Using an Ombudsman to Reduce Work Comp Costs

The workers’ compensation process is a contentious process regardless of the different protections states offer litigants and defense interests.  This is based on the inherent need for justice in making sure the rights of all parties are respected and the payment of benefits in made in a timely manner.

 

In order to address the changing dynamics and increased cynicism within the systems, states are seeking creative solutions to inform parties of their rights without being an advocate.  One such method of accomplishing this goal is the creation of an ombudsman program to make sure parties are aware of their rights and avoid needless litigation.

 

 

What is an Ombudsman?

 

The term ombudsman has its origins in accident Rome, where a government official would monitor elected officials.  Their role was to ensure the government was not taking advantage of their position.  In essence, it was an undercover inspector of the government.  This same form of oversight took hold in indigenous Scandinavian culture under the term “ombudsman,” with an entomology derived from Old Norse.  Translated literally it means a “proxy representative.”

 

 

Role of an Ombudsman in Work Comp

 

With the increasing demands of workers’ compensation disputes, many states have developed the position of an ombudsman to oversee and assist all interested parties in the workers’ compensation system.  This ensures the rights of the injured worker are being considered in the process, but not being an advocate for either side.

 

 

Ombudsman: Watchperson and Neutral

 

Jurisdictions with an ombudsman program often locate this office inside their industrial commission or labor department.  Although the position is located within an agency that ultimately decides workers’ compensation disputes, the role serves a distinct capacity of not taking sides.  The focus is always to improve the process for all, at the expense of nobody.

 

Ombudsmen assist injured workers in the following ways:

 

  • Develop and provide clear and concise information regarding an employee’s rights within the workers’ compensation system;

 

  • Assist unrepresented employees if they have problems in contacting a claim handler. They can also direct the employee to the correct representatives inside an employer when dealing with self-insured employers; and

 

  • Serve as a resource for additional human services an employee might need. This can include information on assistance with finding housing and medical care during disputes over primary liability and the reasonableness/necessity of medical treatment.

 

An ombudsman can also assist employers and small business in the workers’ compensation process.  Help on these issues can include:

 

  • Provide information on correct workers’ compensation processes and timelines. This includes how to correctly complete a First Report of Injury following a workplace incident;

 

  • Matters concerning workers’ compensation insurance coverage, or even issues concerning coverage disputes; and

 

  • Notifying employers of their rights within the workers’ compensation process.

 

An ombudsman should never be an advocate for a party in the workers’ compensation process.  This includes never providing legal advice to an employee, employer or insurer/self-insured employer.  While the role is somewhat limited, proactive stakeholders can publicize the role of an ombudsman and use one as a resource to educate all involved in the process.

 

 

Conclusions

 

Ombudsmen play a defined, but important role in many workers’ compensation resources.  While they are mainly used for educational purposes, stakeholders concerned about costs in programs can use them to their advantage.  This includes educating the labor force and working with one on troublesome issues to improve the system or processes.

 

 

 

Michael Stack - AmaxxAuthor 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/

 

©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.

Reducing Work Comp Cost via Focus on Cultural Competence

The changing American workforce requires workers’ compensation professionals and stakeholders to step outside their comfort zones and challenge stereotypes and bias.  This includes the ability to work with people from different ethnic backgrounds to promote a workplace dedicated to safety.  This requires full engagement from leaders within the company and insurance carriers.

 

 

Common Cultural Barriers to An Effective Work Comp Program

 

The great American melting pot continues to change.  This includes immigration from different parts of the world with people who seek their pursuit of happiness and a better life in the United States.  These changes impact workers’ compensation programs based on barriers that need to be broken down.  Common barriers include:

 

  • Mistrust of the government, including courts and government officials. Workers’ compensation programs involve a component of government involvement, including industrial commissions and judges.  A mistrust of these officials can impact how immigrants perceive justice.

 

  • Perceptions within one’s community by ethnic groups following a work injury. Even in instances where an injury is temporary, there is an underlying stigma attached in some communities that transcends the confines of the law and a workers’ compensation act.  Lack of self-worth following an injury trickles down to prolonged medical care and receipt of indemnity benefits.

 

  • Inherent risk of injury to new immigrant populations. Countless studies demonstrate non-white and/or non-English speaking populations suffer work injuries at a greater frequency than Caucasian and/or English speaking populations.  Like immigrants from Europe in the late 1800s and early 1900s, today’s immigrants tend to have fewer transferable job skills as whole and gravitate toward positions resulting in a higher frequency of injury.

 

 

Proactive Approaches to a Changing Workforce

 

Members of the claims management team and their employer counterparts can take a hands-on approach to managing their risks when it comes to workers’ compensation matters.  Here are some practical and easy to implement strategies, which will increase safety, reduce program costs and improve employee morale.

 

  • Thinking beyond English and Spanish. The American workforce continues to change and evolve.  With each passing year, more languages are spoken in the workplace.  Never assume that the region of your business limits the possible number of languages spoken.  Assumptions should also never be made that all members of the workforce can read signs.  Providing verbal and written safety instructions are key.  Use a competent translator if in doubt.

 

  • Develop a cultural competency within the workplace. People from around the world develop customs and beliefs based on their world view.  What may seem odd to some, is the norm to others.  Look for opportunities to bridge the gap and develop trust by your actions.

 

 

The Irrelevancy of Immigration Status

 

A review of various workers’ compensation laws point to the conclusion that one’s immigration status has little relevancy when it comes to questions on compensability of a workplace injury.  In a majority of situations, courts have held one’s immigration status does not impact the ability to receive indemnity and medical benefits following a workers’ compensation injury.

 

Stakeholders should be proactive and follow all state and federal employment laws in their hiring practices.  Following this rule can avoid issues down the road when it comes to return-to-work, job search and making a job offer post injury.

 

 

Conclusions

 

Interested stakeholders in workers’ compensation programs are faced with many challenges.  Among these include the need to accommodate a diverse workforce.  Central to this matter should be tenants that drive any program—treat all employees with respect and dignity.  Going the extra mile to ensure all employees are safe in the workplace takes little effort and can only improve the cost effectiveness of a program.

 

 

 

Michael Stack - AmaxxAuthor 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/

 

©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 Ways to Get the Most From Medical Treatment Guidelines

A majority of states have some type of medical treatment guidelines in their workers’ compensation systems. They are generally intended to get the highest quality care to injured workers with an eye toward reigning in costs. Unnecessary treatments and medications can often be avoided when guidelines are followed.

 

But just as the workers’ compensation system is different in every jurisdiction, Medical Treatment Guidelines can vary widely from state to state. Organizations that operate in multiple locations may find it confusing to keep up with each jurisdiction’s guidelines; they may also get pushback from medical providers or others involved in the claims process. Understanding some of the challenges and following a few steps can help get the most benefits from guidelines.

 

 

What They Are

 

Medical Treatment Guidelines are written from a clinical perspective to help lend consistency and best practices in determining medical care for injured workers. They are a set of procedures, pre-appraised resources and tools intended to be the gold standard in medical treatment.

 

There are a variety of Medical Treatment Guidelines in workers’ compensation. The American College of Occupational and Environmental Medicine and the Official Disability Guidelines from the Work Loss Data Institute are the most prevalent, although many jurisdictions use just portions of each. Several states have developed their own, either based on either of the two national guidelines or developed in-house.

 

Some are intended to be educational tools for medical providers, while others are used as criteria to approve or deny treatment. Some are created via a strict scientific regimen. Others are approved by physicians on more of a consensual basis.

 

Proponents say properly written and followed guidelines can prevent inappropriate treatments and get injured workers back to function and work quicker. They point to the overprescribing of opioids as an example of a consequence for the failure to have guidelines. Better safety, clinical outcomes, shorter treatment, and improved return-to-work rates are among the benefits.

 

 

Challenges

 

While the Medical Treatment Guidelines may be the rule of the land in some jurisdictions, they are not cast in stone. That can be a positive factor, in that it allows for exceptions; however it can be a problem if medical providers either don’t understand the guidelines or refuse to adhere to them.

 

There are additional challenges posed by Medical Treatment Guidelines.

 

  • Some are published online, while others are put manually into a system.
  • Some jurisdictions struggle with keeping their guidelines current according to the latest medical research.
  • Lack of info. Some of the more common occupational injuries have no associated Medical Treatment Guidelines.
  • Everyone involved in a claim — the claims adjuster, nurse case manager, physician, UR and bill payment personnel must know and understand them for maximum effectiveness.
  • Dispute resolution. Some states have a dispute resolution process focused on evidence-based medicine, while others do not.
  • Decision makers. The treating physician has the final say in some jurisdictions, while payers can direct care in others.
  • Approval/denial process. In some instances, the best treatment for a particular injured worker goes against the Medical Treatment Guidelines, but the provider fails to adequately explain the rationale.

 

 

Solutions

 

Understanding, consistency and common sense are key to getting the most out of Medical Treatment Guidelines. Here are steps to do that.

 

  1. Organizations need to understand the guidelines of each jurisdiction in which they operate. They need to pass on that information to their claims handlers, nurse case managers, physicians and all others involved.
  2. Coordinate. In addition to understanding the Medical Treatment Guidelines, those involved in the claims process must be consistent in their application.
  3. Work with doctors. Medical providers need to be on board with the guidelines for them to be effective. In cases where physicians may be leery of guidelines dictating the treatment, organizations should explain that exceptions are allowed.
  4. Where an injured worker has comorbidities, psychosocial issues or other extenuating circumstances, the guidelines may not offer the best hope for a positive outcome. Organizations must be willing to take a holistic approach to each injured worker and encourage those involved in the claims process to fully evaluate medical treatment requests that run counter to the guidelines.
  5. Overcoming denials. In situations where the best treatment does not concur with the guidelines, there should be a smooth process to review and decide on them quickly. For example, physicians working with the organization need to understand how to properly document exceptions to the guidelines and explain why recommended treatment can improve function.
  6. Communicate. Keeping stakeholders in the loop is critical. Any changes in guidelines must be passed on as soon as possible.

 

 

Summary

 

Medical Treatment Guidelines are not a panacea or ‘the silver bullet’ to quickly resolving claims. But where they exist, they are based on scientific evidence.

 

At the same time, treatment dictated by guidelines is not always right for each injured worker. Common sense and individual medical diagnosis of cases must also play a part in the decision making process.

 

 

Michael Stack - AmaxxAuthor 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/

 

©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.

First Step to Make Unions A Significant Asset to Return to Work

Hey there, Michael Stack here, CEO of Amaxx and founder of the Amaxx Workers’ Comp Training Center. I run a virtual company. I write a blog. I sell our books. I do virtual training and consulting. What that allows me to do and my family to do is have some flexibility as far as our location of where we live and work. Now our home is in Kennebunkport, Maine, but for this summer and actually last summer as well, we’ve spent the summer living and working in Steamboat Springs, Colorado. While it’s a little bit of a challenge uprooting and settling into a new office and settling into a condo, etc, for that time, the reason that we do it is that it gets us out of our own way. It gets us out of our own paradigms and beliefs to take a look at our routines and assess what it is that we want to keep moving forward as we start the new school year and what are those things that we just do just because we do them. Being in this different environment allows that perspective in order for us to really make those changes. It’s been incredibly valuable for us and also enjoyable to enjoy this new space.

 

 

Unions Can Be Significant Asset to Return To Work

 

In workers’ compensation, one of the most commonly held beliefs is that return to work in a union environment is difficult if not impossible to be successful. I want to challenge you today to take a look at that paradigm, that belief, from a different perspective, because a union environment, while it might not be that easy to get corrected, there are some challenges and some steps you need to go through, can be one of the biggest assets to success in worker’s compensation. The first place to start on this, you need to know where you stand initially. I want to have you review two things for you to get that understanding of where you’re starting so that you can now put those pieces in place to start to mend that relationship and work together as a partnership rather than against each other.

 

 

Review Collective Bargaining Agreement

 

First thing that I want you to have you look at is your collective bargaining agreement. What does it say in regards to return to work? Now many collective bargain agreements will address this point specifically in regards to transitional duty or temporary jobs or modifications of jobs. There are many though however that won’t address this point at all. What you need to do in that scenario is take a look at what the precedent is. What has been done? What is typically done at your organization with your union in regards to return to work? That’s step number one.

 

 

Examine Leadership Beliefs

 

Step number two then is you need to look at the beliefs of your senior leadership and the leadership of the union. What are those commonly held beliefs and paradigms that they exist in in regards to return to work with this employment and union relationship? It may be that one side believes something about the other that just isn’t true. We’ve seen that happen many times over. Once you can get that understanding of where you stand, then you can start to mend that relationship and work together towards being successful. I hope this challenge for you today comes to fruition, that you can look at your union relationship as the potential for being a significant asset to return to work rather than being difficult or impossible. Again, I’m Michael Stack with Amaxx. Remember your work today in workers’ compensation can not only save significant work comp dollars, but it will dramatically impact someone’s life, so be great.

 

Learn more: How to Execute Successful Return to Work with Unions

 

Michael Stack - AmaxxAuthor 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/

 

©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.

9 Steps to Get the Best Out of Your Workers’ Comp Adjuster

Having a great claims adjuster can be invaluable. Claims are processed smoothly, timely, and satisfactorily.

 

But getting the ideal adjuster is not always possible, and employers often blame adjusters when things don’t go as efficiently as they could. Should you seek a different adjuster, or just accept that you’re stuck with a dud? Actually, you may be able to avoid both. By taking a step back to gain some insight into the adjuster’s world and using a few simple strategies, you may be able to turn things around.

 

 

Set Realistic Expectations

 

The adjuster’s role is the fair and reasonable settlement of claims. First step is to figure out what that means to you and how it fits in with your company’s claims handling plan. Setting up expectations is important. If there are no clear directions or goals, you really can’t blame the adjuster for failing to meet your expectations.

 

For example, do you want the adjuster to be in constant contact with you, or do you want communication only when absolutely necessary? You need to determine that and let the adjuster know.

 

If you expect the adjuster to resolve claims within a certain period of time, are you doing all you can to facilitate that? How soon are injuries reported? Is that on a consistent basis? Do you have a timeframe for when and how investigations are performed?

 

Other factors can also affect the resolution of claims. Not having a return-to-work program or light duty/transitional work can make more work for the adjuster, along with the lack of a fraud prevention program. Make sure your actions and goals are in line with your expectations of your adjuster.

 

 

Understand the Adjuster

 

It can be upsetting when the adjuster doesn’t get back to you when you think he should, or denies treatment on a claim with no explanation or approves a questionable claim. But seeing things from the adjuster’s standpoint can help.

 

Instead of lambasting the adjuster, consider what is happening on his end. Being an adjuster can be a thankless job;

 

  • There are constant questions, emails and phone calls, often from disgruntled employees, employers or others.
  • His caseload may be overwhelming.
  • There are constant deadlines that may or may not be achievable.
  • The turnover for the profession is such that his office may be understaffed at any given time.
  • While you might be easy to work with, others may not be.

 

You can find out what’s going on by talking with the adjuster.

 

Build a Relationship

 

Developing a bond with the adjuster can go a long way toward having a better connection with him. Working better with the adjuster can involve a few simple steps:

 

  1. Pay him a visit. A ‘chairside visit’ is a great way to establish a good relationship with an adjuster. For this informal meeting, you literally sit at his desk to understand the demands of his day. You can also take the opportunity to learn how he handles claims; the intake process, medical-only and lost-time claims, and catastrophic claims.

 

  1. Get to know him on a personal level. While you don’t need to be best friends, you can find out a little about him — his home life, kids, hobbies, etc.

 

  1. Realize he is the expert. Even if you don’t like the way he’s handling a claim show him respect. That said, find out his expertise level. If he’s new to the profession, he’s probably not the right person to handle complex claims. On the other hand, a highly experienced adjuster might be bored handling simple, medical only claims.

 

  1. Ask questions. There may be good reasons for the way he’s handled certain aspects of a claim. Don’t just get angry, find out why. Ask open-ended questions that are not accusatory. Putting him on the defensive won’t help your relationship, and it likely won’t get you answers.

 

  1. Give praise when warranted. If the adjuster does a particularly good job with a claim, tell him so. He’s probably much more used to hearing negative comments than true appreciation. Doing so will make things much easier when you later have concerns about a claim.
  2. Listen to what he says. You may have ideas to solve some of the challenges he’s facing.

 

  1. Offer to help. There may be things you can do that would help him expedite the claims process.

 

 

Conclusion

 

If you’re having problems with your adjuster, first look at your own program. Having an organized plan for claims handling and relaying that sets up realistic expectations.

 

Then, work with the adjuster. Develop a bond so you can easily find out the reasons for any problems and set up strategies to avoid future challenges.

 

 

 

Michael Stack - AmaxxAuthor 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/

 

©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.

Follow 8 Steps to Create Effective Workers’ Comp Pre-Loss Programs

The best way to reduce workers’ compensation costs is to ensure there are no injuries or illnesses. While that may sound implausible, all accidents and injuries are preventable.

 

Companies that take that concept to heart see significant savings on their own bottom lines. It just takes a firm commitment from management and a concerted, continuous effort to implement a successful workers’ comp pre-loss program.

 

In addition to reduced accident frequency and substantially lower workers’ compensation costs, companies that embrace a pre-loss program also benefit from better product and service quality, enhanced productivity, lower indirect-injury costs, and an overall improved image in the community.

 

 

Management’s Role

 

An effective pre-loss program starts at the top, with the recognition that management is ultimately responsible for preventing workplace accidents. Additionally, there must be a person or people designated to ensure accountability for safety decisions that have been made.

 

Managers and supervisors need to lead by example and reinforce safety policies that are implemented. That includes heading or attending safety committee meetings, participating in the investigation of any and all lost-time injuries that do occur, and integrating safety and health into overall strategic business plans.

 

Top tier leaders should establish safety performance improvement objectives and follow-up on the progress made for approved safety improvement plans. Finally, they should track and include adherence to safety objectives in employee performance reviews.

 

 

The Plan

 

Developing and implementing an effective safety policy takes time and effort. It begins with small steps.

 

  1. Set goals — Realistic improvement goals should first be established. Employers can look at their data or work with their insurer/third-party administrator for any trends in terms of accidents and injuries. For example, are there specific facilities and/or job duties that are more susceptible to workers’ compensation claims? Once trends have been identified, employers can determine ways to reduce those claims and set goals; however, the goals must be realistic, communicated to all employees and tracked.

 

  1. Training — All new employees should be required to undergo safety orientation. However, safety training and education should also be provided on a regular, ongoing basis to all employees. In large corporations, that duty falls to safety management staff. But even small companies can ensure ongoing training by managers and/or supervisors who are trained. The training should be formal and documented. Working safely should be considered a condition of employment

 

  1. Enforcement — Supervisors must enforce safety rules and regulations consistently. In fact, executing the company safety policy needs to be an integral part of the supervisor’s job description.

 

  1. Timely Investigations — All accidents should be investigated within 24 hours. The sooner the better, since the incident is still fresh in the minds of any witnesses, as well as the injured employee.

 

  1. Facility Hazard Inspections — Part of a good pre-loss program includes regular inspections of company facilities to identify and correct any hazards that may exist. Workers who might be affected by identified hazards should receive special training.

 

  1. Employee Engagement — Workers need to be encouraged to actively participate in the safety program. They should be included in safety committee meetings, facility hazard inspection teams, and training of new employees in their departments. Employees should be rewarded for reporting unsafe working conditions and behaviors.

 

  1. Companywide — The safety plan requires the cooperation of all departments, especially HR, production, engineering, and maintenance.

 

  1. Transparency — Safety as a topic should be openly discussed informally as well as in safety committee meetings. Workers should feel comfortable talking about potential hazards and possible solutions with their supervisors and one another.

 

 

Safety Culture

 

The success of a pre-loss program depends largely on the overall safety culture at the organization. All personnel should be engaged in the idea that safety and health is simply the way business is done at the company.

 

Rather than a reactive strategy where there is action taken once an accident occurs, the organization needs to have a proactive strategy to identify and address potential safety problems. Again, that starts at the top.

 

Managers and supervisors must treat workers fairly and consistently. They must believe and convey that they and the company are truly concerned about the well-being of their employees. They also need to foster an atmosphere of respect — with their workers and among employees.

 

 

Post Injury

 

While the idea of a pre-loss program is to prevent workplace accidents and injuries, there should, nevertheless, be a specific process in place for any claims that do occur. The post-injury claims management process should include the following elements:

 

  • Formal RTW — A documented return-to-work process that is laid out and communicated to all employees should be established. Included should be restricted-duty job descriptions.

 

  • Physician Involvement — Treating physicians and other medical providers should be familiar with and engaged in the RTW process. They should have access to the restricted-duty job descriptions. Physicians should also be invited to tour the facility/facilities to better understand the job tasks.

 

  • Solid Relationships with Claims Specialists — employers should establish good working relationships with claims managers and administrators.

 

 

Conclusion

 

Spending resources at the front end of the workers’ compensation process is too often ignored by companies. But employers that fully embrace the idea of safety at every level of the organization report significant cost savings, increased productivity and better morale among their employees.

 

 

 

Michael Stack - AmaxxAuthor 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/

 

©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.

Accuracy in Section 111 Reporting of ORM Vital to Avoiding Unnecessary Repayment Demands from Medicare

While the Commercial Repayment Center (CRC) has faced some valid criticism over the course of the past year and half in relation to its recovery efforts on behalf of the Centers for Medicare and Medicaid Services’ (CMS), not all problems start with the CRC. CRC’s recovery efforts are driven by the data employers, carriers and self-insured entities report to Medicare through the Section 111 Mandatory Insurer Reporting process. Chief among the data elements reported is acceptance of Ongoing Responsibility for Medicals (ORM) and the termination thereof. If this data is reported inaccurately or there is a failure to report required data, then the applicable plan may be faced with inappropriate recovery demands by the CRC.

 

 

Applicable Plan Reporting of ORM is the Catalyst for CRC Recovery Efforts

 

Since October 5, 2015, the CRC has had responsibility for the recovery of conditional payments where the insurer or employer (including self-insured entities) is the identified debtor, known in CMS terms as the “applicable plan.” The CRC learns of opportunities to recover through the Section 111 Mandatory Insurer Reporting process. In other words, the applicable plan is the catalyst for Medicare conditional payment recovery by its reporting of ORM.

 

The mandatory reporting provisions of the Medicare Secondary Payer Act require the applicable plan to report to Medicare in three instances – the acceptance of ORM, the termination of ORM and issuance of a Total Payment Obligation to the Claimant (TPOC), settlement judgment, award or other payment. In regard to ORM, two key data elements reported are the date responsibility for ORM is accepted and the accepted diagnosis codes. Once this information is reported the following actions are initiated by CMS’s contractors:

 

  1. The BCRC, which handles Medicare coordination of benefits, should deny payment for medical bills submitted for payment in which the billed diagnosis codes match or is similar to the reported diagnosis codes.
  2. The CRC identifies medical claims that Medicare has paid that it deems related to the reported diagnosis codes.

 

Upon the CRC identifying treatment related to the reported diagnosis codes, it will issue a Conditional Payment Notice (CPN) to the applicable plan which itemizes charges deemed related to the injury. The applicable plan has 30 days from the date on the CPN to dispute charges after which a Demand Letter will issue demanding repayment for the charges identified by the CRC. A Demand Letter provides 120 days from receipt of the letter for the applicable plan to appeal all or some of the charges or issue payment. If payment is not issued within 60 days of receipt, interest begins to accrue from the Demand Letter date.

 

 

Reporting Accurate Acceptance of ORM and Diagnosis Codes

 

The trigger for reporting ORM is a claimant identified as a Medicare beneficiary and the assumption of ORM by the applicable plan. ORM is reported when the applicable plan has made a determination to assume responsibility for ORM, or is otherwise required to assume ORM—not when (or after) the first payment for medicals under ORM has actually been made. Accordingly, the ORM acceptance date is typically the date of injury.

 

Along with the ORM acceptance date, at least one ICD-10 diagnosis code must be reported for the diagnosis that has been accepted on the claim (If more than one diagnosis has been accepted, then additional diagnosis codes are reported). While medical provider billing records are often used to determine ICD-10 diagnosis codes to report, these should be used as a starting point, not an ending point, in identifying the correct codes to report to Medicare.

 

Keep in mind that medical providers, and especially hospitals, will often insert into billing records any diagnosis reported to the provider, which are not necessarily the same diagnoses that are being accepted on the claim. Consequently, the person responsible for determining the correct ICD-10 diagnosis code to report, usually the claims handler, must make an independent determination, separate and apart from the medical provider, as to whether the particular diagnosis is being accepted on the claim. If the billing records do not properly represent what is being accepted, or if further diagnosis codes are required to better define what is accepted, then online ICD-10 resources are available to identify codes which correctly represent the accepted body parts and conditions.

 

Once ORM and the diagnosis codes are reported, ORM is generally not addressed again until the date of ORM termination. However, causally related diagnoses may change over time, either expanding or retracting depending upon the circumstances in the claim. Accordingly, it is important to update the reported ICD-10 codes as necessary over the course of the claim.

 

 

ORM Termination Key to Cutting Off Liability to Medicare

 

Once ORM is accepted, CMS claims the right to recover against the applicable plan through the date of ORM termination. As such, recovery efforts by the CRC may happen years after the ORM was first reported. Further, if there is failure by the applicable plan to terminate ORM when appropriate, then the plan may receive repayment demands from CRC for time periods in which it has no liability to pay for medical treatment. An applicable plan may terminate ORM through the Section 111 Reporting process under the following situations:

 

Settlement with a release of medicals

No fault policy limit reached

Complete denial of the claim

Statute of limitations has run or medical benefits have otherwise been exhausted pursuant to state law

Judicial determination after a hearing on the merits finding no liability

Statement from treating physician – signed statement from the injured individual’s treating physician that he/she will require no further medical items or services associated with the claim/claimed injuries.

 

Keep in mind that closing a claim file is not a trigger for ORM termination unless it is accompanied by one of the above situations.

 

Providing CMS with an ORM termination gives a bookend to recovery by the CRC. If no termination date is provided, then CRC assumes the applicable plan remains liable for injury-related payments.

 

 

Recommendations for Ensuring Accurate ORM Reporting

 

The reporting of ORM acceptance and termination and defining accepted diagnosis codes is so important because it is the applicable plan’s admission of responsibility to pay for medical care during the reported time period and for the reported diagnoses. If an error is made in reporting or there is an omission in reporting, then it can result in attempts by Medicare to recover for conditional payments unrelated to the injury or for time periods during which the applicable plan is not liable. Errors in reporting can also lead to inappropriate denials in the payment of claimant’s medical care by Medicare or Medicare paying for medical care for which the applicable plan is responsible.

 

 

Recommendations to avoid these errors and omissions:

 

  1. Train Claims Handlers on ORM Reporting: If a claims handler is responsible for inserting the data required for ORM reporting, then they require training as to when ORM acceptance and termination is to be reported and how to determine the appropriate diagnosis codes to report with ORM acceptance.
  2. Effective Quality Assurance of ORM Reporting: Even with training, errors will occur. Additional resources placed into quality assurance of ORM reporting, such as double-checking claims for proper ORM termination and appropriate diagnosis code choices avoids the expenditure of additional resources at a later date to correct errors in reporting and correction of unnecessary recovery demands from the CRC. If you are an employer or carrier relying upon a TPA to report, it is especially recommended that a QA process be in place to check the data entered by the TPA.
  3. Ensure Reporting Platform is Accurately Reporting: Section 111 Reporting is electronically based and requires a data exchange with Medicare. Errors can and will occur in this data exchange. Ensure you have a trusted and reliable reporting agent to assist with accurate reporting to Medicare.

 

Finally, if any correspondence is received from the CRC or the U.S. Treasury Department claiming conditional payment recovery it must be acted upon immediately. Do not assume the letter was issued in error and will simply go away. If you do not believe you are liable for the conditional payments for which the CRC is claiming recovery, first confirm you have correctly reported ORM and then work with your MSP compliance partner to appropriately dispute the charges.

 

 

 

Author Dan Anders, Chief Compliance Officer, Tower MSA Partners. Dan oversees the Medicare Secondary Payer (MSP) compliance program. In this position, he is responsible for ensuring the integrity and quality of the MSA program and other MSP compliance services and products. Based upon his more than a decade of experience in working with employers, insurers, TPAs, attorneys and claimants, Dan provides education and consultation to Tower MSA clients on all aspects of MSP compliance.  For questions stemming from this article please contact Dan Anders at (888) 331-4941 Daniel.anders@towermsa.com.

Relieve Workers’ Comp Burden by Assessing Honesty, Resiliency, and Attitude

 

Hey there Michael Stack here. I’m the CEO of Amaxx and I’m also the founder of the Amaxx Workers Comp Training Center. Now I read a pretty interesting blog post written by Karen Yotis on the Lexis Nexis legal newsroom blog. You can find a link to that article below.

 

Karen Yotis Blog Post: Morbidity, Disability, Cost, Pain & Distress: Exposing the True Burden of Workers’ Compensation

 

 

Assessing the Burden of Work Related Injuries

 

But in that post she referenced an article in the American Journal of Public Health entitled Assessing the Burden of Work Related Injuries, Illness and Distress. Now the point of this article in the journal was really calling attention to the need for more research on understanding the more global impact of work related illnesses. It talked about the family impact, the work impact and really this overall wellbeing indication including the social consequences. Now there’s some political drivers and motivations behind really the desire to write this article and desire for more of that research but what I’m more interested in is the impact that it has on you. And your organization. And the perspective that can be gained from the motivation of this article.

 

 

So I want to talk about that point. And I have two how-tos to share:

 

 

Workers’ Compensation Goes Far Beyond The Injury

 

The first is realizing as is referenced in the article that workers compensation goes far beyond the injury to one individual and the pain that’s occurring in their back or their shoulder or their knee and the ability to get that person back to work. We talk a lot about direct costs and indirect costs of workers compensation and realizing what that means for our bottom line. But I also want to call attention to those psychosocial and social consequences within your own organization. The impact that it has on the amount of trust your employees have. The impact that it has on the engagement of your workforce and the impact it has on the amount that that workforce feels you care about them. Studies have shown and reinforced the importance of trust and care in the recovery of workers compensation and workers compensation costs.

 

 

Assess Honesty, Resiliency, Attitude

 

The second point and one of political drivers and the point for you to be aware of is that 5% of workers compensation claims account for 80% of workers compensation costs. 5% of claims account for 80% of workers compensation costs. So from your organization’s standpoint, what does that mean? I want to give you a how to on this. This comes from Dr. Christopher Brigham’s book Living Abled and a presentation that we gave together last year.

 

 

Now there’s some more sophisticated modeling and serving that you could implement in your program but I want to give you some simple things to look out for when a claim occurs, that if these things are in play, you may need to bring in some additional support and resources for having that claim prevented from being a much larger and more significant and costly claim than it needs to be.

 

 

Take a look at the employee’s honesty, resiliency and attitude. Honesty, resiliency and attitude. If the person is less than truthful, typically in their employment career, it they’ve had minor setbacks that have caused them major setbacks and they have a real tough time getting over those, or they have a poor attitude at work. These are clear red flag indicators that you’re going to possibly need some more intervention from preventing that claim from being much larger and much more costly than it has to be.

 

 

So have that global perspective and be aware of those claims because it will have a dramatic impact not only on your bottom line, but also on the lives of your injured workers.

 

 

Again I’m Michael Stack with Amaxx. And remember your success in workers’ compensation is defined by your integrity. Be great.

 

 

 

Michael Stack - AmaxxAuthor 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/

 

©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 Items Claims Handlers Want From Their Defense Attorney

Workers’ compensation defense attorneys may lay awake at night wondering what their claims handler really wants.  Besides getting their files closed in a timely manner, they want to work with defense attorneys committed to a zealous defense of the file in an ethical and cost-effective manner.  Here are some tips that can help defense attorneys sleep better at night knowing they are giving their claims handler what they want.

 

 

Calculate the Average Weekly Wage (AWW)

 

The AWW is the basis for most indemnity benefits in a workers’ compensation claim.  Failing to calculate it correctly can increase the cost and exposure of the claim.  A seasoned defense attorney needs to communicate with the employer and receive additional explanation from the employee on a number of issues.  The list can be endless, but some special considerations include:

 

  • Whether the employee was a full or part-time worker;

 

  • Whether the employee was working any additional jobs outside the employer involved in the claim;

 

  • Investigation into the nature of any fringe benefits the employee was receiving. This includes tips, bonuses, insurance benefits and other forms on potential income; and

 

  • Special circumstances concerning the employee’s employment. This is especially the case when the injured worker in a seasonal employee, construction worker or part of a union collective bargaining agreement.

 

 

Calculate and Evaluate the Indemnity Exposure

 

Once the AWW is correctly calculated, the defense attorney can provide an accurate analysis to the claims management team about wage loss exposure.  This includes information on the following benefits:

 

  • Temporary Total Disability (TTD)—Benefits paid when the employee is temporarily off work due to injury or disability;

 

  • Temporary Partial Disability (TPD)—Benefits paid when the employee returns to work, but at reduced hours or rate of pay;

 

  • Permanent Partial Disability (PPD)—Typically a hybrid benefit based on the AWW and the number of weeks disability assigned by statute or rule to an injury; and

 

  • Permanent Total Disability (PTD)—Benefits paid when the employee is permanently precluded from returning to gainful employment based on their age, training and experience, and the type of work available in the geographical area. Various presumptions may apply concerning an employee’s receipt of Social Security Disability benefits.

 

 

Aggressive Defense Strategy That is Cost-Effective

 

Members of the claims management team also appreciate an aggressive defense strategy that moves a case toward settlement in an efficient and cost-effective manner.  Considerations for such planning include:

 

  • An immediate status report upon receiving the claims file, with periodic reports that are robust and evaluate the strengths and weakness of various defenses, a reasonable strategy and probable outcome;

 

  • Identification of missing information that needs to be discovered in order to provide an accurate analysis and defense. This includes a plan on how to uncover this information and whom might be a witness at hearing; and

 

  • Recommendations on how to move a case toward settlement. This includes information concerning the timing of an independent medical examination or independent vocational evaluation.

 

 

Medicare Secondary Payer Compliance

 

Medicare Secondary Payer compliance is an important part of any workers’ compensation claim analysis.  This includes recommendations on the following topics:

 

  • Whether a service provider should be utilized to prepare a Medicare Set-aside allocation;

 

  • If the Medicare Set-aside should be included for review and approval under the voluntary CMS process; and

 

  • Matters concerning conditional payment identification and repayment.

 

 

Conclusions

 

The wants of a workers’ compensation claims handler are quite simple.  They expect professionalism and responsive defense counsel to assist them on all claims.  While the defense attorney might not have all the answers, they need to assist the claims handler in discovering the information and reporting on it timely.  This also includes a reasonable analysis, while being a zealous advocate.

 

 

 

Michael Stack - AmaxxAuthor 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/

 

©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.

How to Help Frustrated Injured Workers’ OUT of Work Comp System…And Save Money Settling Tough Claims

Imagine a scenario where an injured worker who’s been receiving workers’ compensation benefits for years and shown no interest in settling the claim is suddenly willing and even happy to do so, and both he and the payer are pleased with the agreement. The payer gets the long-term claim off the books, and the injured worker has someone guiding him through the medical system while helping to manage his money long after the settlement is reached. Both parties save money in the process.

 

This panacea is not only possible, it is happening; and at no extra cost to the payer or injured worker. Professional administration is enabling an increasing number of settlements to occur and leaving all parties feeling grateful with the results. Professional administration organizations that have a solid background in all aspects of workers’ compensation are becoming the answer to the frustrations faced by long term injured workers.

 

The concept of professional administration is not necessarily new in the workers’ compensation industry, but until recently it was generally cost prohibitive for many organizations. Recently that has changed, as newer entrants have found ways to save money for all concerned.

 

The way it now works is simple and effective:

 

  • Those with the appropriate competence are able to offer significant discounts to injured workers through their networks of medical providers and pharmaceuticals.
  • They function much as an engaged claims adjuster would in terms of helping the injured worker find the best providers.
  • However, the injured worker’s care is not subject to utilization review.
  • The professional administer also helps the injured worker manage his settlement money, whether lump sum or structured, and can ensure injured workers receiving Medicare are compliant with government reporting requirements.

 

 

Overcoming Frustrations

 

Professional administration can work well for any injured worker with a long-standing claim but is especially advantageous for those exasperated with the system;

 

  • Tired of Utilization Review denials.
  • Required to drive many miles from home to see an approved physician – whom she may not like.
  • Attorney has abandon the injured worker as she has already settled the indemnity portion of claim.
  • The idea of settling the medical portion of claim makes her even more anxious, as she is afraid she will ultimately run out of money.

 

Such stories are fairly commonplace in the workers’ compensation system. Injured workers who have been in the system for a long time are afraid of the unknown, post-settlement scenario and are therefore willing to continue receiving benefits indefinitely.

 

Professional administrators can be invaluable in helping to reach a settlement and after the agreement is set.

 

 

Pre-Settlement

 

Among the many concerns of long term injured workers facing a potential settlement are the financial unknowns; how much will various treatments and medications cost, now and in the future? What if unexpected complications arise – will there be enough money to treat them? What if durable medical equipment becomes necessary – is there enough for that? Is the settlement money enough to ensure living expenses can be covered for the long term? Who should manage the money?

 

More concerns are present when the injured worker is receiving Medicare:

 

  • What medical services should be funded through Medicare?
  • What if Medicare is mistakenly billed for a treatment the injured worker should have covered?
  • How, when and where are the Medicare reporting requirements handled?
  • What if they are reported improperly?

 

It’s easy to see why many injured workers would be leery of settling their workers’ compensation claims. A professional administrator can price out the prescriptions and treatments and show the injured worker an accurate picture of the costs, especially when network discounts are included. Competent organizations get involved with all parties to the claim before a settlement to reach the best solution for all concerned.

 

 

Post-Settlement

 

Typically, there is no help for an injured worker after a settlement is reached. Those with extensive and expensive medical needs and/or those not comfortable managing the settlement money feel lost.

 

  • With a professional administrator involved, the injured worker has full control over choice of providers, and an expert helping to manage the settlement funds.
  • In addition to discounts for medications and providers in the network, there may be a 24-hour/7-day-a-week phone line available to discuss care issues.

 

Because of the savings associated with a professional administrator, injured workers often have money available for things such as a child’s education, starting a new business, or taking an exciting trip. Above all, they have peace of mind about the future.

 

 

 

Michael Stack - AmaxxAuthor 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/

 

©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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