Give Your Work Comp Adjuster A Hand To Achieve Better Outcomes

Handshake Between Businessmen

Handshake Between Businessmen

Adjuster Objectives:

 

Some objectives of every workers compensation claim adjuster should be to:

  • Promptly investigate.

 

  • Monitor medical care.

 

  • Process the workers compensation claim to a timely full disposition.

 

  • Maintain constant dialogue with employee, employer, and all other entities directly connected to the loss.

 

  • Secure any potential recoveries.

 

  • Develop the loss for the best outcome possible.

 

  • Be adequately educated, trained and continually self-educated for continued professional growth.

 

Additional adjuster objectives:

 

  • Clearly compensable claims should be paid promptly at the proper benefit rate, medical care should be the best available, and prompt return to work should be a priority.

 

  • The adjuster should be available to assist the injured employee as needed.

 

  • Good claim work results in minimal disability, good employee relations, and lower claim cost.

 

  • Conversely, claims that are questionable, malingered, fraudulent, or suspect for any reason, require the claim adjuster to be extra determined so that a good investigation and claim preparation can sustain declination and litigation.

 

  • Workers Compensation Claims are always under time guideline and handling pressure. Decisions and actions must be made or done quickly.

 

 

Employer Injury Coordinator & Assisting The Adjuster

 

The adjuster has primary responsibility for successful claim disposition.  However, the adjuster can only be as effective as the information gathered during investigation.  Therefore, every employer should strive to get the full facts, and supporting documentation to the adjuster as soon as possible after the loss occurs.

 

Every employer should have at least one person assigned to establish policy and procedures to implement when an injury occurs.  The person should know and understand all requirements of the workers compensation management program, including the employer and employee responsibilities.

 

One of the biggest responsibilities of the employer injury coordinator is communication with the claim adjuster.  This should be done as necessary, and during acute stages of a claim it may be daily.   As time passes on this claim this should continue on a regular weekly schedule.

 

 

Conclusion:

 

Worker’s Compensation Adjusters need to have good education, training, and the highest objective standards in order to reach proper handling and resolution of claims.  However, they cannot achieve this without proper employer support and interface.

 

Employers who designate an employee to be the workers’ comp injury coordinator to assist the claim adjuster will reap the benefits of better claim handling and cost.

 

 

 

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

 

 

©2016 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.

 

NAMSAP Endorses Surgeon General’s “Turn the Tide Rx” Campaign

namsap-imageNAMSAP says workers’ compensation MSAs are still allocating for high doses of long-acting opioids, against evidence-based guidelines.

 

Business Wire version: NAMSAP Endorses Surgeon General’s “Turn the Tide Rx” Campaign

 

Elmhurst, Illinois (September 12, 2016) — The National Alliance of Medicare Set-Aside Professionals has endorsed the U.S. Surgeon General’s “Turn the Tide Rx” campaign to end the opioid epidemic. The campaign’s goals are to educate prescribers and the public about opioids, change the cultural perception of addiction, and mobilize health care professionals to improve prescribing practices.

 

NAMSAP wants physicians to adhere to evidence-based guidelines pertaining to opioids. The organization also would like to see the Centers of Medicare and Medicaid Services follow its own Part D guidelines when reviewing and approving Workers’ Compensation Medicare Set-Asides (WCMSAs).

 

The Turn the Tide Rx website promotes guidelines that encourage physicians to prescribe the lowest effective dose of immediate-release opioids only for acute pain and only for short durations, usually three days or less and rarely more than seven days. It says: “Higher dosages of opioids are associated with higher risk of overdose and death, but higher dosages have not been shown to reduce pain over the long term.  Extra precautions should be used when increasing to greater than 50 morphine milligram equivalents (MME) per day.”

 

“Opioid guidelines have been around for years, but there are situations where the treating physician is writing for high doses of long-acting opioids. In those cases, CMS requires that the WCMSA allocate for these opioids for the patient’s life expectancy,” says NAMSAP President Gary Patureau. “Our members often see more than 50 MME per day on workers’ compensation and general liability claims for people with chronic pain who have life expectancies of 20 to 40 years or more. Essentially, CMS is condoning the dangerous and inappropriate use of opioids.”

 

The campaign’s website also warns, “It is is especially dangerous to combine opioids with alcohol or sedatives, like benzodiazepines (e.g., lorazepam/Ativan, alprazolam/Xanax, diazepam/Valium).” Patureau says opioids and benzodiazepines are frequently prescribed together and allocated on WCMSAs.

 

“Post settlement, many Medicare beneficiaries do not reach their life expectancies,” he notes.  “What is causing their deaths?  No one is tracking this, but we suspect overdose is responsible for some.”

 

For more information on the Surgeon General’s campaign and to download educational materials, please see www.turnthetiderx.org. The Turn the Tide Rx endorsement is the latest of several NAMSAP initiatives to reduce opioid use in MSAs. The organization has conducted webinars on the topic and proposed evidence-based limits on opioids in MSAs in March.

 

 

About NAMSAP

 

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

 

# # #

 

 

Media Contact:  Brian S. Bailey, NAMSAP Executive Director, (855) 677-2776; Brian@NAMSAP.org
Web: www.NAMSAP.org

What Is The Claim Handling Score At Your TPA?

claim-handling-scoreEmployers often wonder if they are getting quality claim handling on their workers’ compensation claims.  At the same time, the third party administrators (TPA) providing claim services to employers often struggle with producing a quality product due to the facts and circumstances of each claim being different.

 

 

 

Top-Tier TPAs Evaluate Every File for Claim Quality

 

Each TPA will have a set of Best Practices stating what is expected on every claim.  A top-tier TPA will not only have the written set of Best Practices, they will evaluate the adjuster’s claim quality using both performance measurements and diagnostic indicators to evaluate the adjuster’s performance.

 

As every activity of the adjuster on the claim file is recorded in the electronic notes of the computer file, it is simply a matter of data mining to determine if the adjuster is complying with the established Best Practices.  When the workers’ compensation adjuster enters a new file note, the date and time is automatically recorded.  Each file note has two drop-down selection codes, one for type of activity being completed and one for the type of person contacted – employee, employer, medical provider, employee’s attorney, defense attorney, etc.  After the note is coded, the actual details of what was accomplished are entered.  For example: “Requested Dr. Smith’s office to email us the office visit notes.”

 

With all this data, the grading and evaluating of the adjuster’s performance becomes highly measurable.  To prevent ‘gaming’ of the system, the TPA will have internal auditors reviewing select files, or with some top-tier TPAs all files, to insure accuracy of what is recorded in the system.  For example, if the adjuster coded the file note ‘contact – employee’, but the details of the file note reflect only left a voice mail, the proper coding should have been ‘attempted contact – employee’, and the file note coding can be corrected.

 

 

 

Areas of Evaluation

 

The areas of quality evaluated and graded through performance measurement include:

 

  • Initial employee contact within 24 hours

 

  • Initial employer contact within 24 hours

 

  • Initial medical provider contact within 24 hours

 

  • Initial reserve within 72 hours

 

  • Reserve review with 30 days

 

  • Initial report to client within 14 days

 

  • Status reports to client every 30 days, or as previously indicated in a prior report

 

 

The areas of quality evaluated and graded through diagnostic indicators include:

 

  • File on diary

 

  • Proper completion of claim progress notes

 

  • Reserve worksheet to support reserve changes

 

  • Timely ISO filing

 

  • Timely supplemental ISO filings

 

  • Payments made on closed files

 

With all the data generated, the computer program calculates the adjuster’s performance.  The computer program can be set to select only indemnity claims or it can include all claims.  The computer identifies all claims reported within the reporting month (normally a calendar month, but data can also be compiled on any 30 day period).  For example:  The computer identifies all indemnity claims assigned to Adjuster Jones during July, it reviews all data for the claims that had initial employee contact within 24 hour, and calculates the percentage of claims where the employee was contacted within 24 hours of the initial report of the claim.

 

The computer program completes the calculation for each of the performance measurements and diagnostic indicators and assigns a numerical percentage score to each category.  The computer combines all the categories into a numerical score for each adjuster to provide the TPA management a quality score for each adjuster.

 

 

Claim Quality Scores are Invaluable Tool for TPA

 

The quality scores compiled by the TPA are an invaluable tool that can be used for several different purposes. The score results can be used as:

 

  • A component of the adjuster’s semi-annual or annual performance review

 

  • A promotional tool to sell the TPA services

 

  • A motivational tool to encourage the adjusters to perform at their maximum

 

  • A way to encourage friendly, internal competition in each office to see which adjuster can provide the highest level of service

 

In addition to building adjuster’s pride by scoring well, some TPAs offer bonuses for top scores or a bonus to everyone who exceeds a predetermined mark.  For example – $100 monthly bonus for a score of 95% or higher, or a $500 annual bonus for averaging 97% or higher for the entire year.  Other prizes can be offered for the most improvement, the highest overall performance, etc.

 

 

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

 

 

©2016 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 The Difference Between Sprain & Strain To Save Work Comp Dollars

sprainIn order to properly monitor and control workers compensation losses, it is necessary for the employer to have a working knowledge of traumatic injuries and occupational diseases.  For adjusters this knowledge is mandatory.

 

 

The Exposures:

 

The following sample questions demonstrate the need for medical fact information knowledge and understanding:

 

  • What are usual treatments for the injury or disease?
  • What are the normal recovery periods?
  • Will there be any residual disability?
  • What are the problems associated with improper treatment?
  • Did the mechanics of the loss or job exposures cause the injury claimed?
  • What underlying health conditions might be aggravated by this injury?
  • Is treatment in compliance with accepted medical practice?
  • Is there a prior record to demonstrate apportionment possibilities?
  • What apportionment ratios are possible?
  • What are indications that point to the need of an independent medical examination?
  • What questions and findings need to be presented to the examining medical practitioner?
  • Should the examination be done by a specialist, a general practitioner or physician’s assistant?
  • Are all facts of the occurrence and medical treatment available for presentation to the examining doctor?

 

 

Difference Between Sprains & Strains

 

The difference between sprains and strains is a classic example.  The terms are often used interchangeably, yet the actual injuries are quite different.  Their cause, severity, course of treatment, and residual possibilities vary greatly.

 

 

Sprains

 

Sprains are generally associated and limited to ligament stretching or tissue tearing.   Typically, they occur to knees, ankles, or wrists, and happen while walking, running, jumping, or falling.  The incident is usually abrupt or sudden and is prominent in sports or sports like activity.  Falling, while limbs are in out stretched position, or sliding, are ways sprains happen.

 

Symptoms are usually apparent almost immediately.   There is pain, swelling, bruising, loss of functional capacity, and weight bearing or applied pressure may be intolerable.  The patient may feel a pop or tearing sensation.  The symptoms can vary on intensity depending on the degree of severity.

 

Treatment generally consists of an x-ray or MRI, immobilization, pain medication, and applications of external heating or cooling devices, non-weight bearing, physio therapy, and possibly surgery. Use of crutches, slings, wheel chairs, walkers, and canes may also be necessary.

 

Recovery Disability can range from several days to twelve weeks without surgery. Hospitalization can range from several days to weeks depending on severity, and total disability can range from days to months.

 

 

Strains

 

Strains are caused by twisting, or pulling of the muscle or tendon.  They also occur from prolonged repetitive movement, and/or over use.

 

A strain is an acute situation brought about by trauma, blows to the body, improper lifting, and stressing.  The symptoms may be immediate or develop over a few days.  Strain symptoms are pain, localized swelling, cramps, muscle spasm, inflammation, loss of muscle function, general weakness of the muscles involved, and radiating symptoms following nerves.

 

Chronic strains develop over time as a result of repetitive motion or over use and symptom onset is delayed.  These cases may be accepted for other possible medical conditions.

 

The treatment and grades of strains are similar to strains, however full rupture of muscles often occurs and requires surgical repair.  Carpel Tunnel Syndrome is one of the chronic strain injuries and may need surgical intervention at the wrist level.

 

Recovery Disability parallels that of strains.

 

Learning and Reference Sources:

 

In addition to formal medical education courses, there are other places where medical knowledge can be obtained.  A few are:

  1. ACOEM and/or ODG Guidelines
  2. Local First aid and EMT classes
  3. Medical dictionaries
  4. Medical hand books designed for lay people and to be used in home or business
  5. Training sessions led by Medical Practitioners

 

Summary:

 

A strong medical knowledge of traumatic injury and occupation diseases is necessary.  This will allow for expected treatment, recovery periods, residual disability, and medical payments.

 

 

 

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

 

 

©2016 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.

 

Pay Without Prejudice – Solution To Big Work Comp Problem

Imagine this scenario … you started working for your company about six years ago. One day you’re walking into work in the parking lot … you slip and fall and you hurt your back. There’s a question of whether or not that injury is work-related. You go in to get medical treatment. You’ve get a great health insurance plan but they won’t cover your medical expenses, because you have a work comp claim that’s in dispute. Also, because your work comp claim hasn’t been accepted you can’t get medical expenses covered under that plan either, so, now you’re left to have your injury continue to get worse.

 

 

Delayed Or Denied Medical Treatment Is Big Problem

 

This scenario that I’ve described is a problem in our industry. I’ll say it again. This scenario that I’ve just described is a problem in our industry. I’m Michael Stack, with Amaxx, and, today I’m going to be talking about a solution to that problem. It’s called, Pay without Prejudice, and, in Maine, it’s Statute Number 222, called Provisional Payments of Certain Disability Benefits.

 

I want to graph this out for you and show you what this looks like. It’s very common and a big problem, as I said, in our industry. Let’s talk about this. You have your back injury … here’s the time of injury. I’m going to graph this out in blue and in red. In blue’s going to be the cost of the injury, and in red is going to be the severity.

 

You have what might be a very simple injury. It might be something that just needs a little bit of treatment and you can get back to work right away, but because you can’t get your medical expenses covered, there’s a delay in treatment. Your injury gets worse and worse and worse. The cost is going to follow, of course, in a very similar timeline when it becomes more and more expensive.

 

The longer the delay in treatment the worse your injury becomes, the more expensive the injury becomes, the more of an impact it has on that individual’s life, the less likely they’re going to be coming back to work. The more likely they’re going to be out on a lifetime disability claim, the longer that injury goes untreated. This is a problem in our industry.

 

 

Pay Without Prejudice & Maine Statute 222

 

Here’s the solution. It’s called, Pay without Prejudice.” In Maine, again, it’s Statute number 222, Provisional Payment of Certain Disability Benefits. This is a concept we talked about in The National Work Comp Conversation, and, this Maine Statute really came into the conversation during those discussions. Basically, what it says is that there’s no delay in benefits. Even though a work comp claim is in dispute, you cannot delay or deny the benefits to get that medical treatment. It’s written right into the statute in Maine.

 

If you’re not in the State of Maine, you can write this right into your account handling instructions … your account service instructions. If you’re a self-insured employer, or, if you have a high-deductible plan this is a concept that should be in your policy, because this back injury can get addressed right away. This person can get right back to work and these costs remain contained. It creates a better outcome for the injured worker and significantly controls your work comp costs.

 

If it’s determined that your claim either was or was not compensable the appropriate carrier … either the health insurance carrier or the work comp carrier, can be reimbursed for those expenses appropriately. Pay without Prejudice, and, in Maine … Statute Number 222 … Provisional Payment of Certain Disability Benefits. If this is not in your state talk to your legislators. If this is not in your account handling instructions this is a concept that should be. Remember your success in worker’s compensation’s defined by your integrity … so, be great.

 

 

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

 

 

©2016 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.

 

Low Back Pain: Dealing with the Proverbial Pain in the Butt!

back-painInjuries to the lower back and the symptomology associated with such claims make up a significant portion or all workers’ compensation claims.  This requires members of the claims management team to be proactive when it comes to injuries involving the lower back.  It also serves as an opportunity to understand the origin of such incidents and take steps to prevent them.

 

 

The Anatomy of the Spine

 

The spinal cord is the core of a person’s central nervous and skeletal system.  It is an important part of the body’s infrastructure.  It is made up of many important parts that holds a person together.

 

With respect to the spinal cord, several key segments claim handlers need to understand.  This includes:

 

  • Cervical spine: This is the region of the spine that connects to a person’s brain stem.  It is comprised of seven (7) vertebrae.  In layman’s terms, this region of the spine is called the neck.

 

  • Thoracic spine: This is the midsection of the spine and is comprised of 12 vertebrae.  This portion of the spine does not bend back and forth as often, which allows vertebrae fractures to heal with some certainty.

 

  • Lumbar spine: This is the lower part of the spinal cord and is comprised of five vertebrae.  Like the cervical spine, this part is subject to many stresses of everyday activities.  Functions such as bending, twisting and sitting place extreme stress and are subject to a part percentage of everyday and work-related injuries.

 

There are also other important components to a spine.  They include:

 

  • Sacrum and Coccyx: The sacrum typically includes five vertebrae structures, which are attached to the lumbar spine.  In turn, the sacrum is connected to the coccyx, which is commonly referred to as the “tailbone.”  These bones are also involved in countless work injuries.

 

  • Discs: These are the spinal cords “shock absorbers” and are similar to a jelly donut.  Injuries to discs result in herniations, which causes them to lose their absorbency.

 

 

Dealing with Secondary Gain in Low Back Pain

 

Degenerative changes in the spinal cord, especially the lower back, are common for any person to experience over their lifetime.  This is based on activities of daily living that places stress on the vertebrae.  Studies indicate that the average American over the age of 40 has some degenerative changes in their back, which may include herniation without symptomogy.  The result of this is for members of the claims management team to be proactive when handling a claim involving a spinal cord injury.  Factors that delay recovery often include:

 

  • Common themes for this characteristic include the age of the employee;

 

  • Tenure in a position (both long and short term);

 

  • Language or other cultural barriers;

 

  • Lack of interest in returning to work;

 

  • The presence of return-to-work opportunities; and

 

  • Seriousness of the injury.

 

 

Identifying Secondary Gain and the Low Back

 

One common test used to identify malingering is the Waddell’s Test.  Gordon Waddell developed this test in 1980 to indicated symptom magnification in low back injuries.  This test can be a part of an independent medical examination, as well as a review by the treating physician.  Proper use of this test includes the following:

 

  • Superficial tenderness or overreaction exhibited by the patient;

 

  • Testing that does not cause stress on the spin, but results in pain;

 

  • Examination techniques that include distraction and re-verification when the patient is properly oriented; and

 

  • Disturbances that do not have a known etiology.

 

Claimants who exhibit a “positive” test should be scrutinized and possibly treated for other underlying conditions, which can include depression, or other psychological/psychiatric conditions.

 

 

Conclusions

 

Dealing with low back pain claims can be challenging for members of the claims management team.  Through properly training and understanding of the spinal cord, members can develop tactics to identify symptom magnification and resolve troublesome claims.

 

 

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

 

 

©2016 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.

 

Using Evidence Based Medicine In The MSA Review Process

RitaWilson

Rita Wilson, CEO, Tower MSA Partners

Rita Wilson, CEO, Tower MSA Partners

… on using evidence based medicine in the MSA review process

 

While CMS includes evidenced based medicine in its MSA evaluation resources, it does not require treatment to line up with science in order to be approved and allocated.  Consequently, many MSAs allocate for inappropriate medical procedures and pharmacy regimens that threaten patient safety.

 

Claims should be staged to identify treatment issues and cost drivers prior to preparing an MSA.  A proper pre-MSA Triage compares six months of medical records to clinical guidelines and this process frequently identifies recommended procedures or surgeries that have not occurred – and may never be needed.  To avoid funding procedures that will never take place, the next step is to contact treating physicians to clarify recommendations and make sure the medical records reflect ensuing changes.

 

Triage should also detect inappropriate pharmacy regimens that pose risks to patient safety and drive up settlement costs.  Often, injured employees are taking opioids, benzodiazepines and other drugs deemed inappropriate for their conditions by evidence-based guidelines.  Off-label use of certain drugs, like Lyrica, is another issue because Medicare will not pay for off-label use of certain drugs.  Sometimes there are prescriptions that have never been filled.  If not addressed, CMS will require their costs to be allocated in the MSA.  A best practice MSA provider will work with treating physicians to discontinue inappropriate medications, monitor tapering and secure the documentation CMS requires to allocate for the updated pharmacy program.

 

Applying EBM to claims is an extra step in the settlement, but well worth the time.  It protects patient safety by making sure treatment is sound and reduces costs by removing drugs and procedures that fall outside science.  It’s the right thing for the patient and the payer.

 

 


Using Evidence Based Medicine In The MSA Review Process

 

The concept of future medicals and Medicare Secondary Payer compliance is a challenging component of any workers’ compensation claim management team seeking to reduce costs in an ethical manner.  The voluntary Medicare Set-aside review process established by the Centers for Medicare and Medicaid Services (CMS) compounds this problem.  Use of Evidence Based Medicine (EBM) is one method that concerned parties can use to challenge CMS polices and provide a consistent result that meets the needs of workers’ compensation programs.

 

 

Understanding the Voluntary MSA Review Process

 

CMS started to provide guidance to parties regarding the workers’ compensation Medicare Set-aside review process in 2001.  This took the form of policy memoranda that was sometimes contradictory and confusing.  In an effort to streamline the process and make it more understandable, CMS changed course and consolidated this information into the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide.

 

CMS will review a proposed WCMSA amount when the following workload review thresholds are met:

 

  • The claimant is a Medicare beneficiary and the total settlement amount is greater than $25,000.00; or

 

  • The claimant has a reasonable expectation of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.00.

 

Consistent with federal regulation interpreting the Medicare Secondary Payer Act, CMS cautions parties that they must still consider Medicare’s interests even if a settlement does not meet the specified voluntary workload review thresholds.

 

 

Understanding CMS Policy Concerning Future Medicals

 

CMS does consider every workers’ compensation case in a proverbial vacuum.  For instance, “counter-highers” concerning the MSA allocation often arise in the following situations that most interested stakeholders consider unreasonable:

 

  • Degenerative changes that naturally occur resulting in prolonged medical care and treatment for a work injury that arguably only aggravates, but does not accelerate the an underlying condition. This prolonged care CMS seeks reimbursement for is often the result of the natural aging processes or prior non-work related injuries that sometimes require surgical intervention and costly prescription drug use;

 

  • The ongoing and sometimes excessive use of prescription pain medications. This is especially the case when it comes to opioid-based prescription medications, which significantly spike the cost of workers’ compensation claims.  These prescription medications can only be effective when used for acute pain relief and not long-term maintenance care; and

 

  • Issues raised in independent medical examination reports regarding the reasonableness and necessity of future medical care and treatment. Although these reports are prepared at the request of the employer/insurer, doctors performing these examinations have adequate foundation for issuing their expert opinions within a reasonable degree of medical certainty in a legal or administrative hearing.  CMS policy does not recognize the validity of these reports in the WCMSA review/approval process.

 

 

Using Evidence Based Medicine to Counter CMS Objections

 

EBM is a recognized approach within the practice of medicine that seeks to optimize the results in patient care via medical evidence based on research and design.  In the case of questions concerning the use of opioid-based prescription medications, this process is used to demonstrate the effectiveness of a certain treatment regimen and denote when the continued use losses it benefits.

 

Using EBM to stage the claim for submission and approval by CMS in the Medicare set-aside process does require work, but the payoff is significant.  The process includes utilization of medical records, scientifically supported medical research and an evaluation of trends to demonstrate the best course of future action for an injured worker in an effort to modify treatment.  It also includes a review of possible treatment modalities that discourage prescription drug abuse and deliver savings the interested stakeholders and an acceptable level of care to the injured party.  The use of medical experts to challenge inappropriate treatment, and the process of maintaining oversight over the claim until the CMS accepted evidence is obtained to demonstrate drug regimen can be time consuming, but the result is long-term savings and a CMS approved MSA that concurs with EBM guidance.

 

 

Conclusions

 

The challenges of the workers’ compensation system require members of the claim management team to be proactive.  One area includes the use of EBM to challenge CMS orthodoxy when it comes to costly future medical projections, which often include excessive use of dangerous opioid-based prescription drugs.  While costly, the use of EBM can reduce the threat posed by legacy claims.

 

 

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

 

 

©2016 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.

 

Chronic Pain: A Double Dose of Trouble

chronic-painDealing with “chronic pain” is an issue the workers’ compensation claims management team deals with on a daily basis.  This is highlighted by the daily dose of news about the prescription drug epidemic and the countless Americans who are either addicted to these legal medications, or become addicted to street drugs as the result of using them to deal with work-related injuries.  It is important to claim handlers to be proactive on this issue for the benefit of the injured employee and the bottom line.

 

 

What is Chronic Pain?

 

From a clinical standpoint, “chronic pain” is pain symptomology that lasts from three to six months following the onset of injury.  This can be the result of a specific incident such as a slip/fall injury, an aggravation or acceleration of an underlying condition or an injury resulting from workplace exposure or repetitive activity.

 

In most incidents, healthcare professionals in the United States deal with chronic pain by prescribing opioid-based pain medications.  These medications come in many forms and names people have come to know.  They include:

 

  • Codeine (available in generic form)
  • Fentanyl (Actiq, Duragesic, Fentora)
  • Hydrocodone (Hysingla ER, Zohydro ER)
  • Hydrocodone/acetaminophen (Lorcet, Lortab, Norco, Vicodin)

 

These prescriptions are useful as they relieve pain for a period and allow a person to recover from injury.  They are derived from opium, which is commonly processed into the street drug known as heroin.

 

 

Quick Facts on Opioid Addiction

 

  • From 2000 – 2013, the drug screening industry grew by $1.2 billion.

 

  • Workers’ compensation insurers in California alone spend about $100 million per year for opioid-based pain medications.

 

  • Prescriptions for buprenorphine and naltrexone—two drugs used to treat opioid addiction have risen to nearly 8 million in the last number of years.

 

  • At least 20 states allow doctors to both prescribe and sell drugs, often at dramatic markups.

 

  • Prescription drugs dramatically increase the cost of a WC claim:
    • $13,000: Average cost of a claim without opioids
    • $39,000: Average cost of a claim with Percocet
    • $117,000: Average cost of a claim with long-acting OxyContin

 

 

Issue Identification and Practical Solutions

 

Members of the claims management team are on the front lines of the battle against chronic pain and its “tax” on workers’ compensation programs.  Claim handlers can look for patterns and help identify issues early on before it becomes a larger problem.  This can especially be the case if a claimant overdoses as part of their medical care and treatment related to a work-injury.  If the death is related to the injury, the cost of the claim increases in the form of death benefits.  Fraud, waste and abuse are other drivers.  It is recommended to leverage a Pharmacy Benefit Manager relationship to help manage both cost and utilization of prescription drugs.

 

Key signs a claimant is abusing their prescription medications include:

 

  • Prescription medications that are often lost or stolen. In most instances, they are being sold to a third party or being given to family members.

 

  • Increasing use of pain medications without subjective reports of improvement. This information can be obtained from a claimant’s medical records and pharmacy receipts.  Information can also be gleaned when speaking to a claimant regarding issues concerning the injury.

 

  • Use of multiple doctors or pharmacies to obtain pain medications. While most states have pharmacy-reporting programs in place, it is still easy for people to game the system and obtain prescriptions from multiple sources.

 

  • Resistance to treatment agreements that include random urine samples or treatment plans.

 

 

Conclusions

 

Members of the claims management team play a necessary role when dealing with chronic pain.  This is an important function as monitoring this issue can help contain costs, while at the same time reduce unnecessary expenditures in any workers’ compensation program. A best in class Pharmacy Benefit Manager relationship should be leveraged to successfully manage chronic pain.

 

 

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

 

 

©2016 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.

 

What Is The Identity Of Your Work Comp Management Program?

Your identity. How you tell your story. How your clients, as well as how your own employees view your organization. More specifically, your worker’s compensation management program. I’m Michael Stack with Amaxx, and today I’m going to be talking about branding. The importance of it, as well as how you apply that concept to your work comp management program as one of the first steps of implementation.

 

 

Two Words Create Immediate Understanding & Expectation

 

Now, one of the longest standing and most respected organizations in our industry, this week is launching a re-branding campaign. The company I’m referring to is Ringler. I want you to take a look at what they’ve done, because when I saw the new brand, I was both inspired and impressed. If you look at this new brand, you’ll see two words: “Everybody wins.” To give you a little bit of context here, Ringler provides creative and objective settlement solutions that protect the injured worker and really create a better outcome for them, as well as significantly reduced worker’s compensations costs for the payer side.

 

Two simple words. Clients, injured workers, plaintiff and defense attorneys, all members of the claims management team can simply and immediately understand how the interaction is going to go with their organization. They could not have done a better job to set that expectation and create that identity for their company.

 

 

What Is The Identity Of Your Work Comp Management Program?

 

I ask you, what is the identity of your organization? What is the identity of your work comp management program? What is the expectation for how that interaction is going to go? Do you have one? When you’re starting to implement a work comp management program, one of the first steps of implementation is creating this brand, creating this identity, creating this logo. One of the examples that I like to give, if you work for the Acme company, is you get around, you get your employees involved, you get your supervisors involved, you get your senior management involved. It should be the first step in really getting this process involved, getting people on board with what you’re doing.

 

You sit around a table, and you come up, and you brainstorm some ideas, and you come up with the Acme IPAR program. The Acme Injury Prevention and Recovery Program. Obviously, this is going to be tailored to your organization, for what makes sense, for what fits, for what really has some meaning for your company. It should be the first time you get together, you come up with this acronym, you come up with this logo, you come up with this identity, and you come up with this expectation for how things are going to go at your organization.

 

 

First Step In Building A Successful Work Comp Management Program

 

When you’re talking to your employees, when you’re explaining it to vendors, when you’re having these interactions, you can say, “Well, this is how we do it here at Acme. This is our Acme IPAR program. This is the expectation for how things are going to go.” It’s the first step in building a successful work comp management program, so sit down, brainstorm, have some ideas, create that expectation, and create that identity for your organization.

 

Congratulations to Ringler on a very successful and a very good job on creating your brand and your identity. It’s something that we can all learn from. Remember, your success in worker’s compensation is defined by your integrity, so be great.

 

 

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

 

 

©2016 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.

 

The Doctor Will See You: Using Treatment Parameters in Work Comp

Reducing workers’ compensation claim costs requires that members of the claims management team and other interested stakeholders know and understand the law.  Part of this includes using medical treatment parameters as a tool to promote the effective management of medical costs.

 

 

What are Medical Treatment Parameters?

 

Medical treatment parameters are not present under every workers’ compensation act.  About half of all jurisdictions employ some form of these guidelines.  This requires the claims handler to research the jurisdiction they are working in to understand if they are available.

 

The use of treatment parameters were developed to provide reasonable guidelines for care of all compensable workers’ compensation injuries.  All interested stakeholders, which included medical providers, vocational experts, developed them and attorneys from both sides and other parties involved in the process.  The result is they serves as a baseline to measure the effectiveness of medical care and treatment and promote quality health care.

 

 

When do Treatment Parameters Come into Play

 

Generally, all medical care and treatment provided to an injured worker is required to be reasonable and necessary to cure and relieve the effects of the work injury.  Workers’ compensation medical treatment parameters, which are not applicable in all situations, require that a medical provider demonstrate the medical care they provide results in continuous improvement in injury care that moves the employee toward maximum medical improvement, or full resolution.  When it comes to medical treatment parameters, it is important to remember they only apply in the following situations:

 

  • Claims where primary liability has been admitted, but there is a dispute concerning the treatment plan, or whether the medical care and treatment is reasonable and necessary; and
  • Instances where primary liability is denied, but later admitted. At that point, the treatment parameters can be used as a defense to the medical care and treatment being received by the employee.

 

It is important to review applicable statues and regulations before asserting a defense based on medical treatment parameters.

 

 

Using Medical Treatment Parameters in Your Claim

 

There is a statutory presumption that the medical treatment parameters are reasonable and necessary.  In essence, they are a “one size fits all” for workers’ compensation medical care.  While it is impossible to categorize all work-related injuries, a vast majority of them are covered under these guidelines.  Major injuries covered include:

 

  • Injuries and conditions to the spinal cord, including disc herniations, vertebrae fractures and pain symptomology;
  • Upper extremity conditions including fractures, dislocations, and common syndrome including carpal tunnel and lateral epicondylitis (tennis elbow);
  • Traumatic brain injuries and cognitive dysfunctions;
  • Psychological, psychiatric care and mental illnesses; and
  • Reflex sympathetic dystrophy (RSD) or other neurological conditions.

 

 

 

What is Covered under Medical Treatment Parameters?

 

Medical treatment parameters set forth the frequency of medical care and treatment provided to the employee.  The rationale is this avoids excessive care, waste and abuse within the system.  Common procedures covered include:

 

  • Imagining such as x-rays, MRIs and CT scans;
  • Use of prescription medications, including the use of opioid-based drugs;
  • Physical therapy and chiropractic care; and
  • Procedures that must be attempted prior to surgery.

 

It is important to note that departures are permissible in jurisdictions with medical treatment parameters.  An example of who this works can be found in Jacka v. Coca-Cola Bottling Co., 580 N.W.2d 27 (Minn. 1998).  In Jacka, the Minnesota Supreme Court noted that “the treatment parameters cannot anticipate every exceptional circumstance, we acknowledge that a compensation judge may depart from the rules in those rare cases in which departure is necessary to obtain proper treatment.”

 

 

Conclusions

 

Workers’ compensation medical treatment parameters are designed to avoid waste and abuse within the system, while at the same time ensuring injured workers receive their entitled care.  This requires members of the claims management team to determine if their jurisdiction has applicable parameters, understand how they can be used and effectively use them in the claim handling process.

 

 

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

 

 

©2016 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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