NAMSAP Presents “Opioids in the Life of the MSA” Webinar on June 21

The National Alliance of Medicare Set-Aside Professionals continues its three-part webinar series “Opioids in the Life of the MSA”on June 21 starting at 2 p.m. Eastern.


The series explores the issue of long-term opioid use for noncancerous pain in workers’ compensation MSAs and how the Centers for Medicare and Medicaid Services are addressing it. Part one discussed how applying evidence-based medicine improves MSA outcomes.


Part two focuses on current policy and federal efforts to manage the opioid epidemic.  Presenters are Mary Nix, health science administrator, National Guidelines Clearinghouse, Agency for Healthcare Research and Quality and Pamela Schweitzer, assistant surgeon general and chief pharmacist officer, United States Public Health Service, along with the Workers’ Compensation Research Institute’s Policy Analyst Vennela Thumula and Economist Dongchun Wang. The 90-minute webinar covers:


  • WCRI’s new research on interstate variations in opioid usage;
  • Real CMS-approved MSAs allocating for high opioid dosages;
  • Applying evidence-based guidelines to policy;


“In light of the recent evidence-based studies demonstrating the long-term impact of opioid prescriptions for chronic, non-cancer pain, our industry needs to come together to ensure we neither condone nor institutionalize the problem,” said NAMSAP President Gary Patureau. “All the players in the MSA process have an obligation to aged and disabled injured persons to work toward healthier, safer and more effective patient outcomes.”


NAMSAP has recommended that CMS adopt limits on opioids in MSAs based on opioid guidelines published by the Centers for Disease Control.


“We regularly triage cases where an injured employee takes both short- and long-acting opioids for chronic, non-cancer pain,” said Rita Wilson, NAMSAP board member and CEO of Tower MSA Partners. “We hope this webinar series will heighten awareness among policy makers of inappropriate opioid use in workers’ compensation and encourage CMS to align its WCMSA review policies with evidence-based medicine.”


There is a $63 webinar fee for NAMSAP members and an $83 fee for non-members. For more information, please see



Headquartered in Illinois in NAMSAP is the only non-profit association exclusively addressing the issues and challenges of the Medicare Secondary Statutes and its impact on workers’ compensation and liability settlements.  Its members are comprised of MSA providers, insurance carriers, and third-party administrators. Contact NAMSAP at 855-677-2776 or via

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Media Contacts:  Helen Patterson, 813-690-4787;

Gary Patureau, President, NAMSAP & Exec. Director, Louisiana Association of Self Insured Employers; 225-338-0705;


Sleep Deficiency and Fatigue Causing More Workplace Injuries

This infographic was provided by Eastern Kentucky University:

Sleep-Deficiency-and-FatigueThe number of health risks in the United States is incredibly high. When employees feel sick or need medical attention, they are entitled to sick days, which means there will be less productivity at the workplace while labor costs will remain the same. Furthermore, other employees will have to do extra work to cover for the sick employee. That is why integration of health and wellness strategies in the workplace is highly recommended. To learn more, checkout this infographic below created by Eastern Kentucky University’s Online Bachelor of Science in Occupational Safety program.



Americans are Sleeping Less


A team from the University of Chicago conducted a study on the sleeping habits of people and how these are affecting their work. They found that Americans have significantly reduced their sleeping time over the years. In the 1970s, the average was 7.1 hours per night. Nowadays, this has been trimmed down to just 6.1 hours per night. Many sleep between one and two less than they did sixty years ago according to the researchers. The statistics regarding those who are currently employed are even more worrying. About 3 in every 10 workers are only able to sleep for about 6 hours or even less.



Workers Short Sleep Duration


The time of work, number of jobs, and number of hours on the job all contribute towards shorter sleep duration. For instance, 44% of them turned out to belong to the night shift while only 28.8% belonged to the dayshift and the rest occupying other time slots. Around 37% of the respondents said that they are juggling two jobs or more and 36.2% declared that they were working more than 40 hours every week.


With these figures, it really is no surprise that their responsibilities are eating away at their resting time. The transportation and warehousing industry is the number one culprit while healthcare and social assistance, along with manufacturing, also contribute greatly to the sleep deprivation of US workers.



Reasons for Sleeping Less


It’s not only the quantity of sleep that is plunging but also the quality. Research shows that between 50 and 70 million adults in the US suffer from sleep disorder. Insomnia is particularly common. Individuals with this condition have difficulty falling asleep or stay sleep throughout the night. Billions of dollars are lost due to absences, accidents, and decreased productivity as a result.


Sleep apnea is another major problem. This breathing disorder can attack for brief periods during the night. These intervals are often enough to wake the person up and prevent restful slumber. It is a fairly widespread condition affecting 22 million Americans.


Some of the problems can be traced not to medical issues but to the working conditions themselves. According to the Bureau of Labor Statistics, at no point have Americans been working longer hours than today. As much as 22 million work outside the typical 9-to-5. These graveyard and rotating shifts result in less than ideal rest. Some are on-call 24/7. Their schedule cuts into their sleeping time by 2 to 4 hours.



Workers with Sleep Problems


Lack of restful slumber has troubling consequences. People become increasingly prone to being injured because of their diminished state. In fact, a look into the accident data shows that most of them occur during periods that are traditionally devoted to sleep: between 12 midnight and 6am, as well as the siesta hours between 1pm and 3 pm.


Working in jobs that have overtime schedules has been linked to a 61% increase in injury hazard rate. Going a little deeper, the risk is greater for people who are over the age of 30 and are sleeping for just 7 hours a night or less. The National Sleep Foundation recommends 7 to 9 hours. Deficit is associated to large-scale disasters like the Chernobyl nuclear tragedy and the Exxon Valdez oil spill.



Steps to Reduce Sleep Problems


For employers, it would be helpful to limit scheduled work to no more than 12 hours a day. Take the leadership in creating a culture that values sleep as a vital part of ensuring productivity. Promote education programs about the subject. Try to reduce shift work, if possible. Devote spaces for quick naps and encourage workers to use them. When the workday is over, let people unplug completely so that they don’t have to bring their tasks at home.


For employees, create healthy habits that will ensure enough rest every night. Avoid late engagements, food, and caffeine prior to bedtime as these will make the body more hyper. Set a period that can be consistently be devoted to slumber. Get in bed, keep the phone away, shut down the computer, and turn off the lights before to scheduled time to eliminate distractions. – See more at:


Brigette Nelson of Express Scripts & Michael Stack of Amaxx To Speak On Opioid Abuse Solution

Managing Morphine Equivalent Dose to Address Solutions for Stakeholders Seeking to Reduce Work Comp Costs


HINGHAM, Massachusetts – Stopping the prescription drug epidemic in the United States and its devastating impact on the workers’ compensation system is the focus of an upcoming presentation at the National Rx Drug Abuse & Heroin Summit in Atlanta March 28-31st.  Brigette Nelson, Senior Vice President of Workers’ Compensation Clinical Management at Express Scripts, and Michael Stack, Principal of Amaxx, a national leader in reducing workers’ compensation program costs, will be headlining the discussion on the effective use of Morphine Equivalent Dose (MED) management.


“Notwithstanding all the discussions about the drug epidemic within the workers’ compensation system, interested stakeholders are failing to implement common sense reforms within the programs,” said Brigette Nelson, Senior Vice President of Workers’ Compensation Clinical Management at Express Scripts.  Nelson continued, “I am excited to be a part of the discussion and look forward to offering solutions to address real issues driving up costs in the workers’ compensation system.”


Morphine Equivalent Dose (MED) is a calculation used to compare and contrast different pain medications to one another. Express Scripts’ MED program calculates the narcotic medication’s morphine-like potency, or MED, at the time it is being filled (before it has been dispensed to the injured worker).  This helps reduce the chances an injured worker will become addicted to prescription pain medication, and can be particularly effective in preventing overdose in those claimant’s consuming 100mg or more of narcotic pain medications.


According to Stack, “The goal of effective MED management is to make sure the injured worker receives the care they are entitled to, but at the same time avoid future problems of addiction.”  The concept is gaining acceptance nationwide in addressing the issues faced by countless workers’ compensation programs.  “The key to the program is controls at the point of sale to ensure only safe medications are dispensed. This program is helping injured workers avoid problems related to prescription drug abuse, and cutting costs” said Stack.


Nelson added, “The goal of the MED program is to not only start a discussion, but provide some real life examples of how MED management works.  Studies demonstrate that when properly implemented, workers’ compensation programs not only reduce the medical portion of a claim, but return employees to work faster.”  Stack also pointed out other benefits of implementing MED management in a workers’ compensation program.  “Everyone has a win through MED management, including the injured worker.”


The presentation titled Pharmacy Pain Points: Ensuring Safety of Morphine Equivalent Dose will take place on Wednesday, March 30, at 3:30pm as as part of the Third Party Payer track at the National Rx Drug Abuse & Heroin Summit.




Overweight and Underpaid: Weight Discrimination at Work

The Centers for Disease Control and Prevention recently found that over 50% of the variation in people’s health was related to social factors – such as income and race – a revelation which has shocked many as some commonly assumed that health behaviors had the largest impact. This finding shows that health diseases like obesity are not solely caused by eating habits, but also factors such as low-incomes. Despite these low-incomes, this infographic shows that obese individuals spend 42% more on health care costs than healthy weight people, putting them in a tremendously vicious cycle.


The following infographic, created by Eastern Kentucky University’s, takes a closer look at the issues and prejudices overweight individuals face in the workplace.


Free “Power Of One” Workers’ Comp Training Series from Amaxx Promises Career Impact

Series Offers How To’s And Strategy For One Individual to Master Organization’s Work Comp Costs


HINGHAM, Mass.—Jan 11, 2015— With regular company mergers, acquisitions, and changes in management, professionals in the workers’ compensation industry know that the only certainty is constant change.  Individuals looking to stabilize and grow their career in the workers’ compensation industry will get practical how-to’s and strategy to master workers’ compensation and positively impact their career.


The series will cover the detailed path of how one individual can drastically influence the cost of workers’ compensation at their organization to make themselves an invaluable asset. Lessons that have been field-tested by Amaxx, workers’ comp cost-control experts, for more than 25 years.


Topics include the specific tasks and systems that create the most impact on work comp costs, how to bring management and employees on board, as well as how to implement these systems to achieve incredible results.


“Besides risk managers and human resources professionals, the training is invaluable for adjusters, vendors, attorneys, brokers, carriers, and anyone else interested in controlling workers’ comp costs,” said Rebecca Shafer, head of Amaxx and America’s leading workers’ comp cost-reduction expert.


Amaxx also recently launched COMPClub, a workers’ comp training service and community that has already attracted 75 members nationally.  COMPClub includes Amaxx’s annually updated cost control guidebook, live workshops, monthly webinars, small-group mastermind calls, a newsletter, networking events and more.


Registration for the free training series, “Power of One: How Your Impact On Workers’ Compensation Will Change Your Career” is available at As supplemental material, those registered will also receive a free copy of “Your Ultimate Guide To Mastering Workers’ Comp Costs – Mini Book”.


Amaxx ( helps employers in all industries reduce workers’ compensation costs through education, publishing and consulting.

Use Investigation To Curtail Work Comp Claim Costs

Investigator Functions:


Using investigators during workers compensation claim handling is often necessary to reduce case cost and exposure.   Investigators may be needed to investigate for fraud, malingering, claimant activity, subrogation, physical inspections of the loss scene, and criminal evidence for prosecution.


Investigators have strong experience and investigative ability that the average claim adjuster is not exposed to.  They may have had police training, special investigative schooling, government training.  Many investigator’s are ex-employees of governmental and law enforcement organizations.


An investigator can perform background investigations of prospective employees.  Such investigations may be necessary for security positions, pre-existing medical conditions, prior claims, past criminal data, or any other facts that can no longer be gained from usual personnel references.  The cost for such investigation may well be worthwhile as it can prevent the hiring of an undesirable candidate.


Investigators are generally required to be licensed by the state, the local municipality, and be cleared by local law enforcement as well.   Most jurisdictions have laws or regulations outlining what a investigator can and cannot do.  These guidelines cover many things.  A few examples are: entrapment, harassment, search and seizure, wiretapping, video and camera filming’s, constitutional violations, safety, and privacy restrictions.



Screening for an Investigator:


It is necessary to screen and explore the qualifications, expertise, and performance of the potential investigator you plan to hire.  Require the candidates to furnish the following:


  1. Resumes for each investigator in the investigator organization.
  2. A complete history of the company, its owners, financials, licenses, and certificates of operation and local police department standing. Retain copies in a permanent file.
  3. Reliable references from other claim units.
  4. An estimate or actual accounting of cases where their work was successful in litigation.
  5. How well and who will testify in litigation proceedings. What is the testimony and witness impression record on judge or jury?
  6. Any records where the investigator organization was sued, faced criminal, or negligent action.


Contracting with an Investigator:


When the unit claim manager is satisfied with the investigator background investigation and is proceeding to engage its services prepare a written contract.  The contract should:


  1. Stipulate authority levels, and the claim file reviewing procedure. Identify the claim persons who will have power to authorized investigator service.
  2. Determine fees, allowable expenses and billing procedure.
  3. State reporting times and procedures (do not allow repetitive information to be entered).
  4. Declare procedures on how to identify and confirm that they have the proper persons under investigation.
  5. State all surveillance should be scheduled when the investigated person will be moving.
  6. Require surveillance be conducted on non-business hours, after storms, weekends and holidays when necessary.
  7. Determine when and how to supply cost estimates, revisions and necessity for changes.
  8. State how to document and preserve evidences for litigation needs.
  9. Site procedures and authorizations to work with employer, defense counsel and other involved entities.
  10. Specify any special reporting procedures required by the employer.
  11. Cover procedure for notification for conflict of interest or any situation that could impede the investigation.
  12. The investigator is not to undertake any investigative step that could be done by the claim adjuster without clearance and authority.
  13. Specify all instances desired for the investigator to contact the adjuster from the field during investigation.
  14. Detail how, and when to request authority to handle an investigation needing special investigation methods.



Controlling the Investigator:


Once the case is assigned and under investigation the claim adjuster needs to be alert to all activity and be pro-active in:


  1. Exploring failures to obtain desired results.
  2. Watching for excess investigator activity.
  3. Limiting waiting time for results.
  4. Exploring any other point of procedure or handling that will or could impact the claim or investigation.




Using investigators in the process of workers compensation claim handling can be a vital tool to curtail, mitigate, limit claim exposure, and reduce file cost.  It should be used when facts indicate potential fraud, malingering, subrogation, field investigation and claimant surveillance when claimant activity becomes suspect.


  • Chose a claim unit investigator wisely.  Investigate for experience, education, qualification, and licensing. Check all references and past performance with their clients.
  • Prepare a contract that clearly declares all methods of operation, fees, and associated expenses.  Clarify reporting requirements, authority, and contact persons.
  • Maintain close follow through contact for desired results.  Do not just assign the case to the investigator and wait.  This can allow for excess activity and billing.



Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a monthly basis working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact:



©2015 Amaxx LLC. All rights reserved under International Copyright Law.


Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Free Workers’ Comp Cost-Control Training Series from Amaxx Covers Success Essentials

HINGHAM, Mass.—Aug 18, 2015—Anyone who’s struggling with spiraling workers’ compensation costs will get answers from a free three-part training series on controlling workers’ compensation costs. 


The series will cover the essential elements of cost containment as field-tested by Amaxx, workers’ comp cost-control experts, for more than 25 years. The first session will be held August 20. 


Topics include essential elements of workers’ comp cost containment that have been implemented by Amaxx at some of the largest self-insured employers in the USA, the counterintuitive first step to getting a program started, how to lay the foundation that will be the cornerstone of a program’s success, as well as how to overcome the most common obstacles to cost control, begin implementation, and start to see results.


“Besides risk managers and human resources professionals, the training is invaluable for adjusters, vendors, attorneys, brokers, carriers, and anyone else interested in controlling workers’ comp costs,” said Rebecca Shafer, head of Amaxx and America’s leading workers’ comp cost-reduction expert.


Amaxx also recently launched COMPClub, a workers’ comp training service and community that has already attracted 65 members nationally.  COMPClub includes Amaxx’s annually updated cost control guidebook, live workshops, monthly webinars, small-group mastermind calls, a newsletter, networking events and more.


More information on and registration for the free training series, “Essential Elements of Worker’s Comp Cost Containment” is available at


When To Update Work Comp Reserves To Reflect Exposure

Reserving a file is extremely complicated.  It is probably the one of the most difficult aspects of working a claims desk.  As if keeping up with cost trends is not hard enough, the mere fact that no two files are the same only add to the complication. 


There are many factors to consider, including not only the medical and wage exposure itself, but also the comorbidities of the patient involved.  You have to consider their own personal medical issues both occupational and non-occupational, their body habitus, age, secondary gains, social influences, motivation, employer/employee relationship, and the list can go on.



Base Reserve Is Set At File Inception


For most carriers, a base reserve or default is set in the file at its inception.  This merely indicates whether the claim is a medical only or if it shows lost time potential right from the start.  All carriers are different and have different policies, but for the most part some sort of reserve is supposed to be set within 30 days of receipt of the claim.


This 30-day base reserve reflects known exposure at that time.  Within 30 days, the adjuster should have a good idea of the potential outcome of the claim.  But as we know, potential outcomes change with the weather.


So when is the appropriate time to adjust the reserve again?  Common claim practices will tell you to adjust the reserve when something changes the exposure.  However, anything can change the exposure.  Therapy failing?  Lack of a promised light duty job? Injections did not help resolve the injury?  These are all failed projections that on paper looked to hold some promise to resolve the claim.  So, should the reserve increase by several tens of thousands of dollars when each or all of the above fail to yield promise?


The answer is maybe.  The issue here is to look at the risk drivers on each file, along with the injury itself.  Has an Independent Medical Exam been completed?  Have proper diagnostics showed objective evidence of surgical issues?  If the answer to all of the above is yes, then I think the adjuster would have enough medical and objective evidence to warrant an increase based on known exposure at that time.


However, there are additional things to consider.  Those include surgical likelihood, prognosis post-operative, potential for permanent restrictions, vocational aspects, legal probability with a denial or dispute on coverage, etc.


Additional Resource: 

Your Ultimate Guide To Mastering Workers Comp Costs Excerpt…Reserving Practices and The 5 Reasons Reserves Are Higher Than Expected


Anything Can Change The Exposure At Any Time


Anything can change the exposure at any time.  A good adjuster will always be a few steps ahead.  Most claims start out with minimal exposure, but the adjuster has to look beyond that.  This information should be coming from the employer early on, namely return to light duty work potential, and the overall history of the claimant that comes from the employer.  Is this worker plagued with a large claim history?  Are they a long term worker with an occupational exposure issues?  Did they also have personal medical leaves, prior surgical issues, attendance problems, and so on.  This is the first clue that this claim will not be a nominal medical only.


The adjuster has to put enough reserves in within the first 30 day period to expect the unexpected.  If the adjuster failed to do so at that point, then they are not considering proper exposure on the file.  If that did happen, then this claim will be destined for stair-stepping of reserves–quite possibly considered the biggest no-no in the insurance world. 


Most carriers state that the ultimate exposure on the file should be placed within one year from the injury date.  So between that first initial 30-day period, and the one year period, what would drive a reserve increase, and when should it be completed?


The answer will depend on the injury, the surgical probability, and the invasiveness of the treatment involved.  Add to that the light duty work probability, the long-term light duty work accommodation possibility if any, and then the secondary gain aspects the claimant may have—including litigation probability.  Any or all of those aspects have a large effect on the reserving of the claim, and before that adjuster pulls the trigger on a reserve increase they have to consider both the known and the unknown, along with the probability of invasive medical treatment including multiple surgeries, extended rehab and recovery, medication changes, etc.




There Is No One Answer – All Parties Need To Work Together To Arrive At Game Plan


If you had expected this article to give you the ultimate answer of how and when to increase a reserve, you are now starting to understand the complexity of reserving and how difficult it is to complete that task.  The real answer is that there is not one aspect.  The answer of when to pull that trigger involves a myriad of possibilities.  The only way it can be successful is when all parties are involved in the claim.  This includes the employer, the adjuster, a nurse case manager, and possibly legal counsel.  Everyone has to arrive at a game plan, and a number to reflect the known and unknown exposure on a claim.


The simple answer is this:  Expecting and reserving for a worst case scenario is OK.  A better than expected recovery is a good thing, and taking down a large reserve number at the time a file closes is a good thing.  However, under-reserving and stair-stepping a reserve is always never looked upon favorably.  The adjuster has to take the proper time to reflect on the file from all avenues, all probable outcomes, and all contributing factors.  Failure to address each aspect on its own merits will result in disaster.



Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, and founder of COMPClub an interactive training program teaching workers’ comp cost containment best practices.  Through this platform he is in the trenches on a monthly basis with risk managers, brokers, consultants, attorney’s, and adjusters teaching timeless workers’ comp cost containment strategies, as well as working with members to develop new tactics and systems to address the issues facing organizations today. This unique position allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact:


©2015 Amaxx LLC. All rights reserved under International Copyright Law.


Employers/Carriers/TPAs/Brokers/Vendors looking for additional information FREE resources for Workers Comp cost containment best practices are invited to access Amaxx Workers’ Comp Cost Containment Essentials training series


Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.



Workers Comp And The Most Dangerous Industries In The U.S.

This infographic was created by Eastern Kentucky University’s Bachelor of Science in Occupational Safety program.  


Cost Containment For The Claims Management Team

The workers’ compensation claim management team is charged with numerous responsibilities.  One of the more important functions is to ensure the claim is being properly managed with the containment of wage loss and other indemnity benefits.  This is a multi-factored process that requires skill and dedication from all team members.



Independent Medical Examinations and Other Experts


Use of the independent medical examination (IME) is usually the sole opportunity the employer/insurer has to defend a claim with a medical expert of their choice.  This is a right governed by the pertinent workers’ compensation act and must fit into specific parameters.  Some of the more important guidelines include:


  • Distance an employee can be required to travel for the evaluation;
  • Reimbursements that must be made prior to or immediately after the examination; and
  • Timing of the evaluation and service/filing requirements of the report.


Not every case will require an IME, so it is important to properly evaluate the case and make sure all pertinent documents are received prior to scheduling the evaluation.



Use of Vocational Experts


Other vocational experts often are used when evaluating an employee for return-to-work, work hardening, job search efforts and retraining.  They can also be used in cases where the employee is claiming entitlement to permanent total disability (PTD) benefits.  Laws regarding the use of vocational experts vary and may be subject to other statutory or regulatory guidelines.  Before scheduling a vocational examination, it is important to check into the following matters:


  • The qualifications, training and expertise of a vocational expert;
  • Investigation into the claims being made by the injured worker and whether such an evaluation is ripe for additional scrutiny; and
  • The ability of the vocational expert to give credible live courtroom testimony; if permitted.


The use of a Functional Capacity Evaluation (FCE) is also important.  A FCE is defined by some as a “set of tests, practices and observations that are combined to determine the ability of the evaluated to function in a variety of circumstances, most often employment, in an objective manner.”


During a FCE, the injured party will typically meet with a neutral vocational expert, or one chosen by the employer/insurer and perform a series of tests.  This can include written tests to measure the claimant’s cognitive and educational functions.  In other parts of a FCE, the employee will undergo a battery of physical tests to assess the appropriateness of work restrictions in place by medical doctors and evaluate their ability for participation in work hardening, retraining or other rehabilitation efforts.



Telephonic (or Internet) Case Management or Intervention


Changes in technology are creating new opportunities to reduce the costs of managing a workers’ compensation claim.  Due to the increase in accessibility of technology, claim management teams can reduce costs of handling claims via the telephone and Internet.  While laws are slow to adapt, change is coming to how claims will continue to provide injured claimants with the care they deserve, while at the same time providing cost effective alternatives to those concerned about claims administration and proper handling.





Claims management teams seeking efficiency need to evaluate their programs and adapt to changing times in order to remain competitive.  These changes can be made without sacrificing the rights of injured workers.

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