In 1989 the federal law known as the Worker Adjustment and Retraining Notification Act (WARN Act) went into effect. The intent of the WARN Act was to provide employees with time to plan for their future employment with another company when the employer had to do a mass layoff. The WARN Act has in many ways morphed into the Workers Compensation Claims Preplanning Act (that is not a real title), which provides ample time for dishonest employees to plan and execute fraudulent workers comp claims.
The WARN Act requires employers with more than 100 workers to give a 60 day notice before laying off workers. Employers must issue a WARN Act notice if a facility closing or other Reduction in Force (RIF) will cause more than 50 employees to be without a job. The WARN Act also applies to companies that are staggering the layoffs if the employer is laying off more than 500 employees in any 30 day period, or more than one-third of the workforce if the company has less than 500 employees. If the employer does not provide the notice timely, the employer is required to continue the pay and benefits of the layoff workers for 60 days from the date the employees are notified of the layoff. Plus, in some cases the employer can be fined $500 per day per employee for not giving the layoff notice timely. Please consult your labor law attorney for additional information on WARN Act requirements. WCxKit
Statistics show that workers comp claims spike by an average of 50 percent after a plant closing or other mass layoff is announced. This jump in claims always results in a future jump in the employer’s workers compensation premiums, as claim frequency is the primary factor in the calculation of the employer’s workers comp premium.
Unfortunately, there are times when a RIF is necessary due to a slow-down in business, a need to cut costs, a need to change the organizational structure, or a change in the company’s business strategy. However, the employer does not have to pay bogus work comp claims as a cost of doing business. There are numerous actions an employer who is planning a RIF should take prior to the announcement of the RIF. We recommend employers who must RIF employees to take the following actions.
1. Keep intentions to yourself and only communicate with those who need to know. The less time unethical employees have to plan their fraudulent claim or to think about doing so, the lower the number of bogus work comp claims.
2. If it is becoming obvious that the company needs a RIF, do not put it off. The longer you wait, the greater the distortion the rumor mill will create. The long wait provides ample time for unethical employees to not only plan their workers comp claim, but also to share their plans with other employees that would not be considering work comp fraud, until they learn others are going to file bogus workers comp claims.
3. When a RIF is announced, place a strong emphasis on the unemployment compensation benefits the employee will be receiving. Employees who are less anxious about their source of income are less likely to commit work comp fraud if they know they will have another source of income while they look for another job.
4. Learn how your state handles unemployment compensation in conjunction with workers compensation. Some states allow both at the same time, other states allow one or the other, and some states allow an offset (reduction) in workers comp benefits for employees drawing unemployment compensation.
Prepare for all workers compensation claims that may be received
5. Consult with the third party administrator (TPA) or insurer so the TPA can plan to handle the additional workers comp claims quickly so there is no waiting. If there is a delay in beginning claim investigations, the likelihood of properly defending the claim is reduced, evidence is lost and affirmative defenses are less likely. TPAs should handle these claims aggressively and early which requires sufficient staff.
6. If not already done, a "dedicated" or "designated" adjuster assigned to handle the claims for your company is needed. If you expect a large number of new workers comp claims, it is preferable to handle all of them in the same claims office. This way the claims adjusters are familiar with working conditions.
7. If you have been utilizing more than one defense firm, pick the best attorney and pre-arrange for one attorney (best) or one firm (acceptable) to handle all work comp litigation that occur after the announcement of the RIF.
8. If an employer is closing the facility or making a major remodeling, invite the defense attorney(s) to the facility so the defense attorney(s) can familiarize themselves with the facility.
9. Video record the areas/equipment/machinery that would most likely be included in any injury scenario, especially if the plant is to be renovated or demolished.
10. Video record job functions for the medical providers, especially those that would most likely be included in any injury scenario.
11. Make a list of all key personnel, managers and supervisors, including the home address, home phone number and cell phone number, who can testify if necessary.
12. Make sure all personnel records are up to date, especially health insurance records and sick time documentation (for example: the employee who took sick time for the back injury that occurred at home may now claim an aggravation of the pre-existing condition to continue the medical care and to draw indemnity benefits).
13. An exit physical should be considered especially if the employees work in a high decibel area or have been exposed to chemicals or other irritants while on the job. This action should be reviewed with your defense attorney and claims supervisor as to the benefits versus the risk.
14. An exit interview can identify potential future workers comp claims. Provide the employees with a form to complete to list any known medical condition.
15. Do not forget the employees who were already out of work and drawing indemnity benefits before the RIF announcement. Their incentive to return to work has been removed in situations where their department or plant is being closed. Every possible effort should be made to get these people back to work before the RIF.
16. Work with an offsite transitional duty vendor so that employees who are on transitional duty can be employed elsewhere until they are fully recovered and at MMI. Be prepared to place ALL employees who are on transitional duty in a paid position elsewhere. Charitable positions are also an option as is home-based employment.
It is essential that all workers comp claims reported after the announcement of a RIF be completely documented and thoroughly investigated promptly. Once the facility is closed and people and evidence is no longer available, it is much more difficult for the workers comp adjuster to handle the claim properly.
It should be noted that not all workers comp claims that occur after a RIF is announced are fraudulent. There will be legitimate injuries that occur. There also will be employees who have worked through other minor aches and strains who now feel they must report their work-related medical condition. (WCxKit)
When you are planning a large scale RIF, you will have a lot going on. The control and prevention of fraudulent work comp claims is necessary to not lose some or all of the financial benefits the company obtains from a RIF.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com.
Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Sometimes, despite an employer's best efforts, some employees just do not want to come back to work (not having to work for a steady paycheck is a pretty good deal). The usual way employees block their return to work is by exaggerating the physical demands of their job. When asked by the orthopedic doctor how much lifting the job entails, the employee remembers the one time in his 20 years of employment where he picked up a 90-pound bag of concrete mix. What the doctor hears is the poor employee is lifting 90-pound bags all day long. The orthopedic in an effort to avoid a malpractice claim, tells the employee you cannot do that, and keeps the employee off work for another month.
A lot of savvy risk managers and workers compensation coordinators are furnishing the medical provider with a copy of the employees written job description as soon as they know who the medical provider is or is going to be. This often helps to get the employee back to work as soon as the employee is physically able to return to work. However even with a written job description, there are times the doctor does not have a clear understanding of the employee’s job.(WCxKit)
With YouTube and all the other video display sites on the internet, the use of video to show and describe things is quite common. Video job descriptions are now easy to create, simple to watch and they make it much easier to understand processes when the medical provider is not previously familiar with them. There are also videos and photos on Facebook that are now commonly used to dispute claims on inability to work.
Before you start making a video of the employee’s job, stop and plans what you want to show. Read through the written job description. Does it cover everything the employee does? Ask another conscientious employee who does the same job how the written job description can be improved (no need to mention the other employee’s work comp claim). Be sure to make note of everything the currently working employee states needs to be added to, or taken out of, the existing job description.
Obtain a copy of the injured employee’s medical restrictions. Identify the limitations the medical provider has placed that are preventing the employee from returning to work (this will be important when making the video record of the job description).
Ask the working employee to allow you to video record the work routine, the daily task and the most difficult parts of the job. Be sure to capture on the video the way the working employee has to move, bend, stretch, twist, walk, sit, stand, etc. Show all repetitive motions. Show all lifting whether it is a 40-pound box of materials, or a feather-light single piece of material.
Be sure to have the sound turned on during the video of the job and ask questions. Some of the questions you will want answered in your video include:
1. How much does that item weigh?
2. How often do you have to pick up the item?
3. Is it easier to do your job sitting down or standing up?
4. How far do you have to reach?
5. How many times a day to you repeat that motion?
6. What can be done to make the physical demands of the job easier?
7. Show me the most difficult part of your job.
8. Without mentioning the injured employee, ask about each limitation that has been placed on the injured employee, for example:
a. “If for safety reasons we said not to lift more than 20 pounds, could you still do your job?”
b. “If you were unable to stand for more than four hours at a time, would you be able to do the job sitting down?”
c. “Would it make the job easier if you alternated between standing and sitting?”
d. “Would you be able to do your job if we limited the repetitive motion to XX repetitions per hour?”
Keep in mind there is the possibility that the conscientious employee will state “you cannot do this job if you cannot lift 40 pounds” or something similar that will validate the fact the injured employee is not malingering and really cannot return to work, yet.
If necessary, edit your video job description to keep the length down to about five minutes. That is about as much time as you can expect the doctor to take away from his/her many other duties to watch the injured employee’s video job description.
When you are satisfied the video record will answer all the potential concerns of the medical provider and properly portray the injured employee’s job, ask the nurse case manager to view the video job description. See if she has any concerns about the injured employee’s capabilities to return to work. If she does, determine how the job might be modified for the injured employee to return to work.(WCxKit)
The nurse case manager is a good way to get the video record in front of the medical provider. The nurse case manager can explain your desire to get the employee back to work and also explain how any necessary job modification will be accomplished to meet the injured employee’s restrictions. If necessary, add to the video any job description changes needed to accompany the employee’s restrictions, showing the way the modified job will be done. When the medical provider sees the employee can do the regular job, or a modified duty job, the formerly injured employee will soon be back to work.
Author Rebecca Shafer
, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com.
Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Workers’ Compensation Costs Can Be Reduced by Implementing Operational Best Practices: Learn How With This New Guidebook.
A company that wants to implement a new workers compensation program or revamp an existing system will find this book helpful. Maybe your company has recently expanded and you realize the need to train a workers compensation manager or regional coordinators how to hold down compensation costs. Whatever your need, here is the answer:
Workers Compensation Management Program: Reduce Workers’ Comp Costs 20%-50%.
Used by more than 150 firms across the country, this is THE book to help every employer develop a more effective workers compensation program to reduce workers compensation costs. It is based on field research and decades of experience in workers compensation from all aspects of the business. Best practices are described in detail for each person in the injury process.
This easy-to-read manual has been updated for 2012. It now includes:
An index for quick topic look-up so you can view a term or a procedure and see all relevant references.
NEW – Workers Compensation Basics
Purpose of Workers Compensation
Who Pays for Workers Compensation?
Parties Involved in Workers Compensation
Benefits for the Employer
Independent Contractors
Benefits for the Employee
Injuries Covered
Types of Workers Compensation
How Losses are Categorized
How Losses are Reported
Calculating Your Premium
How Mod Effects Your Premium
Good/Bad Mod Example
Five Ways to Reduce Your Mod
NEW – Fundamentals of Cost Containment
Reasons Workers Compensation Costs are High
Who is in Charge?
Work Ability Form Properties
Who is Responsible for Managing Workers Compensation Claims?
Who is Responsible for Managing Workers Compensation Process?
Hidden (Indirect) Costs of Workers Compensation
Additional Costs
Calculating WC Costs
External Obstacles to Cost Control
Internal Obstacles to Cost Control
NEW – Working with Your Adjusters or TPA
Account Handling Instructions
MD Participation
NEW- Reporting a Claim
Critical Issues
Essential Intake Considerations
Nurse Triage
NEW- Directing Medical Care
Occupational Health Clinics
Remote Health Services
Directing Medical Care in California
NEW- Return to Work
What to Include in a Transitional Duty Policy
Non-Profit, Volunteer or Charitable Positions
Employees Who Never Return to Work
Coordinating WC with Federal and State Leave Statutes
NEW – Other Indemnity Cost Containment Services
Telephonic Disability Intervention
NEW – Medical Cost Containment
URAC Certification
Mental Health RNs
Chronic Pain Programs
An Aging Workforce
At Home Recovery Services
Medical Fee Schedules
Fee Schedule Coding
ICD-9 and CPT Codes
NEW- Physical Therapy and Physical Rehabilitation
Differences between Physical Rehabilitation Programs
Pharmacy Benefits Management Program
Authorized Drug Formulary
Toxicology Screening
NEW – Fighting Fraud and Abuse
Medical Terminology Used to Identify Malingering
Reviewing Investigation Reports and Videos
Avoid good Day/Bad Day Syndrome
NEW – Claims Resolution and Settlements
Conditional Payment and Final Demand
Pharmacy Component of MSA
California Settlement Process
A 183-page guide covering how to assess your workers compensation program, design program materials, roll out a program to the organization, and monitor and manage the program once implemented.
Written by a national expert on workers compensation cost containment with over 25 years experience helping companies reduce their losses 20% to 50%.
T. Ronca, a workers’ compensation defense attorney from Long Island, NY, said the
book is an invaluable desk reference. “It is one of the tools that should never be out of reach for a risk manager. Direct employer involvement with claims in the first weeks is the difference between success and failure. This manual will guide the conscientious employer through the pitfalls,” Ronca said.
What’s more, the book can be delivered with your company logo on the cover and a full-color ad for your company on the back cover.
Take it out to the field. Text tabs are available to put on each chapter and it is ready to go as your company training manual. All you will have to do is customize the Training Agenda that is in Part I of the book.
Included in the manual are topics such as: Return to work and transitional duty, claim reporting, employee communications, controlling fraud and abuse, directing medical care, medical cost containment solutions, post injury response procedures, reporting procedures, working with your carrier and third party administrator. There is information about physical therapy, pharmacy benefits management programs, training supervisors and gaining management commitment. It also contains concepts of claim settlement and resolution as well as safety and loss control. New areas are identified above.
There are 5 sample worksheets in the manual to help organize an efficient workers’ compensation program. These include: timetable for implementation, the injury coordinator job description, and several sample roll-out letters. We recently received a terrific phone call from a third-party administration firm saying how the manual provided an organized way to train clients at loss prevention and has helped their clients put "layers of better WC management" in place. Everyone benefited.
One large distribution firm wrote to us to say the chapter on safety and loss control led to a company-wide safety change that only cost a few hundred dollars but prevented a specific type of injury that had been draining its budget, says Rebecca Shafer, Esq., President of Amaxx Risk Solution, Inc. who authors the book. Shafer is a national expert on workers’ compensation cost containment with more than 25 years of industry experience helping many companies reduce their losses 20-50%.
When you order your copy of Manage your Workers’ Compensation Program from Advisen at
http://corner.advisen.com/wcbooks, the 183-page guidebook shows how to assess your program, design program materials, roll-out a program to the organization, and monitor and manage the program once implemented.
The workbook is also available with a customized front and back cover for bulk purchases. Discounted rates apply to bulk orders.
One company said, "After reading the manual, we took a look at past workers comp practices and saw that every department did things differently. Manage Your Workers’' Compensation Program 2012 gave us the guidance we needed to standardize our workers’ compensation programs across the country. It was like a pre-prepared lesson plan," according to the risk manager.
A regional hospital in North Dakota wrote that, "Our small company expanded rapidly and we actually didn’t have any official workers’ compensation program in place. This manual gave us step-by-step procedures from the first meetings with management to monitoring the final program. Buying and reading the book was almost like hiring another employee – one who was an expert in workers’ compensation."
Who Uses the Workers’ Compensation Book?
Risk Managers and Workers’ Comp Managers find it useful learning about the cost containment niche and use it for themselves and to bringing new team members up to speed very quickly. The book becomes a “lesson plan” tool.
Safety Directors use the book to train supervisors in workers’ compensation claims management. They learn more about their area of responsibility — post loss cost containment — adding to their overall knowledge. They also learn what to do after an injury and what steps are supposed to take place during the first 24 hours.
Brokers use it for prospects, as well as, to learn about specific aspects of cost containment, passing their knowledge on to their clients. For example, when discussing how to develop a return-to-work program and a client asks about, “off-site return-to-work programs,” the broker quickly finds the relevant section in the book, reviews it and passes the answer on to the client, along with a copy of the cost containment book with the broker’s logo.
Adjusters use the book to gain a better understanding of the employer’s perspective. Adjusters also want to learn more about cost containment to add to their overall workers’ compensation knowledge in order to grow their careers and stay abreast of new services.
Account Producers give the book to prospects during formal presentations to illustrate their company is on top of the workers’ compensation industry. The book makes an excellent client gift.
Vendors such as doctors, physical therapy networks, occupational clinics and medical management firms learn how their service might fit into the workers’ compensation marketplace, what is important to employers, and what they look for in medical services to enable the vendors to enter the workers’ compensation marketplace.
The manual is a cost-cutting tool to learn more about systematic and operational techniques for reducing workers compensation costs.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
Posted in
Claim Audits & File Review,
Communication with Employees,
Coordinating Medical Care,
Federal Workers Compensation,
Fraud and Abuse,
Insurance Issues, Rates, Premiums,
Lowering Premiums & Experience Mod,
Management Commitment,
Medical Cost Containment & Managed Care,
Medicare Set Asides (MSAs),
Professional Development Issues,
Return to Work and Transitional Duty,
Risk Management,
Safety and Loss Control,
Settling WC Claims,
TPA and Claims Administration,
WC 101,
WC in Other Countries (International) |
It is never too late to start thinking about how to be more proactive when it comes to handling your insurance losses. You can implement a program or plan any time, provided you roll it out to the right people and your employees or workers understand the initiatives and reasons behind it.
Sometimes workers don’t understand how insurance works. Commercial insurance is a monster to address. It is hard to explain how an underwriter comes up with the numbers they do in order to assign a premium to your workplace. But the bottom line that should be communicated is that every dollar that goes out from the insurance company/TPA could affect the insurance cost. If you have higher costs, maybe you cannot give out higher bonuses. Or maybe increased costs result in certain workers not getting a pay raise. All workers will understand when you put it into a sense of how if affects them directly. So let’s go over some simple loss reduction techniques to refresh your mind for 2012:
1. Make a commitment to promoting safety
If you are going to do this, go all out. You need to establish the rules and procedures, and then you need to come up with a way to drill it into everyone’s mind. The perfect way is by having rules enforced, and violators punished. Not harsh, severe punishments, but more than a slap on the wrist. Make them park in the back of the lot. Make them wear a different color safety hat than everyone else, or a vest that claims they broke the safety rules. Have the punishment be something that is part tongue-in-cheek, but it gets the point across and leads to some good natured ribbing from other coworkers.
On the other side, reward safety achievements. Use gas cards or coupons for free food as gifts. Do raffles and hand out a few prizes to the person that was the most safety-oriented. Whatever you do, make the reward something more tangible than a pat on the back.
Also you can post safety rules and violations on signs and place them all over your work floor, in the bathrooms, in the break areas, etc. Make sure they are at eye-level where people can see them, and color them accordingly so they are hard to miss. Use diagrams and stick people to represent the injury that could occur if you stuck your hand into the saw blade with the machine on. If may seem elementary, but your workers will see those drawings everyday and probably laugh at them, but the more they look at them, the more they remember, and the safer they just might be.
2. Make safety paramount
When you have a safe work environment, you have more productive employees. This is due to the fact that your safe machines are running like they should. Nobody is worried about something breaking or someone getting injured by doing certain jobs. Safe workplaces have fewer workers comp claims.
Obviously there is a direct link between safety and work comp. The less safe you are, the more work comp injuries you will have. And that leads into higher premium exposure. If your claims skyrocket, the costs increase, and that could increase the cost of your premium for your work comp policy. So it all begins with safety. Safety is the key to keeping comp costs down. Which, in-turn, controls premium costs.
3. Have well-defined safety policies and the need to implement them
If workers are not following the safety rules, that is a problem. A rare violator that has to wear the vest of shame is one thing. But if you have a guy breaking the safety rules everyday, you have an issue. You have to investigate why the worker is not following the rules. Document your findings, and then follow through with safety training or re-education on the proper safety function for the particular machine or device they may be using. Maybe they were taught by another employee to use the machine incorrectly. Whatever the reason, investigate it, document it, then retrain and follow through until the person understands and is capable of safely operating the device or doing the work task within your defined safety rules and procedures.
4. Can the employer fire a worker that disobeyed a direct, known safety protocol?
Wow, is this a Pandora ’s Box of a question!!!!! There are numerous case law decisions within any jurisdiction that comment on this matter. I hear this question ALL THE TIME! The answer is "Yes, sometimes" and "No, at other times."
My advice is to always consult your counsel and adjuster before you do anything. Improper termination may open yourself to a world of fines and legal issues, and even though you think you may be doing the right thing that is not for you to decide. Consult your attorney before ever making such a decision. The choice will vary by accident, and no two will be the same.
5. Safety violations cost employers money!
If people are hurt, they cannot do their job, which decreases production, which in turn decreases profit. Jobs get completed late, others have to make up for the gap in work, etc. As mentioned earlier, safety violations in any form will always cost you money. The safer you are, the more productive, the more profitable.
Think Zero Accidents as your goal! People say, "Oh, that's impossible." But it's only impossible if you don't try.
6. High employee morale helps to reduce losses
Several studies show the link between morale and workers comp losses. Happy workers are happy because they have jobs they like; they have manageable workloads, safe working environments, etc. Disgruntled employees are overworked, underpaid, and under stress. They typically are working with potentially unsafe materials, in an unsafe shop, where there is a lot of risk for injury. Sooner or later they will stumble upon that risk, and injure themselves.
Actually the studies linking morale to work comp show they are linked up mostly in subjective injuries: back pain, muscle pain, headaches, etc. The more unhappy the workforce, the more subjective claims seem to surface.
7. Timely claim reporting saves money
And as always, and we say it time and time again, the sooner you get that work comp claim to your carrier to be assigned to an adjuster, the quicker they are on the case, the better the result will be. The more you delay in calling it in, the more it will cost you down the road. WCxKit
So, remember, it’s never too late to start thinking about safety, and how it impacts your bottom line. Think carefully about each job task and what risks your workers face. Solicit feedback from your employees. Involve them in this process, and hear what they have to say. The more they are involved, the more they will participate, and the more successful your program will be. Be safe!
Author Rebecca Shafer
, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com.
Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
It is time to address a topic about causal relation in a workers comp case. This case involves a teacher and school aid in a library, where the desktop computer is being replaced by a laptop. Soon after the switch, both employees begin to complain about neck pain since the height of the monitor on the laptop could not be adjusted from person to person, and extended use was causing some neck pain. The insured wondered if the change to a laptop was causing the neck problems and if these would be considered as workers compensation cases. We discuss the investigation of causal relation here.
- What does the treating doctor say in the medical records?
The most important aspects of this case will be the causal relation statements the physician makes. If the two employees are of the same height and build, why are they complaining of pain, more importantly how is the laptop situated, and how is that causing neck pain? Prolonged sitting in a non-comfortable ergonomic position can lead to strains of the neck, but at a normal desk this should not cause neck pain. Is the laptop screen at eye level or situated down inside the actual top of the desk, where the employees are looking down at the screen? Or is the laptop mounted on top of something where the neck is in a constant extended position? Are other employees complaining of pain or having a hard time viewing the screen of the laptop? WCxKit
It is important to remember in this situation that if an employee comes to an employer and complains of pain and wants to pursue a workers comp claim with supporting medical documentation stating a work injury is present, then it is the employer’s duty to call the claim in to the carrier. The adjuster will make the determination, if the claim is compensable. Certainly more than one employee complaining about the same issue can lead to a more convincing case, but it does not mean it will be automatically accepted. Take pictures of the desk and of these people sitting at the desk as they normally would and send those on to the adjuster as well, so the adjusters can see the setup of the work station and pass that information on to the physician. Being able to actually see the worker sitting as they normally would will help them arrive to the proper decision on the case.
- Does either employee have a history of neck pain from another source?
One of the first questions the adjuster will ask is if either employee has a history of neck pain or prior surgery. This could predispose them to having pain if the neck is positioned in certain ways. Again it does not mean that the laptop setup itself is responsible for the pain. It could be pre-existing post-surgical pain that is the culprit. Prior auto accidents involving whiplash complaints can also contribute to neck pain in the future. Also the employees’ activities outside the workplace are unknown. Maybe one or both of them are engaged in activities that fatigue the neck, and this laptop exacerbated that non-occupational pain. A question about whether the injury could have another cause is part of a normal investigation in just about every workers compensation claim.
- Is the workstation adjustable or not?
If these employees are of different height, can the chair or workstation be adjusted to properly fit them? And if so, are they still complaining about pain? If nothing is adjustable, are other employees of similar builds complaining about the position of the laptop screen? Why or why not? Again, if no other employees are complaining about any problem with the laptop, then go back to these two employees. What is the relationship to each other? Do these two often hang out at the school? Are they in common positions and have similar duties? How long are they actually sitting at this computer and how often are they required to be moving up and around during the day? All of these questions are part of a normal investigation the adjuster will do, and as the employer, try and gather as much of this information as possible to help the adjuster make the proper determination on the claim.
At the same time the claim is investigated by the adjuster, the incidents should be reported to the safety director who should review the workstation design. Consider having an ergonomic consultant review the set up. Ask your TPA or insurance carrier what resources are available for ergonomic consulting. Consider what other equipment could be provided to make the work station more comfortable.
- Has the adjuster performed an IME or peer review yet?
Usually background searches have been completed for prior injuries, and the next thing is to gather all of the medical evidence and set an IME with a qualified physician or occupational medicine doctor to address the causal relation. Is there any objective evidence of degenerative arthritic conditions in the neck that can contribute to this pain? Was an MRI performed, and if so are there any objective results, and, if so, how can they relate to the ergonomics of the workstation? This should all be part of the normal investigation on the claim, and all of these questions should be included in the cover letter to the IME doctor, so that doctor can specifically address these questions with the correct answers, using objective medical evidence to back up the opinion.
- What is the decision–is this compensable or not?
This is the million-dollar question. There are cases like this where these are accepted injuries under workers comp and similar cases where coverage is denied for similar complaints. The lesson here is that no two cases are the same. Maybe one of these employees has no pre-existing condition, and the other one has a prior surgery. This could play a role in which case is compensable and which one is not. It will be up to the adjuster on the file to make a decision on the compensability. Even if the employer disagrees with the decision, there is little to do to swing the case the other way. Let the adjuster do a thorough investigation and stand by the decision. If the worker disagrees with the decision, there are ways to appeal the decision and research to pursue that on their own. That is the choice of the worker. WCxKit
Summary
Ergonomic claims such as this one are going to happen at some point. The key thing to remember as the employer is to do a thorough investigation. Gather as much information as possible, even if it appears to not matter in the final outcome. The adjuster always prefers too much information rather than not enough. Take pictures, and assist the adjuster in any request they have. They will make the proper decision on the claim, since that is an adjuster’s job day in and day out. If, however, you disagree with the decision, make sure to talk this out with the adjuster and the claim supervisor.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
If you are going to sell business insurance to the business community, you need a strong basic understanding of workers compensation insurance. While companies will be concerned about having insurance for their buildings, inventory, and vehicles, and will understand the need for various types of property insurance, the same companies will look at work comp insurance as a governmental mandated cost of doing business.
As their agent, you need to be able to explain to your client business the importance of workers compensation and how it works.
While your clients, the companies, will think about their property insurance exposures, they will have a far higher frequency of workers compensation claims then property claims. Therefore, selling and servicing workers compensation insurance can be challenging for any agent, even experienced ones. The successful insurance agent will be the agent who can explain the advantages of all types of business insurance including workers compensation.(WCxKit)
A major part of the challenge of workers compensation insurance is the way it is different from the other various business lines. With property insurance, the cost of the claim can normally be ascertained fairly quickly and easily. The longer life of some work comp claims, along with the variables of medical treatment, income replacement, and a third party (the employee) who has a different perspective and different motivation, makes the evaluation of the cost of the work comp claim much more complex.
The complexity of work comp is what often keeps insurance agents from being as educated in workers comp as they are in the other insurance products they sell and service. However, learning the parameters of work comp is not nearly as difficult as you might think. To assist you in becoming more proficient in work comp, we have put together a guide that has become quite popular both with agents/brokers and with risk managers/corporate financial control management.
Our guide will assist agents in better understanding the entire work comp process which will assist you, the agent, in providing a higher level of service to your clients when they have a claim or even when they just want a better understanding of workers compensation. The chapters of the guide that will be of special interest to insurance agents include:
1. How an employer should assess their work comp program.
2. How the employer should structure their work comp team.
3. The forms and documents the employer will need to process/submit their work comp claims.
4. The training the employer will need in their work comp program.
5. The management and monitoring of the employer’s work comp program.
Additionally, as the agent, you will want to understand what is going on with the client’s work comp claims. Learning more about the claim progress will allow you to answer the questions your clients have about their claims. Knowing the differences between the way property and work comp claims are handled will allow you to better service your clients. Some of the topics that benefit insurance agents and allow for a better understanding of workers compensation include:
1. The role of the third party administrator in the work comp claim.
2. The differences between bundled and unbundled services.
3. The importance of proper account handling instructions.
4. The role of medical management in the claim.
5. The best practices of work comp claim handling.
6. The ability of the employer to control the selection of the medical providers.
7. The importance of a return to work program at the client.
8. The importance of a solid safety program.
9. How to fight fraudulent claims. WCxKit
It is important that the agent can answer all of their client’s insurance questions including the questions on workers compensation. We encourage you to learn work comp to the point that you can answers all your client’s questions. If you want to know more about cost containment, learn more about our book Workers Compensation Management Program: Reduce Costs 20% to 50%.
Author Rebecca Shafer
, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com.
Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Workers Compensation Laws change frequently. This is only a summary; a complete copy of the most up-to-date version can be found at: www.WorkCompResearch.com , an excellent service.
In Kansas workers compensation coverage is compulsory as to all employment, including corporate executives and employees of charitable organizations. Coverage is elective for individuals, partners or the self-employed. There are some exceptions. Real estate brokers and real estate salespeople on commission are excluded from the compulsory requirements. Also, farm labor and employees of any employer whose gross annual payroll is $20,000 or less are excluded from compulsory coverage.
Obtaining Coverage
To obtain workers compensation coverage in Kansas, the employer has three options which are
- purchasing a workers compensation insurance policy from a state approved insurance company
- applying to and being approved for self-insurance status with the Kansas Department of Labor.
- being a part of a group-funded self-insurance plan that has been approved by the Kansas Department of Labor
Claim Reporting
The employee must provide notice of the injury to the employer with 10 days and up to 75 days with just cause. The actual claim of the employee must be served on the employer within 200 days after the accident, or last payment, or within 1 year of the employee’s death with death occurring within 5 years after the date of the accident. WCxKit
Medical Benefits
In Kansas, the employer selects the medical provider for workers compensation claims. The employer is required to provide all reasonable and necessary medical care free of any charges to the employee. The employer is also liable for up to $500 of employee incurred medical bills at a non-authorized doctor. The employee can also apply to the Director of Workers Compensation for a change of doctors. The employee is entitled to all medical treatment needed to cure or relieve the effects of the injury. Prayer or spiritual treatment is permitted by agreement.
Temporary Total Disability Benefits
The temporary total disability (TTD) benefits are calculated as two-thirds of the employee's average weekly. The maximum amount of TTD benefits that can be paid is $555.00 per week. The state maximum is subject to annual increase/decrease each July 1st, based on the state’s average weekly wage. The state minimum weekly benefit is $25.
The first 7 days of disability (the waiting period) is not paid to the injured employee unless the employee is disabled for more than 21 days. TTD benefits can be paid until a cap of $100,000 has been reached.
Temporary Partial Disability Benefits
In Kansas if the employee is able to return to any type of work, but at a lesser rate of pay then the amount the employee was earning prior to the injury, the employee is entitled to temporary partial disability (TPD) benefits. The TPD benefits are paid at two-thirds of the difference between the pre-injury wage and the post-injury wage. The TPD benefits are paid for up to a maximum of $100,000. The TPD benefits plus the post-injury pay rate cannot exceed the state's maximum indemnity benefits rate.
Permanent Partial Scheduled Disability
Kansas uses a Schedule to establish the value of an injury to all extremities, the shoulders, eyes and hearing. Each body part has a set number of weeks it is worth with a shoulder being worth 225 weeks of compensation and the number of weeks decreasing with other extremity body parts having lesser value down to a toe, other than a big toe, being worth 10 weeks of compensation. A 20% loss of use of the arm, which is scheduled at 210 weeks, would result in a permanent partial scheduled disability award of 42 weeks (210 weeks X 20%).
Permanent Partial General Disability
When the employee sustains a permanent partial general disability of a body part not listed on the Kansas Scheduled Injuries list and the employee is not permanent totally disabled, the employee receives permanent partial general disability. If the employee is able to return to work and is earning at least 90% of the average weekly wage, the employee is given a percentage of the whole body impairment based on the AMA Guidelines, Fourth Edition. The maximum in weeks is 415 weeks. An employee with a 10% rating would get an award of 41.5 weeks of compensation. The maximum an employee can collect for permanent partial disability is $100,000.
Permanent total disability
Kansas permits the employee to collect a maximum of 415 weeks of indemnity benefits for all types of indemnity combined, but the total amount of benefits collected for permanent total disability is $125,000 instead of $100,000 (the amount of TTD benefits paid to the employee is included in the $125,000 indemnity benefit cap).
Death Benefits
The burial expenses in Kansas are covered for a work-related death up to $5,000. The death benefits for a dependent spouse and children follow the same guidelines as TTD benefits – two-thirds of the average weekly wage – currently a maximum of $555 week, and a minimum survivor’s benefit of $370 per week, except there is a dollar maximum for death benefits in the amount of $250,000 with children, or $200,000 without children. If there is no spouse and no dependents, the death benefit is reduced to $25,000. WCxKit
Vocational Benefits
Vocational Rehabilitation is on a voluntary basis in Kansas. However, once it is started, it cannot be terminated without the agreement of the employee. The vendor of the vocational rehabilitation may be changed for good cause supported by substantial evidence. If so, the employee may select the replacement vendor from a list of three qualified vendors provided by the employer.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com.
Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
As any employer with locations in more than one state knows, the workers compensation policy is written specifically for the states where the employer has physical facilities. On the Information Page that comes with each new policy or policy renewal, is Item 3.A (for most insurance carriers) which designates the states where the workers compensation policy is applicable. Workers compensation coverage does not apply to claims filed in other states.
While the insurance carriers attempt to limit the exposure to claims occurring where they may not have claims offices, or knowledge of the workers compensation statutes, the states take a much broader approach. The workers comp statutes of most states specify when and how the workers comp act applies out of state. Normally, the state statute will indicate that if the contract to hire was negotiated within the state, the workers comp laws apply regardless where the injury occurs. (WCxKit)
Most state workers comp statutes will have extraterritorial provisions that state if the principal place of employment is within the jurisdictional boundaries, a workers comp injury occurring outside of the state boundaries is still covered by the state law. The workers comp statutes also normally specify that any work related injury occurring within the borders is subject to the workers compensation statutes, even for employers and employees whose place of business is not within the state line boundaries.
When the employee is injured in another state where the employer does not normally do business, the extraterritorial provisions of the state workers comp act work great, as long as the employee elects to utilize the benefits of the home state workers compensation act. The problems occur when the employee elects to file the claim in a state where the employer does not have a physical location and the employer does not have workers compensation coverage.
The usual reason an employee files for benefits in a state other than the home state is the amount of temporary total disability (TTD) benefits that will be paid. Consider the highly successful salesman from Georgia earning $1,500 per week. If he is injured in Iowa with its high maximum weekly TTD rate, he will receive $1,000 per week while he is unable to work, if he elects Iowa for workers comp benefits. If he elects Georgia benefits, the TTD rate is capped at $500 per week.
This creates a coverage issue for the employer. When the workers comp policy is purchased, the employer should have the insurance agent or broker specify in Item 3.C of the Information Page the other states for which coverage is requested. Some agents will approach this by listing every state and territory except North Dakota, Ohio, Washington, Wyoming, Puerto Rico and the US Virgin Islands (the four monopolistic states and two monopolistic territories where the state/territorial governments provide the workers comp coverage). This can result in an accidental oversight where the agent leaves out a state.
A better approach is to insert the following on the Information Page in Item 3.C: “All states and US territories except North Dakota, Ohio, Washington, Wyoming, Puerto Rico and the U.S. Virgin Islands and those states listed in Item 3.A of the Information Page.” While this is the best approach to out of state coverage, some insurers, especially single state insurers or small regional insurers, will object to providing workers comp coverage in other states where they are not licensed to do business.
Most employers think of the workers compensation policy and the workers compensation coverage as one and the same. Actually, the workers comp policy is divided into several sections with Part 1 being the actual workers comp coverage. Part 2 is employer’s liability insurance which covers injuries to employees when workers comp coverage does not apply. Part 3 is Other States Insurance. With this coverage, workers compensation and employers liability insurance is provided for incidental exposure in states not listed in Item 3.A of the Information Page.
It should be noted that Other States Insurance covers only incidental exposures. When the employer starts to have employees in a state on a regular basis, the states needs to be included in those listed in Item 3.A of the Information Page. If your business has employees who occasionally travel out of state, it is a good idea to routinely review your coverage with your insurance agent to confirm that your policy provides for incidental out of state exposures.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
Morale hazard is loosely defined as the presence of an outside item or system that affects typical behavior. I like to use an example of SUV-type vehicles. Because of added safety features and the enormity of the vehicle, drivers report feeling safer and often take more risks then when driving smaller, less-safe vehicles. For example, an SUV driver may be more aggressive during dangerous snowy conditions, or drive more aggressively in general simply because she feels safer. WCxKit
To put this in a Workers Compensation context, the morale hazard is the comp system itself. The system’s rules and laws make people behave differently than if they were presented with the same injury and medical scenario outside of the work comp atmosphere. We further discuss these scenarios below:
1. Increased pain behavior
Within the WC world, adjusters often complain about claimants overreacting to pain and complaining about the presence of pain with even the most trivial injury. This is thought to happen due to the nature of the claimant feeling that they have to prove their injury to the doctor and to the carrier. Even though, as adjusters, we understand injuries occur and most times they do indeed hurt, the need presents itself for the claimant to feel as if they have to be sure to state how unbearable this particular injury is, in order to make the injury seem more believable.
If you take WC presence away, when a similar strain injury occurs, outside of the workplace, for example, the reaction may be wildly different. Claimants may shrug off the pain as “age-related” or due to overdoing it instead of feeling the need to play up the pain to their doctor, as is often the case in workers compensation claims. Adjusters will rely on physicians using the “Waddell’s signs” to evaluate pain behaviors in relation to the severity of injury. As you see, the mere presence of the work comp system can provide the means to making claimants overplay pain as much as possible to make their case more concrete or believable.
2. Increased drug-seeking behavior
Minor strain injuries generally resolve with modified activity and time. But when a work comp case is present, some claimants feel the need to seek out certain types of medications, typically opiate in nature, to cement the legitimacy of their injury. The thought process is, “If I did not have a bad injury, why would I need these stronger medications? Therefore, my claim must be legitimate.”
One factor muddling this is physicians who are quick to prescribe opiate medication even when the clinical need is not present. Strain type injuries can heal with assistance from anti-inflammatory medication, not necessarily stronger opiate classifications of prescriptions. Many resolve with hot/cold compresses, several special deep knee bend type exercises, rest and 1-2 chiropractic treatments. I speak from experience.
Removing the comp system again can show the normal behavior. If a person injures themselves mowing their lawn, if they do not like going to the doctor in general, they may take over the counter medications and feel just as good the next day as if they did indeed take a stronger medication prescribed to them by their physician. So you see, drug-seeking behavior is rampant in work comp cases due to the need for the claimant to seek approval from their comp carrier for that injury.
3. Poor work quality in light duty work classification
If you have the capability for light duty at your factory, when claimants get injured and have work restrictions, proactive employers place them in lighter duty jobs until they get released by their doctor to full duty. A common situation in comp is the worker complaining even the light duty work makes their pain worse. This can happen even when it seems impossible the light work could cause pain. This is due to the presence of workers compensation. Had the worker not been injured, and you placed them in this light-duty job, it is doubtful they would be making the same complaints.
4. Increased work absences due to pain
Similarly, employers may see an increase in work absences due to alleged pain complaints. Workers will say, no matter what job they do, they just cannot get out of bed and back to work due to injury pain. In the example of the lawn-mowing injury – when the comp system is removed, it is probable this worker will show up as scheduled and ready to work as if it were any other day. This again may be due to the claimant feeling the need to legitimize their claim to the carrier. True, sometimes it's not.
5. General avoidance with the employer
Sometimes outright avoidance becomes apparent. Missed phone calls, voicemails not returned, and an employee not bringing in medical slips to the HR department as instructed may start to happen. Remove the comp system and injury, and this wouldn’t happen. A responsible worker injured outside of work keeps the HR department up to date with medication restriction slips. Once you introduce the work comp system to this same scenario, avoidance behavior may come to fruition. WCxKit
To review, morale hazard is the presence of a particular system or entity that can affect a person’s behavior negatively. This is made clear within the presence of workers compensation. Adjusters see these behaviors day in and day out. What the employer calls a “great, dependable employee” could be to the adjuster a claimant who exaggerates pain, has drug-seeking behavior, and exhibits typical avoidance maneuvers in general. This all negatively impacts the claim, and actually makes it more difficult in the long run. From the workers point of view, these behaviors make their claim more legit — just the opposite occurs.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
Employers are continually searching for ways to reduce workers compensation costs. Triage, where a nurse immediately assesses the employee's medical condition and in some cases arranges for the medical care, is growing rapidly as one of the most effective ways employers can control workers comp cost. In triage, the nurse is involved at the very beginning of the claim. The triage nurse evaluates what medical care is needed through a phone call with the injured employee at the time of injury, provides a list of approved in-network doctors or medical clinics, then passes the claim to a nurse case manager who follows through with the medical provider, the employee, and the employer to ensure the needs of each are met. Companies using nurse triage consistently have very high "penetration rates" meaning that a very high percentage of employees utilize in-network providers; penetration rates for companies using nurse triage are frequently higher than 90%, many approaching 100%.
Triage in workers compensation is a concept that has been borrowed from hospital emergency rooms where the triage nurse is responsible for immediate assessment of the individual's injury and organizing the treatment based on the seriousness of the injury. In workers compensation, the triage nurse immediately evaluates the nature and type of the employee’s injury and directs the employee to the proper level of medical care whether it is first-aid, a walk-in clinic, or an urgent care facility. Sometimes the employee is given home-care instructions. (WCxKit)
The proper use of triage eliminates lag time and indecision. The injured employee, the employee’s supervisor or a co-worker (in an emergency situation) can report the occurrence of the injury to the triage nurse by phone. Most triage organizations provide a toll-free “hot-line” number for workers compensation claims to be reported and are staffed 24/7. The triage nurses that answer the calls are trained to obtain all necessary information in order to perform a comprehensive evaluation of the medical needs of the injured employee. The triage nurse will use treatment protocols and algorithms to identify the proper course of treatment. The employee is then directed to the nearest appropriate level medical facility. These nurses are specially trained and have had a minimum of 10 years of clinical experience.
The triage nurse does not stop after directing the employee to the medical facility. The triage nurse can then contact the medical facility to inform them the patient will arrive soon. Or, this can be done by the employer's workers compensation coordinator. The triage nurse provides the medical facility with the information on the employee’s injury along with the employee’s name, address, phone number, date of birth, social security number, employer's name, address, phone number, and contact information. The triage nurse will also provide the medical provider with billing information and adjuster contact information. Reports of daily activity is sent to the carrier/TPA and the employer, if requested.
Nurse triage makes sure the employee gets to the correct LEVEL of care, but the nurse case manager takes over to "manage" care. Note: When triage is too closely integrated into managing care, it looses focus on preventing unnecessary claims and guiding injuries to the right level of care.
Note: The triage system is more likely to refer more often when the triage provider gains economically from opening a claim. Even "features" that seem convenient like 800 numbers and aps that make it easy for employees to find networks clinics themselves result in employees bypassing triage and going straight to the clinics.
After the employee has had time to be treated, the case managment nurse will contact the medical facility the same day and determine the nature of the medical treatment. Sometimes, this can be done by a senior nurse reviewer or the employer's medical director. A senior nurse reviewer is a nurse who reviews and follows ALL claims from beginning to end; they monitor all claims within an insureds book of claims. A nurse case manager will inquire to see if there are any prescriptions that need to be filled, if there is any diagnostic testing (MRI, CT scan, EMG, etc.) that needs to be done, and if there is a need for durable medical equipment. The case management nurse will then advise the workers compensation adjuster of the prescriptions, diagnostic testing, and durable medical equipment that is needed. Once the adjuster approves the requested prescriptions, testing or equipment, the case management nurse will assist in arranging for it.
The case management nurse will also ask the medical facility for the return-to-work restrictions placed on the employee by the medical provider. If the employee can return to work with restrictions, the case management nurse obtains all the information on the work restrictions and contacts the employer to see if the employer can accommodate the return-to-work restrictions. IF the employer has a return to work coordinator, the return to work coordinator can make contacts related to transitional duty capabilities.
The recommendations of the medical facility for future medical care and the date the employee will be returning to the medical provider will be obtained by the case management nurse. If the employee needs diagnostic testing prior to the return appointment being scheduled, the case management nurse can follow up with the medical facility providing the diagnostic testing and provide the test results to the medical provider.
The case management nurse (NCM) will facilitate and expedite the communication between the medical provider, the employer, and the workers comp adjuster. NCM also has the responsibility of keeping everyone informed about the medical status of the employee. The NCM will be in regular contact with the employee, the employer, the medical provider(s), and the workers comp adjuster. All information about the medical treatment, medical progress and return-to-work options are shared with all parties.
The length of time the triage nurse will continue to work on the new workers claim is determined by the arrangement between the employer and the triage company but generally the triage nurse will hand the case to the case management nurse once the initial care is evaluated. The case management nurse will normally continue on the case until the employee returns to work full time however there may be a need for a nurse case manager depending on the severity of the injury or the employee's inability to return to work even in a modified duty capacity. (WCxKit)
Integrating the triage nurse into the initial medical treatment allows the employer or insurer to set the tone and level of medical care and ensure the employee gets the appropriate level of care immediately. Then the nurse case manager helps to coordinate employee's return to work before the employee has the opportunity to adjust to the idea of not working. By providing medical management at the beginning of the workers comp claim, the triage process improves the return-to-work program results, reduces days lost from work, lowers the cost of indemnity payments, and lowers the cost of medical care. Normally, nurse triage can reduce the number of lost time claims by up to 40%.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com.
Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
