industrial units under construction, according to the Health and Safety Executive of Northern Ireland (HSINI).
 
 
Gerald Quinn, trading as QFix, was fined a total of £3,000 ($4,924) after pleading guilty to a pair of breaches of health and safety legislation. Tully & Sons Ltd.’s fine was for a total of £15,000 ($24,617).They also pleaded guilty to two breaches of health and safety legislation arising from the same incident. (WCxKit)
 
 
The heavy concrete floor slab shattered in mid air causing a 19-year-old worker to fall four meters, leading to serious injuries. The concrete slab was being lifted at an angle to allow it to be placed through an opening in the steel work, which was less than the length of the slab. To achieve this, the lifting beam and clamps were arranged so a section of the slab was unsupported, i.e. it formed a cantilever. According to safety experts, slabs should not be lifted in this manner and are not designed to act as a cantilever; therefore, it was a foreseeable event that the slab could fail.
 
 
Tully & Sons Ltd. was the Principal Contractor on site and Gerald Quinn (QFix) acted as the sub-contractor to the flooring manufacturer and was responsible for the lifting and fitting of the concrete floor slab.
 
 
After this recent hearing, Denise Donaghy, an inspector with HSENI’s Major Investigation Team said, “This accident happened due to an absence of planning and coordination between the principal contractor and the sub-contractor responsible for the placing of the slabs. When lifting and fitting pre-cast concrete flooring units, it is important that the lifting operation is properly planned, appropriately supervised and carried out in a safe manner. It is also important that suitable and sufficient steps are taken to prevent falls.”
 

 
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, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact:Info@ReduceYourWorkersComp.com.

Our WC Manual: www.wcmanual.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.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Posted in Safety and Loss Control, WC in Other Countries (International) |


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Predicting Disability Using Medical Treatment Guidelines


The first question from most employers when an employee suffers an injury is: How long will he/she be off work? Estimating the length of time the employee will be off work is not a precise science, but thanks to the accumulation of millions of workers compensation claims and disability cases over the years, there is ample data available to provide a range of time to predict how long it will take the employee to recover from a specific injury.
 
 
A large third party administrator can now estimate disability for any type of injury. Using the disability guidelines available, they can even refine the predicted period of disability using criteria of:
1.      Age
2.      Preexisting unrelated medical conditions
3.      Gender
4.      CPT codes (description of the services provided by the doctor)
5.      Zip codes
 
 
While it almost sounds like you can plug the data into the computer and the computer will spit out the exact number of days the employee will be recovering from their injury, it is more complicated than that. There are numerous other factors that come into play when determining the period of time it will take the employee to recover from the injury including:
1.      The severity of the injury – for example a torn tendon can be a small partial tear, a larger tear or torn completely apart.

2.     
The pre-injury condition of the employee – the physically fit recover faster than the employees who have poor physical conditioning.

3.     
Other injuries – employees with only one injury in an accident recover faster than an employee with two or more injuries, for example one fracture bone as opposed to three broken bones.

4.     
The post injury treatment program – employees who have physical therapy, occupational therapy or a rehabilitation program recover faster than employees with the same injury, but without a post injury treatment program.

5.     
The personal habits of the employee – smoking, alcohol, and illicit drugs slow the recovery process.

6.     
The employee's stress level, sleeping habits and general health.
 
 
From the medical provider or adjuster’s standpoint, if asked to predict the length of time the employee will be recovering from an injury, they will turn to a source such as The Medical Disability Advisor for disability duration guideline tables to provide information about anatomical regions, diagnostic categories, medical specialists, job titles and ICD-9 Codes.
 
 
The data and the tables will provide general answers and assist in predicting the approximate length of disability. The period of disability should not be confused with the length of time the employee will be off work. In most cases, the injured employee can return to light duty or modified duty work before the period of disability is over. To determine if the employee can return to work before the employee is fully healed, the doctor will look at the employee's physical limitations, the necessary restrictions and the employee's ability to deal with the injury symptoms.
 
 
The physical limitations are often centered around the employee's ability to use their musculoskeletal system. The employee will be given limitations on how much force they can exert or weight they can safely move, or how long they can stand, sit, squat, bend, crawl, etc. The limitations are designed to stop the employee from using an injured body part in a way that will aggravate the injured part, slowing or even reversing the recovery process.
 
 
The restrictions are designed to protect the employee, co-workers, and the general public from further injury that might occur when an employee is unable to safely perform the functions of the job. For example, while an employee might be physically capable of returning to work, an employee taking pain medication that creates drowsiness should not be operating machinery or driving a vehicle.
 
 
 For the doctor, one of the most difficult aspects of controlling the period of disability and the return to work, is the employee's ability to deal with the pain symptoms. Some employee's tolerate an injury and the pain associated with it better than others. And while pain can be very real, it is often used as a crutch by people who do not want to return to work. A lack of job satisfaction, available income from workers' comp or another source, the employee's ability to find another job, the desired standard of living and the need for health insurance or other employer provided benefits, often have an impact on the perceived level of pain and the length of the disability period. A simple, no cost way to deal with pain that will work sometimes is for the employer to call the employee and stress how much the employee is needed at work – making sure to let them know they are a necessary part of the workforce. (WCxKit)
 

Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.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.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Posted in Integrated Disability Management |


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Seminars on Texas Pharmacy Formulary and Claims/eBill


The Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) will present a series of free, half-day educational seminars titled Pharmacy Closed Formulary and Clean Claims/eBill. The seminars are being offered in cooperation with Small Business Development Centers.
 
 
The Pharmacy Closed Formulary portion of the seminar will provide an overview of the pharmacy closed formulary rules adopted by the TDI-DWC in December 2010 for both certified network and non-network workers’ compensation claims with dates of injury on or after Sept. 1, 2011.
 
 
The Clean Claims/eBill portion of the seminar will provide an overview of the new TDI-DWC requirements related to submitting paper and electronic medical bills, including a discussion of the changes from the previous requirements and a brief introduction to the new electronic medical billing standards. This presentation also provides an opportunity for new and experienced medical billing employees to recognize how to complete medical bills to minimize insurance carrier returns or rejections after the Aug. 1, 2011 effective date.(WCxKit)
 
House bill 528, which becomes effective June 17, can be found here.
 
Among some the regulations in the bill include:
1.      Insurance carriers must reimburse health care providers in accordance with the TDI-DWC’s pharmacy fee guideline or at a contracted rate.
2.      Insurance carriers may also reimburse health care providers for pharmaceutical services at rates inconsistent with the TDI-DWC’s pharmacy fee guideline if the carrier has a contract with that health care provider that includes a specific fee schedule.
3.      Insurance carriers or their authorized agents may use a pharmacy informal or voluntary network to obtain these contractual agreements with health care providers. If an insurance carrier chooses to use a pharmacy informal or voluntary network, there must be: a contractual arrangement between the insurance carrier or its agent and the pharmacy informal or voluntary network authorizing the network to contract with health care providers for pharmaceuticals on the insurance carrier’s behalf; and a contract between the network and the health care providers that includes a specific fee schedule and complies with the health care provider notice requirements of Texas Labor code.
4.      The carrier must notify each health care provider, at least quarterly of any person, other than the injured employee, to which the network’s contractual fee arrangements with the health care providers are sold, leased, transferred or conveyed.
5.      Each informal or voluntary network that has contracts in effect on June 17, 2011, must report the information listed in the labor code by July 17, 2011.
6.      Failure for a pharmacy informal or voluntary network to comply with the registration requirements will result in an administrative violation.
 
Details of these new requirements will be explained at the conference.
 
Due to limited space, registration is required. For more details on the following educational seminars, visit the TDI-DWC Events and Training Calendar at www.tdi.state.tx.us/wc/events/index.html. Pharmacy Closed Formulary will be presented from 8 a.m. to 11 a.m. and Clean Claims/eBill will be presented from 11 a.m. to 12 p.m. at each venue. Texas workers’ compensation system participants may attend one or both portions of the seminar.
 
 
Training Dates
Date                       City
May 6, 2011          Dallas
May 7, 2011          Fort Worth
May 20, 2011        San Antonio
May 25, 2011        Wichita Falls
June 3, 2011        Corpus Christi
June 8, 2011        San Antonio
June 10, 2011      Houston
June 24, 2011      Edinburg
July 15, 2011        El Paso
Aug. 18, 2011       Austin
 
 
This information was provided by attorney Stuart Colburn, a Shareholder at Downs Stanford in Austin, Texas. Colburn has extensive experience in all phases of dispute resolution before the Texas Department of Insurance, Division of Workers Compensation and in district courts across the state. Stuart represents clients regarding workers compensation, non-subscription, subrogation, and bad faith litigation. He is the founder and the first chairman of the State Bar of Texas (SBOT) Workers Compensation Section; course coordinator for the SBOT the Advanced Workers Compensation Seminar; and course coordinator for the Texas Workers Compensation Forum. He can be reached at:  scolburn@downsstanford.com
Posted in Legal Doctrines, Professional Development Issues, Seminars and Courses |


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Comorbidity Run Amuck – Medical Conditions Make Work Comp Injuries More Costly


Comorbidity is the presence of two or more medical conditions in a person at the same time. When an employee with a prior medical problem has an on-the job injury, the cost of the medical care and the length of time the employee will be off work is normally extended. This does not mean that workers compensation will pay for an employee's pre-existing medical problems, but it does mean that the pre-existing medical problems can complicate the medical care for the workers compensation injury.
 
 
When an employer takes an active interest in the medical status of its employees, it has a far reaching positive impact. Take for example the trucking company that did not have an overall wellness program for its employees. It was not only paying more for the cost of health insurance, it was paying more for the cost of workers compensation insurance. And then the inevitable happened: a truck driver with several — not one or two health issues — but several health issues got hurt on the job.(WCxKit)
 
 
The truck driver, who was driving a tanker truck, decided to check the level of the liquid in the tanker. The driver, 51, climbed up on the catwalk. To hold on, he took hold of a handle for that purpose, but lost his balance and started to fall. By holding on to the handle, he was able to prevent the fall, until all of his 297 pounds was on his arm and shoulder. Rip went the rotator cuff in his shoulder, pop went the handle as it was there for balancing, not to hold 297 pounds, and the trucker fell to the ground.
 
 
The doctor's immediate assessment was probable torn rotator cuff. The MRI confirmed a large rotator cuff tear in this very large guy. Normally, the doctor would schedule surgery, repair the rotator cuff, and send the employee to physical therapy for six to eight weeks, returning the employee to light duty in four weeks and returning the employee back to work full duty in eight to 10 weeks.
 
 
The obesity alone would not have been much of a factor for rotator cuff repair, but the issue that caused the obesity was. The trucker liked beer. A lot of beer, which is how he got to 297 pounds. But the alcohol also brought on other comorbidity factors including hepatitis C and cirrhosis of the liver. The orthopedic doctor did what any other doctor would do, he delayed the surgery until the claimant could get surgical clearance from the gastroenterologist. The gastroenterologist could not see the claimant immediately and four weeks of temporary indemnity benefits were paid while the claimant waited the appointment with the gastroenterologist.
 
 
The gastroenterologist agreed to take the claimant off antiviral medications. The claimant's body needed at least three months to adjust to not having the antiviral medications and for his platelet count to recover adequately for the rotator cuff surgery. Another three months of indemnity benefits.
 
 
The rotator cuff surgery was completed, but then diabetes came into play (I should have mentioned earlier that the trucker was also a diabetic). Three weeks post surgery, the area around the surgical wound began to turn red. Due to hyperglycemia, brought on by the diabetes, cellulitis (infection) of the wound and surgical area developed. The driver went back to the hospital for another surgery to surgically remove the infection. Of course when the wound was opened, the rotator cuff had not healed due to cellulitis and had to be repaired again. The second rotator cuff surgery caused by the comorbidity of diabetes adds both additional medical cost and another three weeks of indemnity benefits, as all the recovery time between the first surgery and the second surgery is loss.
 
 
When you are immobile due to obesity and recovering from two surgeries, have hepatitis C, cirrhosis and diabetes, it is nothing unusual to develop edema (where the body retains excessive levels of fluid). When you are severely bloated, it is difficult to actively participate in physical therapy. With drugs for the edema, physical therapy was only delayed two weeks, but this was two extra weeks of indemnity benefits in addition to the medical cost of the doctor's visit and the pharmacy.
 
 
For brevity of this article, we will not discuss the hypertension and basilic vein clot/thrombosis and how they delayed the medical recovery that further extended the time the employee was drawing indemnity benefits. Also, for brevity we will not discuss the employee's anxiety, depression, panic attacks, insomnia, abdominal pain, jaundice, and weight loss issues as these conditions individually did not prolong the worker compensation claim, but collectively added to the medical cost as the primary doctor had to address the issues or refer the medical issues to other doctors.(WCxKit)
 
 
While few workers compensation claims have this many medical complications, the non-work related medical issues of your employees will interfere with the recovery from the on-the-job injury. You can reduce the cost of both health insurance and workers compensation insurance by encouraging your employees to individually maintain good health and by providing a wellness program.

Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.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.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Posted in Integrated Disability Management, Management Commitment, Medical Issues |


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Irish Minister Wants New Culture of Farm Safety


Ireland’s Minister for Agriculture, Marine, and Food, Simon Coveney TD, called on farmers and those who work in the agriculture sector to foster safety at the National Conference on Health and Safety in Agriculture this June, according to a report from Ireland’s Health & Safety Executive (HSE).
 
 
The challenge that we face is to change behavior and attitudes so that safe working becomes second nature. In recent years the number of fatal accidents in agriculture has been higher than in any other sector,” Coveney said. “The industry is expanding and creating new jobs and this is to be welcomed. However, we don’t want to see a corresponding increase in lives lost.”
 
 
Martin O’Halloran, CEO of the Health and Safety Authority, echoed the minister's concerns about the potential for further increased accidents in agriculture and related industries. “As the activity level in agriculture increases so does the risk of increased fatalities, injuries and work related illness,” he said. “We are committed to working with the key players in the agriculture sector to reduce fatalities, accidents, and work-related ill health. This approach of working in partnership with the strategic partners has been proven to work in other sectors such as construction.”
 
 
John Bryan, IFA president, chaired the proceedings and reaffirmed his support for the Farm Safety Partnership in promoting increased awareness at farm level. “The Farm Safety Partnership has real focus on the key issues and has introduced initiatives in the areas of tractor safety, child safety and livestock safety. Each of these is important in delivering the overall safety message. There must also be an emphasis on getting information to older farmers, who are particularly vulnerable," he said.
 
 
Coveney launched a new HSA guide, Guidance on Safe Handling of Cattle on Farms, at the conference. The guide was developed with assistance from members of the livestock safety working group of the Farm Safety Partnership.
 
The Teagasc Research Centre also provided valuable data for the guide. Teagasc director, Prof. Gerry Boyle said Teagasc is committed to continuing to work in partnership with farmers through Ireland's Farm Safety Partnership. “I would appeal to farmers to use our advisory and training services for health and safety to improve on-farm standards and practices,” he said.  “We are currently conducting seven research studies related to health and safety in agriculture and we will then ensure that these findings are implemented at farm level.” (WCxKit)
 
 
 
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, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact: Info@ReduceYourWorkersComp.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.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Posted in Implementation and Rolling Out Your Program, Medical Issues, Safety and Loss Control, WC 101, WC in Other Countries (International) |


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