How To Use Central Index Bureau To Stop Workers’ Comp Fraud

One of the best fraud fighting tools is provided by the Central Index Bureau report, a division of the Insurance Services Office. It is known as a Central Index Bureau report, a CIB report, an ISO, or as a claim index. The terminology varies from insurance company to insurance company. Regardless of the name, the CIB is a basic record of the insurance claims filed by an individual. What makes it effective is it is one of the very few areas where insurance companies share information.

 

Over 90 percent of all insurance companies are members of the ISO Central Index Bureau. Be sure your insurer is a member too. If not, the insurance company may be paying fraudulent claims which will have an adverse impact on workers compensation insurance premiums.

 

 

Information Reported to Central Database On Every Claim

 

When one of the employees files a workers compensation claim, the basic information about the claim and the claimant (employee) is obtained. The CIB report will contain the claimant’s name, social security number, maiden names, aliases or former names if known as well as address, former addresses if known, occupation, and date of birth. The CIB report will include the accident location, the date of the accident and the alleged injuries. It will identify the type of injury whether it is automobile bodily injury, general liability bodily injury, automobile medical payments or PIP, workers compensation, homeowner’s liability, medical malpractice, or a non-occupational disability claim.

 

The report will identify the medical provider by name and address as well as the lawyer’s name and address if the claimant is represented. The report will also contain the adjuster’s name, the name of the insurance company (or third party administrator), the insurance company’s address, and even the adjuster’s phone number. It identifies who the insured is for the insurance company and the insured’s address.

 

 

Protect Yourself From Paying For Prior Injuries

 

Why is all this information reported to the insurance services office on every insurance claim, including property claims? The reason is to protect the insurance company from paying for a prior injury. The claimant’s attorney is not going to tell the insurance adjuster that he has previously represented Mr. Bad Luck on his five previous injuries, two auto accidents, one slip and fall, and two workers compensation claims against five prior insurance companies.

 

 

Example: Employee Sustains Injury Every Deer Hunting Season

 

Take the example of Mr. Bad Luck. When the workers compensation adjuster interviewed Mr. Luck, he stated he was in excellent health, had never had a real injury before, but now he severely injures his back. The adjuster is alert. She electronically files the Central Index Bureau report and receives an electronic report that lists all the information on Mr. Bad Luck, even though his social security number was changed 3 times and his address four times. Suddenly the claimant has selective memory about previous injuries.

 

In one claim file audit of governmental pool‘s workers compensation claims, the auditor notices the adjuster has received 18 hits (prior injury claims) on one unfortunate employee. The employee was employed 17 years with the same city government during each of the 18 workers compensation injuries. Of the 18 injuries, 14 of the injuries occurred in the first two weeks of November in fourteen different years. It turns out the claimant is a deer hunter, and deer season is the last two weeks of November.

 

Fortunately the claimant always made a fairly quick recovery from various strains and sprains and was able to return to work on the first Monday of each December. The claimant is committing fraud by taking a two to four week leave of absence each year paid for by workers compensation. The employer knew this, and the adjuster knew it too. Why they did not prosecute the claimant for fraud is unknown.

 

 

Fraudulent Employees Often Switch Doctors

 

Please note that most adjusters reviewing a case like this will be aggressive about the claim when the claimant is alleging a new injury to a body part that was part of a prior injury claim.

 

Injured employees like Mr. Bad Luck above will often change doctors so that they can tell the doctor they have no previous injuries. The smart adjuster will share the information with the medical providers on the claimant’s prior injury by obtaining and providing the relevant medical records from the prior medical providers. Also, there is something about the claimant knowing the adjuster is aware of prior injury claims causing many claimants, even those represented by an attorney, to make a speedy recovery.

 

 

Central Index Bureau Submission as Standard Best Practice

 

Make sure the use of Central Index Bureau submissions is a standard part of best practices and is included in your account handling instructions.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, 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 is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 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.

Know Your Role To Take Control of Work Comp Costs

If you leave the management of the workers compensation claims to chance, the chances are you will not have good results.  To have good results in the control of the workers comp claims, it is important that everyone involved – the workers compensation claim coordinator, the floor or field supervisors, mid-management, medical personnel, legal, senior management and even the employees know what roles and responsibilities are in the management of the workers comp claims.

 

Take Control

 

Start by assigning roles and responsibilities to one or more parties in the process – it is a step that can be taken to get things on track. You do not need to assign ALL roles immediately, just take it one step at a time.

 

The duties of every person involved in the workers comp claim from the claim coordinator to the employee should be defined and written down for each participant.  This includes both the pre-accident responsibilities, as well as, the post injury response.  By knowing what is expected of them, each person will be able to take the appropriate action when an injury occurs.

 

 

 

Claims Coordinator Responsibilities

 

The workers comp claims coordinator, whether a full-time job at a medium-size or large employer, or a part-time job at a smaller employer, is the pivotal person in controlling the workers comp claims.  The claims coordinator can be a part of the risk management department or a part of finance or human resources.  The important thing is the claims coordinator has access to all information necessary to control the claim.

 

  1. Establishing a transitional duty program prior to injuries occurring
  2. Providing all new hires and providing annually to current employees the employee brochure on what to do in case of an accident
  3. Arranging immediate medical care at the required medical provider or at the recommended medical provider
  4. Providing the medical provider with a detailed job description prior to the employee arriving for the initial medical treatment
  5. Interviewing the injured employee to obtain a detailed description of how the injury occurred.
  6. Interviewing the employee’s supervisor to verify the description of the accident and what could have been done to prevent the accident from occurring.
  7. Completing the First Report of Injury and providing it to the claims office on the day of the injury
  8. Contacting the employee immediately following the initial medical treatment for the diagnosis, prognosis and expected period of disability, if any
  9. Arranging for light duty / transitional duty / modified duty for the injured employee
  10. Sending the employee a get well card when the employee will be off work
  11. Maintaining weekly telephone contact with the employee while the employee is treating weekly and telephone contact following each medical visit thereafter.
  12. Facilitating on-going contact with the claims adjuster and the nurse case manager.
  13. Coordinating and completing all necessary paper work related to the claim.

 

 

Post-Accident Responsibilities of the Supervisor

 

The employee’s supervisor has pre-accident responsibilities to ensure all employees work in a safe and prudent manner.

 

  1. Accompanying the injured employee to the required or recommended medical provider.
  2. Providing the medical provider with the Work Ability Form and obtaining the completed form from the medical provider’s office
  3. Submitting the Work Ability Form, the Supervisor’s Report of Accident, the Employee Report of Injury and the Witness Report Form to the workers compensation claims coordinator.
  4. Enforcing compliance with the transitional duty program and verifying the work done by employees on modified duty is in accordance to the medical provider’s limitations.
  5. Training all his/her employees on what to do in case of an injury.

 

 

Employee’s Role and Responsibilities

 

The employee needs to be involved in the control of workers compensation claims.

 

  1. Participate in post-injury response training.
  2. Participate in the return-to-work transitional duty program
  3. Attend all employee weekly meetings/office meetings unless physically unable to get to the work-site
  4. Provide the Work Ability Form to the supervisor or claims coordinator after each doctor’s visit.

 

Management Roles and Responsibilities

 

The Best Practices for Injury Management also applies to middle and senior management. Management should have defined roles and responsibilities.

 

  1. Providing a strong safety program and implementing the necessary risk management practices to keep as many workers comp claims from occurring as possible.
  2. Knowing the monthly and on-going cost of workers compensation.
  3. Communicating to the employees how many additional sales or how much additional production is necessary to cover the cost of workers compensation claims.
  4. Determining the medical providers that will be used
  5. Determining the insurance carrier or the third party administrator.
  6. Tracking and reporting lost work days.

 

In addition to the Best Practices for Injury Management noted above, there are best practices for risk managers, medical directors, in-house medical clinics and in-house legal.  These sample best practices listed here are far from complete.  Contact us to learn more about how to control workers comp cost through Best Practices for Injury Management.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, 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 is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 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.

Two Reasons Employees Do Not File Work Comp Claims

There are times that an employee might not pursue a claim or might not have a claim for a work related injury.  While this is uncommon for employees, it does happen.

 

 

Reason1 – Excluded People (no coverage)

 

State Requirements

 

If an employer does not meet a state’s requirements for workers comp insurance, the employee might not have a claim. For example, where states require employers with three or more employees to carry workers comp insurance, and the employer only has two employees, the injured employee would not be able to file for workers’ comp.

 

In addition, some states exclude farm laborers, seasonal workers, domestic servants, real estate agents and direct sellers from coverage in their workers comp statutes.  If one of these employees is injured on the job, they have an option to sue their employer if they believe the employer’s actions caused their injuries.

 

Sole Proprietors and Partners

 

Injured employees that are sole proprietors or a partner in a business are not covered for a workers’ comp injury unless they purchased a workers’ comp insurance policy. Most sole proprietors do not carry this insurance.

 

 

Reason 2-Pursuing a Tort Claim (looking for the deepest pocket)

 

Choosing Own Medical Provider and Pursuing Bigger Settlements

 

In states where a workers’ comp insurer has full rights to subrogation recovery, employees will sometimes not pursue the injury claim against the employer because they want to choose their own medical provider.  For example, if the employee is a traveling salesperson injured in an automobile accident where a third party was at fault, the employee may not file a claim where the accident occurred in a state where the employer controls selection of medical providers and the employer/insurer has full subrogation rights. Instead of the employee being treated by the medical provider selected by the employer or the employer’s insurance company, the employee is treated by a medical provider selected by the employee’s attorney. The attorney may recommend a liberal medical provider who will keep the employee coming back for additional treatment for as long as possible. .

 

 

The longer the employee is off work and the higher the medical bills are, the greater the settlement the employee’s attorney can demand from the insurer of the vehicle at fault in the auto accident.  Attorneys representing injured employees often tell their clients that they can get a much bigger settlement through the tort system than they can through workers comp.

 

 

Injury on a Construction Site

 

An injured employee might opt out of filing a workers’ compensation claim where the injury occurred on a construction site. On a large construction project there are often various subcontractors working at the same time. The employee might have been injured due to the negligence of a third party. The employee again will have the choice between pursuing the claim for personal injury against the responsible party or filing a workers’ compensation injury claim. In states where workers comp insurers right of subrogation has been diminished or taken away, the employee’s attorney will often pursue both types of claims simultaneously.

 

 

Delivery People

 

A delivery person who trips and falls on a defective sidewalk belonging to a business where the employee is making a delivery might choose to pursue a tort claim.   While a delivery person has the right to pursue a workers’ comp claim against the employer, the property owner likely has liability insurance. The award that can be collected on the tort claim may surpass what can be collected on a workers’ comp claim.

 

 

Summary

While an employee usually will not opt out of coverage for a workers’ comp claim, it does happen. There are also times when insurance coverage does not apply to the work related injury. It is important for an employer to know when this occurs and to keep in close contact with the employee in case circumstances change.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, 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 is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 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.

3 Indicators Open Work Comp Claims Are Ready to Settle

Spring is in the air—time to do some spring clean.  This should not be limited to your home.  Use it as an opportunity to employ creative settlement strategies and close out those troublesome files and legacy claims that have been collecting dust in your claims department.

 

 

How to Get Started?

 

The first step in the process is to identify cases that are prime for settlement.  This should start with a review of all open files.  Indicators that a workers’ compensation file might be ready for settlement include:

 

  1. Cases where the employee is at, or should be at maximum medical improvement (MMI)/end of healing period. Identification of this factor includes evidence of a healing plateau or continued medical care without improvement of symptomology.

 

  1. Cases where the employee is nearing the end of entitlement for temporary total disability benefits or other wage loss benefits. Most jurisdictions cap the number of weeks an injured worker is entitled to various indemnity benefits.  It is important to review these cases for settlement as it could very well morph into a claim for permanent total disability benefits or costly retraining benefits.

 

  1. Cases where the employee has recently or will become eligible for Social Security Disability and/or Medicare benefits. Entitlement to these benefits drives claims toward the contention the employee is permanently and totally disabled.  These files require an analysis for exposure regarding future medical benefits, including the recommendation for a Medicare Set-aside (MSA).

 

Once you have identified claims ready for settlement, it is important to contact the employee or their attorney regarding settlement.  What do you have to lose?  Nothing!

 

 

Settling Troublesome Cases: Time to Think Outside the Box

 

Settling a workers’ compensation case is like making a sales pitch.  Preparation is key.  This includes thinking of the various alternatives and developing a strategy.  There are also several tools the proactive claims management team has available to kick-start settlement discussions.

 

  • Independent Medical Examinations (IME): Scheduling an IME is a great opportunity to move a case toward settlement.  This can be especially useful for legacy cases where the employee’s treatment has been inconsistent or sporadic.  The findings from an IME can also be used to initiate litigation with the intent of moving the claims file toward settlement.

 

  • Mediation: This is one of the most underutilized tools in workers’ compensation.  Mediation allows for all interested stakeholders to have a voice and role in settling a claim.  It can also be beneficial to understand the concerns of an injured employee and tailor a settlement to suit their needs.

 

  • Structured settlements: This tool can be used effectively in many instances—not just high value settlements.  The employee receives the full value of their settlement, which is paid out over a period of time via an annuity.  There is built-in “savings” when using this tool the insurance carrier receives based on the actual cost of purchasing an annuity contract.  All parties receive “free” advice and services as the broker who prepares the quote and necessary paperwork is paid via commission from the life insurance carrier who initiates the annuity.

 

  • Medicare Set-asides: Failure to settle cases involving Medicare beneficiaries (or those soon to be entitled) is driven mainly by an irrational fear of being reasonable.  This excessive caution can lead to delay and lost settlement opportunities.  Using a service provider to evaluate the risks is helpful.

 

 

Conclusions

 

It is time for spring cleaning in your claims department.  Now is the time to dust off your troublesome files and think about settlement.  This requires interested stakeholders to review their files, engage the other side and use creativity to drive settlements.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, 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 is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 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.

RIMS 2017 Conference and Other News Tidbits

RIMS Conference 2017: Disrupt the Status Quo & Join the Risk Revolution

“RIMS Annual Conference is a must do for any level of risk professional. By attending you can increase your knowledge and walk away with better deals on your insurance renewals. The conference is well worth every moment.” – RIMS 2016 Attendee

 

 

RIMS 2017 Live Streaming | Monday, April 24 (RIMS Members Only)

RIMS will be streaming RIMS 2017 live on Monday, April 24 at 8:30 am EDT – just for RIMS members. Watch the General Session and Awards Luncheon. Register now and watch for free.

 

 

Derreck Kayongo To Deliver RIMS 2017 Opening Keynote

Have you ever wondered what happens to that barely used bar of soap in your hotel room? This guy did, and he didn’t like the answer. So Derreck Kayongo talked hotels into donating their used bars of soap instead of throwing them away. His Global Soap Project takes donated, melted, purified and reprocessed hotel soap and redistributes it to vulnerable populations around the world. This successful entrepreneur is a renowned expert in environmental sustainability and global health and is using his knowledge to disrupt the way hotels dispose of their “trash.”

 

 

Broadspire Joins City of Murals w/ Jane Golden at RIMS 2017

Look for Jane Golden of @muralarts in Booth 701 on Monday 4/24.

 

 

Tips to Prevent Prescription Drug Abuse at Home

The National Prescription Drug Take Back Day aims to provide a safe, convenient, and responsible means of disposing of prescription drugs. Prescription drug abuse has reached epidemic proportions across the U.S. According to the National Survey on Drug Use and Health, more than 6 million Americans abuse prescription drugs, and much of the abuse begins at home. In fact, more than 70% of those who illegally use prescription pain relievers obtained them through friends or family, including surreptitiously raiding the home medicine cabinet.

 

 

 

Author Michael Stack, Principal, 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 is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 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.

6 Steps to Identify and Address Mental Health Challenges Early

The days of focusing solely on an injured worker’s physical injuries are over. Savvy employers and payers are finding that ignoring behavioral issues can end up costing a boatload of money in delayed recoveries. Early intervention, good communication and worker advocacy are among the best practices to use.

 

Injured workers who have, or develop undiagnosed and untreated behavioral health issues are more likely to fall into the ‘creeping catastrophic’ claim pool; a simple meniscus tear that degenerates into a months- or years-long claim with multiple treatments and medications — and exorbitant costs.

 

Identifying and treating these issues is tricky. The stigma attached to mental health issues prevents many people from seeking treatment; providers and claims handlers are often unfamiliar with signs and symptoms; and payers may be reluctant to pay for something they believe is unrelated to the actual injury. However, it behooves employers and other payers to at least consider ways to target behavioral health issues among their injured workers.

 

 

Behavioral Health Issues

 

Behavioral health issues — also called mental health or psychosocial — include a variety of diagnoses. Anxiety and depression are the ones more commonly seen among injured workers.

 

In addition to an extended duration of the claim, some signs that may indicate a psychosocial issue is present include:

 

  • Pain develops due to non-medical issues.
  • Function does not improve.
  • Multiple providers are involved.
  • Visits to the emergency room with drug seeking behavior.
  • Overutilization of treatments.
  • Catastrophic thinking.
  • Perceived injustice, toward the employer or others.

 

There are myriad reasons why some injured workers develop psychosocial issues, related to such things as adverse childhood experiences, environmental stimuli or genetics. The important thing is to identify them and intervene as early as possible.

 

Identification

 

Training and education are key to uncovering psychosocial issues. Most claims handlers as well as medical providers and others don’t have the backgrounds to detect psychosocial issues.

The injured worker, supervisors, and all others involved in the claim should also be trained to understand the realities of mental health issues. Soft skills, such as communication, conflict resolution, and identifying potential issues should be included.

 

Contact with all injured workers soon after the injury and on an ongoing basis is a best practice. During the conversations, certain screening questions can be asked that might trigger a red flag for potential issues:

 

  • When do you think you will be going back to work?
  • How are you doing?
  • Have you talked with your employer?
  • What does your treating physician say about your recovery and return to work?

 

Such questions can reveal the injured worker’s overall feelings toward his workplace. The answers might signal contention between the injured worker and his supervisor and/or colleagues.

 

The person’s sense of control, or lack thereof over his work can also be an indicator of stress and, potentially, psychosocial issues. People who feel they have little or no control tend to experience more stress. The lack of a sense of belonging at the company, and concerns about job security may also lead to psychosocial issues. The injured worker needs to know his job is safe and that you want him back on the job as soon as possible, even if that means doing light duty.

 

 

Interventions

 

There are formal programs to address injured workers with psychosocial issues. Companies looking to develop their own programs should consider the following:

 

 

Special Attention

 

Once an injured worker has been deemed a potential risk for psychosocial issues, the claim should be handled by those who have been trained and have an understanding of the challenges. Specialized claims adjusters, for example should be assigned the claim. The injured worker should be given a detailed outline of the workers’ compensation process and understand what to expect and what is expected of him. He should be made to realize he does have control over his own recovery.

 

 

Team approach

 

The Claims adjuster, nurse case manager, treating physician, injured worker and anyone else should work together on the claim. The treating physician, for example, needs to be a part of the effort to avoid him undercutting the team’s efforts.

 

 

Clinical interventions with a work focus

 

The injured worker should have access to a mental health provider as soon as possible. If your company or insurer does not already have a psychologist in the network, working with a local provider should be considered. Community resources can be checked to see what is available.

 

 

Goal setting  

 

Working together the team should establish timeframes for various aspects of the recovery, with the injured worker’s buy-in. The focus should be on the injured worker’s abilities, rather than his disability. The employer must be open to allowing the injured worker to return in a light- or modified-duty capacity.

 

 

Conclusion

 

Some state workers’ compensation laws allow coverage for mental injuries while others do not. Regardless of the regulations in a particular jurisdiction, taking a proactive stance and, perhaps spending some money at the beginning of a claim will generally be much more cost effective than ignoring psychosocial issues.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, 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 is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 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.

Two Key Aspects To Controlling Workers’ Comp Medical Costs

Medical costs continue to be a significant driver in workers’ compensation claims across the United States.  This is due to a number of different factors, which include fraud, waste and abuse within the system.  In other instances, the increase in medical specialization is a driver of costs, which can lead to duplicative and unnecessary care.  When this takes place in the context of a workers’ compensation claim, the result is an unnecessary financial burden to the program.

 

Now is the time for members of the claims management team and other interested stakeholders to take control of their programs.  One important way to do this is by being proactive on the medical factors of claims and to direct effective medical care and treatment.

 

 

Responding to Injuries

 

All employers, regardless of size need to take a proactive and immediate approach to every workplace injury.  This includes personnel within the work environment who know how to provide medical care and being responsive to employees who suffer an injury.  Other key elements of an immediate and effective injury response include:

 

  • Rapid response to injury and with 24/7 nurse triage hotline. Time is of the essence to triage the injury and direct the employee to the right level of medical care, whether home treatment or the appropriate medical provider. The ability to use a 24/7 nurse triage hotline is not affected by differences in state laws regarding directing medical care.

 

  • Transportation to a medical facility is also an important component of responding to a work injury. This includes providing a means of transportation for a person who does not need an ambulance.  Instead of making that person drive himself or herself to the appropriate facility, an employer representative should make every effort to provide transportation.  This best practice demonstrates “good will”, and ensures the employee arrives at the medical provider to receive treatment.

 

 

Working with Treating Physicians

 

Having a designated medical facility for initial post-injury care does not preclude an injured worker from seeking future treatment at another location.  It is a general rule that employees suffering from the effects of a work injury have the right to choose their initial medical provider and seek care from a facility of their choosing.  It is important for members of the claim management team to communicate effectively with these treating physicians.

 

When working with the employee’s treating physician, claims handlers and other interested stakeholders should also keep the following factors in mind:

 

  • Professionalism: As a claim hander, you are the “face” of the employer and insurer.  Claim handlers need to understand and respect the doctor-patient relationship.   It is important to be patient and professional at all times. While state and federal privacy laws are relaxed in the context of a workers’ compensation claim, disclosure of information may be delayed.

 

  • Cooperation: This is an essential key when dealing with contentious matters such as workers’ compensation claims.  Building and maintaining cooperation is a two-way street.  Always seek to be a problem solver, not cause them.

 

  • Relationships: People like to do with business with people they like.  This includes working with medical professionals and the injured party.  The expression, “You catch more flies with honey than you do with vinegar,” is something to consider.  An employee suffering from a work injury has a number of worries beyond recovering from the incident.  This includes financial, emotional and family pressures.  Always seek understanding and approach every employee as a person, not just another claimant.

 

 

Conclusions

 

There are no simple solutions to reducing the medical aspects of a workers’ compensation.  Interested stakeholders can take a significant step to addressing this issue through a proactive approach to directing medical care in all injury-related claims.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, 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 is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 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.

4 Communication Strategies to Lower Workers Comp Costs

Here’s a sobering reality: most of the world does not understand the workers’ compensation system. Unless they themselves or a family member has sustained an occupational injury, most people haven’t the foggiest idea how the whole process is supposed to work.

 

That means it’s up to us to make sure an injured worker gets a clear understanding. Why? Because confusion and misunderstandings about the system drive up claims costs. People are afraid and don’t know how or when they will receive medical care or another paycheck. The way the system has historically worked clearly does not help the situation.

 

Think about it. There may be notifications from the claims adjuster, claims administrator, third-party administrator, insurer, pharmacy benefit manager, employer, medical provider or the case manager; with questions or information about the DOI, future medicals, impairment ratings, TTD/TPD/PPD, MMI, or FCE. Add to that a few comorbidities and biopsychosocial risk factors and it’s no wonder some cases go south.

 

 

Effective Communication

 

Ideally, you want the injured worker engaged in the recovery process so he’s motivated to get back to function and work as quickly as possible. Building trust is key. Training supervisors and managers on communication skills can go a long way to preventing animosity; i.e., delayed recoveries, litigation, etc.

 

 

Words

 

What you say has a big impact on how an injured worker responds to the workers’ comp process. You want to avoid creating animosity. Some tips on what to say (or not) include:

 

  • Don’t start sentences with ‘you.’ You don’t want to make accusations against the injured worker. Even if that is not the intention, sentences that start with ‘you’ may be perceived that way.
  • Avoid ‘never’ and ‘always.’ You want to be honest with the injured worker and show you are willing to work with him. Such definitive words may prematurely end a discussion, or provide false hope — neither of which will help.
  • Be positive. Use words that exude optimism. Let the worker know her job is not in danger and you are expecting and looking forward to her returning to work as soon as possible.
  • Use clear and concise language. The person speaking with the injured worker should have his message set and know what and how he plans to say before the conversation starts.

 

 

Tone/Attitude

 

It’s not only important what you say, but how you say it that matters. As the old adage goes, you catch more flies with honey than vinegar.

 

  • Be supportive. Ask the injured worker how he is doing, not only with his injury but overall. Find out if he’s experiencing any particular hardships with which you might be able to help, such as speaking with family members about the workers’ compensation process. Indicate you are interested in him as a person. Also, talk about what the person can do, rather than what he can’t due because of the injury.

 

  • Be friendly. Be polite and nice. Smiling when you speak is a trick used by radio announcers, as it affects how you come across to others.

 

 

Listen

 

Injured workers are often confused about their injuries and how the workers’ compensation process works. Give them a chance to say and ask what they want. Be open to hearing the injured worker’s point of view. Be an active listener by asking clarifying questions and paraphrasing what the person has said to make sure you understand.

 

 

Frequency

 

It’s imperative to keep the injured worker engaged throughout the claims process. That means maintaining regular communication in whatever forms best meet the injured worker’s needs, whether it be via phone, text, email, letter, etc.

 

The first contact should be made immediately following an injury, to show the person you care and are there for them. A phone call is typically best at this stage, as it provides for interpersonal communication. It’s also important to let the injured worker know what to expect throughout the claims process. Some organizations have developed brochures that clearly and concisely explain the workers’ compensation process. At the least, you can verbally tell the worker what he can expect.

 

Ongoing communications should focus on informing the injured worker about the status of his claim, in addition to continuing to show your support and concern. Also, convey the message that the person is still a valued employee. Update him on work-related goings on and send him any newsletters or other communications so he feels he is still part of the workplace. A get-well card signed by coworkers also helps them feel a part of the company.

 

It’s important that all communication with the injured worker is consistent. You should work with the claims handling team, providers, and others to ensure you are all on the same page.

 

 

Summary

 

Fear, misunderstandings and hurt feelings are prime drivers of adversarial relations between injured workers and employers. By working on communication skills and training all who play a part in the claims process, organizations can ensure their injured workers are on board with their recoveries and return-to-work processes.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, 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 is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 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.

Claims Investigations 101: What Every Claim Handler Needs to Know

Investigating a workers’ compensation claim is an important step in claims management, however it can easily be overlooked or poorly done.  Now is the time to review how you investigate claims regardless of experience.  Doing so can save you time and ensure your program is effective and efficient.

 

 

First Things First: Determine Coverage

 

A workers’ compensation insurance carrier is responsible for a claim if they are contracted to provide coverage for an employer/insured.  This is something that should be verified from the onset of claim in order to avoid confusion later on in the process.

 

Verifying coverage is especially important in workers’ compensation cases that involve industrial exposure issues such as asbestos or repetitive trauma occurring over a period of time.  In other instances, insured falling into high-risk categories have multiple insurance carriers.  Conducting a diligent investigation on this matter may result in allowing a carrier to deny liability or identify other parties who may be responsible.

 

Important data points to consider as part of this review include:

 

  • Listed dates of injury on a claim petition;
  • Policy exclusions based on an employee’s different locations of employment; and
  • Dates when a policy was in force along with the requisite policy number(s).

 

 

Witness Identification 

 

All successful claim handlers need to be great sleuths.  They are given a limited set of facts found on the initial claim forms.  It is then their duty to ask questions and locate answers.  Part of this includes locating people who have information concerning the employee and the work injury.  Important people to consider include:

 

  • Employer: This includes not only the employee’s supervisor, but also other people who have contact with the injured party and understand their work activities.  It is especially important in claims subject to dispute such as unexplained injuries or those that take place over the course of time.

 

  • Other Fact Witnesses: These include a broad category of people.  It can include people who witnessed the accident in question, work directly with or have regular contact with the employee.  It is important to determine what information these persons have and also evaluate their credibility.

 

  • Employee: Contact with the employee is also important.  Not only will you be in contact with the employee as part of the injury report, but also following the injury as the claim handler manages the case.  Part of this contact may include a recorded statement.  When engaging in this activity, be sure to understand applicable rules and how to preserve it for use in litigation.

 

  • Expert Witnesses: The increasing sophistication and due process safeguards in workers’ compensation cases is leading to the growing us of experts.  This obviously includes medical doctors to address issues such as causation, the mechanism of injury and reasonableness/necessity of care.  Other experts include vocational rehabilitation counselors and others who can comment on design and safety matters.

 

 

Other Important Components of the Investigation

 

Members of the claims management team are responsible for investigating the claim at its onset.  This includes a number of other important considerations:

 

  • Determining issues of compensability. This goes beyond a determination of coverage and includes the threshold issue of all workers’ compensation claims—whether the injury “arose out of” and was “in the course of” employment;

 

  • Handling the injury triage and making sure the employee receives the medical care and treatment they are entitled to receive;

 

  • Obtain appropriate authorizations. This includes a number of different documents such as medical, insurance, workers’ compensation records and Social Security verification to name a few.

 

 

Organization is Key

 

A well-organized claim file can provide efficiency to internal processes, demonstrate competence to claim managers and assist legal counsel should the matter be referred for defense.

 

 

Conclusions

 

Members of the claims management team play an important role in investigating workers’ compensation claims.  It is important to be organized and work newly received file materials in an effective and efficient manner.  It can also result in a cost savings to your program, which pays dividends to all involved.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, 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 is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 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.

Examine 3 Common Disincentives to Return to Work

Understanding the psychology of human nature is an important component to reducing workers’ compensation program costs.  While most employees are genuinely interested in gainful employment, various collateral sources of benefits in the form of workplace perks can promote higher workers’ compensation costs.  In order to run an effective program, it is important for interested stakeholder and employers to evaluate the financial incentives they provide employees to determine possible detriments to return-to-work and reducing costs associated with workers’ compensation matters.

 

 

Common Examples of Collateral Disincentives

 

Employers offer a variety of different benefits to employees to boost morale and encourage employment.  Some common incentives that can drive higher workers’ compensation costs include:

 

  • Salary Continuation Programs: Under these programs, an employer may offer employees suffering any disability, including one resulting from a work-injury, 100% salary or partial wage replacement greater than what they would receive under a workers’ compensation wage loss rate.  In a majority of these instances, benefits are capped at after period.  Studies demonstrate these replacement programs result in longer disability periods for employees suffering work-related disabilities and injuries.

 

  • Disability Benefits: Many employers offer employees short- and long-term disability benefits.  These benefits are paid instead of salary for disability.  While some employers require employees to subsidize the cost of these benefits, others are willing to pay the price.  Depending on the policy language, an employee suffering a workers’ compensation claim can receive a “windfall” recovery by receiving disability benefits under a private program, plus wage loss benefits under workers’ compensation.

 

  • Supplemental Wage Replacement: Some employers offer supplemental pay for employees when they are off of work.  While this is often used in the correct manner, it can be common for employees off work due to a workplace disability to game the system and prolong their recovery.

 

In many instances, these well-intended incentives can have perverse outcomes.  This is why all parties interested in reducing costs in their workers’ compensation program should evaluate the effectiveness of rewards and fringe benefits on a regular basis.

 

 

Reducing Work Comp Costs and Promoting Efficiency

 

Employers offering generous rewards and other forms of financial compensation to employees should be prepared to expect the worse.  Human nature dictates a certain percentage of the employee population will “game the system,” other otherwise delay recovery.  Concerns regarding a slow recovery should be monitored closely.

 

Employer representatives and other interested stakeholders should pay close attention to employee benefit programs and workers’ compensation costs.  Action should be quick and decisive if it is suspected an injured worker is delaying their return to work.  If this is the case, the following tools can be used to correctly ascertain the true medical status and workability of an employee:

 

  • Independent Medical Examination (IME): There are limitations on when and how an IME can be used.  In many jurisdictions, this type of examination can only be used once.  Other jurisdictions allow for additional visits by a defense medical expert if there is a documented change in condition, or need to properly assess restrictions or maximum medical improvement (MMI) following surgery.

 

  • Independent Vocational Evaluations (IVE): IVE’s are conducted by a trained vocational or rehabilitation expert.  It involves a number of different tests, which can require the employee to undergo physical activities to determine mobility and function.  Other testing can be educational in nature to measure cognitive function and mental abilities.  The timing of the IVE typically coincides with the placement of the employee at MMI.

 

  • Surveillance: This tool can also be used to determine the true physical ability of an injured worker.  It should be performed in a manner consistent with state law and rules governing workers’ compensation proceedings.  Failure to do so can result in adverse consequences to the defense of a workers’ compensation claim, admissions against interest and/or sanctions.

 

 

Conclusions

 

All employees deserve dignity and respect.  However, sometimes attempts to extend courtesy can lead to perverse consequences.  Interested stakeholders in workers’ compensation programs should be mindful of unintended consequences and monitor matters to ensure the true intent of generosity is extended in return.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, 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 is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 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.

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