More about issues and buzzwords that are sure to disgruntle the claims adjuster. These are meant to be lighthearted, but for the most part they are correct. So here we go. The content is provided by an interview with a claims adjuster at a major carrier.
1. Fibbing about never having a workers comp claim before
It is understandable that there is a little distrust between the claimant and insurance adjuster in the beginning. If there was ever a claim of any sort before, the claimants do worry about not being entitled to the benefits. A lot of this has to do with the fear of the unknown. A small percentage of people make being a career claimant their full time job. Yes, really.
But do not get off on the wrong foot early on in the claim. I think most people feel that all carriers “share” information on people. That is true to a point, but not all the time. ISO reports and other ways of sharing information are out there and available to every adjuster, it is just a matter of finding it. The adjuster will probably run through the motions of doing an initial background check with just about every claim they receive. This is part of the initial claim set up. The carrier does this to protect itself against fear of the unknown. Carriers deal with thousands of claimants per year, and they will do what they can to ensure that they are paying claims that should be paid, guided by the statutes within the jurisdiction they do business in.[WCx]
Sage advice is that honesty is always the best policy. Just because there is a claim or two in the past does not mean the current claim will be doomed. But the more attempt to hide it, the more it will come back to haunt. The adjuster’s job is to get the help needed and to get the employee returned to work good as new. If they find claims in the background that were not shared with them, it will become a beacon on the radar. Be assured that the adjuster will go the distance in overturning every rock they have to in order to feel they have completed a thorough investigation. So just be honest, remember the adjuster is there to help not fight. Adjusters take it as a point of pride that the claims they pay are legitimate.
2. Grunting and groaning on the phone while talking to the adjuster
Being in pain is no fun. Just the fact there is a claim to file indicates having some sort of medical issue. But please do not drive the point home by being unable to complete a sentence without groaning in unbearable pain. We understand there is pain, but can a decent laceration be that disabling? Sure everyone has their own pain threshold, and some people can deal with pain better than others deal, but again please just act normally. The more over the top it is, the less believable it becomes. The doctor will also indicate in the notes the pain appears out of proportion to the injury. This is known as one of the several “Waddell’s signs” that are used to judge pain and injury behavior. Like I stated …. just be honest. There are no Oscars for the performance.
3. Trying to charge $40/hour for attendant care services or demanding 24-hour/day medical attendant care
Some states leave wages open for family attendant care. Adjusters prefer to allow the use of the husband/wife as caretaker for assistance with activities of daily living. This makes it easier in recovery, instead of the carrier bringing in an outside vendor and person to do this work for them. It is also cheaper this way, but do not overcharge for hours and duties performed by the caretaker. Nothing will irritate the adjuster more than receiving a bill for 24 hrs per day, 7 day per week attendant care. Obviously this is not reasonable or acceptable. In fact most jurisdictions will have caps and price limits on what is entitled anyway, so again just bill for the services needed and nothing else. The more the issue is pushed, the more of a red flag the adjuster will raise that there are some secondary gain issues going on.
4. Lying about the mileage to be reimbursed
The same goes true for mileage. If the claimant tries to say that the therapy facility is 50 miles away, that makes no sense. Especially if the adjuster resides in the same city. These are all red flags that the adjuster will see and cause more surveillance. And the adjuster can use their own resources (such as Mapquest) to get exact mileage.
5. Being a “Google physician”
The internet has certainly made the physician’s job more difficult. Most people will Google the injury and find out as much information as they can. But the injured worker does not qualify as a medical physician. Try to talk shop with the adjuster, but the adjuster has handled claims like these for years, and they know the timeframe and the improvement step to make, and when they should be made. Any derivation from that timeline template raises the red flag and a watchful eye. So again instead of this helping the scenario, it is hurting it in the long run. It is ok to look around online for some information, but there are also many unreliable resources out there, and do not be misled. The focus should be on doing what the doctors and therapists advise, not on what the “internet doctor” suggests.
6. “Risk drivers”
To finish this article off, I thought I would include the Carrier. I have worked at a few different carriers in my time. And though they all differ in little ways, they are more similar than different globally.
Two words that have irritated adjusters since the dawn of time are “risk drivers.” These are the non-injury facts that can contribute to disability. Risk drivers can include obesity, diabetes, having a young child at home (being off of work decreases daycare costs), not wanting to go back to work in general, pending layoffs at the employer of the injured, smoking, and on and on. There are thousands of possible risk drivers. Some do have actual bearing on the claim, and some are ridiculous. Just because one risk driver can apply to one person, it may not affect another person in the same way. It is all theory, and they all succeed in complicating the claim. Most adjusters don't care about what “could” happen; adjusters want to know what will actually affect the claim, and why it will do so. Adjusters do not care about theory, because the theory may not affect the claim at all. It is just aggravating and pointless to hear those words “risk drivers.” [WCx] Hum… what does this mean for data mining?
Summary
So there it is, words, and issues that annoy adjusters. These will never go away, and will probably increase in use as time goes on. But the main point here is that all of these issues can affect a claim negatively. So if you are a claimant and reading this take note to be honest. It will help the claimant, the adjuster, and the injury scenario. The more honest everyone is, the better the claim can be handled, and the faster the claimant can recover and get 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 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 leave the management of the workers compensation claims to chance, the chances are you will not have good results. To have good results in the control of the workers comp claims, it is important that everyone involved – the workers compensation claim coordinator, the floor or field supervisors, mid-management, medical personnel, legal, senior management and even the employees know what roles and responsibilities are in the management of the workers comp claims. My theme is: Take Control. Start by assigning roles and responsibilities to one or more parties in the process – it is a step that can be taken to get things on track. You do not need to assign ALL roles immediately, just take it one step at a time.
The duties of every person involved in the workers comp claim from the claim coordinator to the employee should be defined and written down for each participant. This includes both the pre-accident responsibilities, as well as, the post injury response. By knowing what is expected of them, each person will be able to take the appropriate action when an injury occurs. [WCx]
The workers comp claims coordinator, whether a full-time job at a medium-size or large employer, or a part-time job at a smaller employer, is the pivotal person in controlling the workers comp claims. The claims coordinator can be a part of the risk management department or a part of finance or human resources. The important thing is the claims coordinator has access to all information necessary to control the claim. [WCx]
Claims Coordinator Responsibilities
1- Establishing a transitional duty program prior to injuries occurring
2- Providing all new hires and providing annually to current employees the employee brochure on what to do in case of an accident
3- Arranging immediate medical care at the required medical provider or at the recommended medical provider
4- Providing the medical provider with a detailed job description prior to the employee arriving for the initial medical treatment
5- Interviewing the injured employee to obtain a detailed description of how the injury occurred.
6- Interviewing the employee’s supervisor to verify the description of the accident and what could have been done to prevent the accident from occurring.
7- Completing the First Report of Injury and providing it to the claims office on the day of the injury
8- Contacting the employee immediately following the initial medical treatment for the diagnosis, prognosis and expected period of disability, if any
9- Arranging for light duty / transitional duty / modified duty for the injured employee
10- Sending the employee a get well card when the employee will be off work
11- Maintaining weekly telephone contact with the employee while the employee is treating weekly and telephone contact following each medical visit thereafter.
12- Facilitating on-going contact with the claims adjuster and the nurse case manager.
13- Coordinating and completing all necessary paper work related to the claim.
The employee’s supervisor has pre-accident responsibilities to ensure all employees work in a safe and prudent manner.
Post-accident responsibilities of the supervisor
1- Accompanying the injured employee to the required or recommended medical provider.
2- Providing the medical provider with the Work Ability Form and obtaining the completed form from the medical provider’s office
3- Submitting the Work Ability Form, the Supervisor’s Report of Accident, the Employee Report of Injury and the Witness Report Form to the workers compensation claims coordinator.
4- Enforcing compliance with the transitional duty program and verifying the work done by employees on modified duty is in accordance to the medical provider’s limitations.
5- Training all his/her employees on what to do in case of an injury.
The employee needs to be involved in the control of workers compensation claims.
The employee’s role and responsibilities
1- Participate in post-injury response training.
2- Participate in the return-to-work transitional duty program
3- Attend all employee weekly meetings/office meetings unless physically unable to get to the work-site
4- Provide the Work Ability Form to the supervisor or claims coordinator after each doctor’s visit.
The Best Practices for Injury Management also applies to middle and senior management. Management should have defined roles and responsibilities.
Management Roles and Responsibilities
1- Providing a strong safety program and implementing the necessary risk management practices to keep as many workers comp claims from occurring as possible.
2- Knowing the monthly and on-going cost of workers compensation.
3- Communicating to the employees how many additional sales or how much additional production is necessary to cover the cost of workers compensation claims.
4- Determining the medical providers that will be used
5- Determining the insurance carrier or the third party administrator.
6- Tracking and reporting lost work days.
In addition to the Best Practices for Injury Management noted above, there are best practices for risk managers, medical directors, in-house medical clinics and in-house legal. These sample best practices listed here are far from complete. There are many additional Best Practices for Injury Management covered in our 2012 Manage The Workers Compensation Program, Reduce Cost 20-50%. Contact us to learn more about how to control workers comp cost through Best Practices for Injury Management.
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
Blue-collar employees are not the only ones that have workers compensation claims. Office workers, especially those that sit in front of a computer all day, are having their share of workers compensation claims. Carpal tunnel syndrome, neck aches, and back aches are common musculoskeletal disorders and they are on the rise. Additionally, eye strain, headaches and stress on the body from poor computer mechanics can interfere with the employee’s productivity.
The wrong placement of the keyboard, the monitor, the mouse, the chair or the work surface can produce unnatural stress on the body, especially if the employee is forced to sit and work in an unnatural position. Poor posture, tilting to either side, leaning forward or stretching to work, all produce pressure on the neck and spine. (WCxKit)
Proper body positioning at the computer is important enough that OSHA has put forth guidelines designed to reduce the number of injury claims that result from improper body alignment with the keyboard and monitor. The goal of the guidelines is to create neutral body positioning. When the body is in a neutral position, the joints of the body are naturally aligned. This minimizes the stress on the muscles, tendons and ligaments.
The OSHA guidelines for computer ergonomics include:
- Hands, wrists and forearms are straight, in-line and roughly parallel to the floor.
- Head is level or bent slightly forward, forward facing, and balanced.
- The head is in-line with the neck and torso.
- Shoulders are relaxed and upper arms hang normally at the side of the body.
- Elbows stay in close to the body and are bent between 90 and 120 degrees.
- Feet are fully supported by the floor or a footrest may be used if the desk height is not adjustable.
- Back is fully supported with the appropriate lumbar support when sitting vertical or leaning back slightly.
- Thighs and hips are supported by a well-padded seat and generally parallel to the floor.
- Knees are about the same height at the hips with the feet slightly forward.
In addition to having the body properly aligned with the keyboard and monitor, the employee should take the following steps to reduce the likelihood of creating a musculoskeletal problem:
- Stand up and walk around for a few minutes periodically.
- Stretch the torso, legs, arms, hands and fingers.
- Dangle the arms by their side, shift the position of their legs and shrug the shoulders.
- Make small adjustments to the chair and backrest.
- Look away from the computer and refocus the eyes on a distant point.
- Vary the work in order to utilize different muscles
Teaching the employees to use proper posture at the computer can be complicated by things outside of the employee’s control. For instance, if every employee has the exact same office chair and cubicle with the same fixed level desktop / work surface, the adjustments needed for a 6 foot tal man will be significantly different then the adjustments needed for a 5 foot tall woman. True ergonomics adapts the workplace to fit the specific needs of the employee rather than forcing the employee to adapt to the work area.
The employee who is sitting back in a chair with proper lumbar support; with the eyes straight forward or looking down slightly; the head, neck and torso in a natural alignment and the feet flat on the floor, will have rarely develop any type of muscular-skeletal problem. The employer can assist the employees to avoid workers compensation claims arising from the use of their computer. The computer ergonomics the employer should consider include [WCx]
- The height of the work surface being designed for the employee’s specific job.
- The office chair being adjustable for the employee.
- The height of the computer screen being adjustable for the height of the employee.
- The computer keyboard and mouse being properly placed.
- The lighting of the surrounding area is appropriate to eliminate glare.
The OSHA guidelines for proper computer posture should be provided to all employees. The safety manager and/or risk manager should work to educate the employees on proper posture at the computer and provide the employees with the necessary furniture, equipment or aids to have proper computer posture. Proper computer ergonomics will eliminate most computer related musculoskeletal injury claims. Many things about ergonomically correct positions are not obvious to the untrained eye, so become educated about risk reduction in this area if you have employees working on computers, and what employer doesn't these days.
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.
Broadspire Rx Summit
Danielle Lisenbey, chief operating officer for the Medical Management Services of Broadspire announced its first annual Rx Summit in Sunrise, FL March 22. As a leader in the industry, Broadspire's first
Pharmacy Issues Summit should prove to be helpful. They write, “The purpose of the meeting will be to bring thought leaders from various organizations together to discuss relevant topics and issues surrounding pharmacy benefits in the workers compensation setting.
The intent is not to share the specifics of what various companies are doing, but rather to focus on the global industry issues themselves and what may be the possible trends and developments for the future. One key objective of the program will be to help to identify and define common threads that run through all components of the industry – across claimants, payors, employers and carriers.
Defining some of these commonalities will help the consumer to maneuver through the market. Each participant is invited to bring one operations executive and one clinical representative. This will be an opportunity to brainstorm and share ideas amongst industry peers that can help to influence positive impacts for all.”[WCx]
Everything Business Corp! Magazine Tells how to Fuse Workplace Wellness Programs With Recovery
An article by Lisa Firestone addresses the way employers are continuing to struggle with a challenging economy. “Maximizing efficiency and productivity is no longer a goal to strive for, it is essential for continued growth and even survival,” she writes. “Recognizing this dynamic, it is not surprising that more and more employers are actively engaging in worksite wellness programs that have proven to be effective in lowering health care costs – in fact, according to American Journal of Health Promotion every $1 invested in a corporate wellness program returns $4 in reduced health care costs and $5 in reduced absenteeism over a period of three to five years.”
To read more on this topic, look
here.
LexisNexis Communities Highlights Weekly WC Hot Stories
The Workers Compensation Law Community Powered by Larsons on LexisNexis offers this week three fascinating news articles:
1. The Defense of Intentional Self-Injury: Russian Roulette, Workplace Frustration, Accidental Drug Overdose, and More reviews Rashness Versus Intention in Self-Injury Cases, Impulsiveness Versus Intention in Self-Injury Cases and Suicide Test as Test for Self-Injury. It can be found
here.
2. LHWCA: Responsible Employer Determination in Cases Involving Multiple Traumatic Injuries: Seeking Analytical Clarity is a thorough look at the same using relevant precedent, post-Albina board decisions, burden of proof; aggravation vs. natural progression: identifying the cause(s) of disability and sequential vs. simultaneous consideration of evidence. It can be found
here.
3. Larson’s Spotlight on Recent Cases: Firefighter’s Rule Did Not Bar Tort Action against Homeowner examines the firefighters’ rule, an important exception to the usual third-party liability rules in which a firefighter (or other first responder) may not recover in tort from a landowner or occupier who has been negligent in starting or failing to curtail a fire. Read more
here.
LexisNexis Editor Featured in Risk Management Magazine
Thomas A. Robinson, a contributing author and editor of LexisNexis resources including Larson's Workers Compensation Law and Workers Compensation: The Survival Guide for Business, wrote a fascinating article that was recently featured in the well-known RIMS magazine. Also a member of the LexisNexis National Workers Compensation Advisory Board, Robinson writes about 10 bizarre WC case that ended unexpectedly
here.
The article is a great read and includes juicy stories such as what the courts decided when an obese employee broke a leg trying to get unstuck from a cafeteria booth, whether a construction worker who lost an eye trying to sledgehammer a found bowling ball on site and whether a fatal heart attack while holding a termination letter is still covered.
For more like it, sign up for the free weekly enewsletters in national and California editions by Robin Kobayashi
here.
Need More, Faster WC Info? We have the Newsletter for You
Check out this LexisNexis newsletter that can keep you on top of what’s happening in our industry. Learn more
here and sign up
here.
Texas Department of Insurance Changes Pay Advance Form
The Texas Department of Insurance Division of Workers’ Compensation recently changed the form injured employees use to request pay advances on their WC settlement checks. The form, DWC Form-047, Employee’s Request for Advance of Benefits, and the DWC Form-053, Employee Request to Change Treating Doctor is for an injured employee to request an advance of his/her workers’ compensation income benefits. The DWC Form-053 is for an injured employee who is not part of a certified workers’ compensation health care network, and whose claim does not involve medical benefits provided through a political subdivision pursuant to §504.053(b)(2) of the Texas Labor Code, to request a change of treating doctor.[WCx]
Workers’ compensation system participants should use the revised DWC Form-047 or DWC Form-053 on and after March 7, 2012. Previous versions of the form will no longer be accepted after June 1, 2012. For more information, check
here.
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.
WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com
VIEW SAMPLES PAGES
MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php
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.
A recent article titled Fuse Workplace Wellness Programs With Recovery, by Lisa Firestone, helps employers in this economy by explaining that maximum efficiency and productivity is essential for continued growth and even survival. Firestone is president and founder of
Managed Care Advisors Inc., a woman-owned, employee benefits and disability management consulting and full service workers’ compensation case management company.
Firestone writes that more and more employers are engaging in worksite wellness programs that lower health care costs. “In fact, according to American Journal of Health Promotion every $1 invested in a corporate wellness program returns $4 in reduced health care costs and $5 in reduced absenteeism over a period of three to five years,” she writes. [WCx]
The complete article, which can be found
here, indicates by targeting and improving employee population health risk factors, worksite wellness programs reduce absenteeism, increase productivity, reduce injuries and improve employee morale and loyalty. Though most wellness initiatives have been focused on reducing risk factors in a working population with the goal of lowering costs and improving productivity, Firestone writes “leaving out those employees who may very well be at greatest risk for long-term disability and significant and ongoing health care expenditures – workers’ compensation claimants. I am in no way downplaying the importance of prevention, or the advantages of a population-based worksite wellness program, in fact, quite the opposite. What I am suggesting is that there is great benefit to be gained for organizations that broaden the scope and focus of their wellness programs to include individuals recovering from work injuries or illnesses.”
Firestone includes these other points in her article:
1. Why not target the recovery period after a work-related injury as an opportune time to introduce or maintain wellness activities?
2. It is essential that the wellness program adapt with the employee and provide programming and support to meet the employee.
3. If your health insurance and work comp programs are handled separately try to get the two departments to work together to institute a wellness program.
4. There are significant resources and information readily available to assist in the implementation and management of effective wellness initiatives.[WCx]
Firestone has been involved in the health care industry for more than 30 years gaining recognition for her expertise in the areas of employee benefit program development, evaluation, and strategic planning. She can be reached at
lfirestone@managedcareadvisors.com www.MCACares.com
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.
WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com
VIEW SAMPLES PAGES
MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php
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.
In the November issue of Risk and Insurance magazine is a very interesting article on a better approach to safety. The article is about how the magazine selected Honda Manufacturing of Indiana for their PreVent Award. The premise of the safety article is trusting the employee to be a part of accident prevention.
The article explains how Soichiro Honda, the founder of Honda Motors “was adamant about protecting the individual in the workplace.” This philosophy is followed by Honda Manufacturing of Indiana. The company strives to give the employees both “the physical and mental training to be prepared to do their jobs effectively and safely.” (WCxKit)
When new employees are hired, they do not start work immediately. Instead, they are provided a two week physical conditioning program emphasizing exercises to simulate the movements they will be required to perform on the job. The program also teaches the employee how to position the body in the best way for job performance in an ergonomically correct manner. If there are any doubts, please note the employees who complete this physical training have an 80% lower injury rate than employees who did not complete the physical training program.
The lead safety person at Honda Manufacturing of Indiana credits this ‘whole person approach’ with the effectiveness of their program, plus the company’s safety program has strong support from the upper management. When Honda was constructing the plant that opened in 2008, the safety program was consulted to build ergonomically correct processes into the production. Honda allows each manufacturing plant to structure its own safety program around the belief that the local personnel know their own facility better than anyone else.
The employees are encouraged to use the physical conditioning program outside of the workplace, plus the employees are taught to monitor their own stress and fatigue levels. They are taught how off the job stress can put them at an increase of injury on the job.
The safety program at Honda is based on the premise that the employee knows the job better than anyone. The employees know what the hazards are and what causes stress on their body which can ultimately hurt them. Honda takes the approach of listening to the employees, trusting what the employees have to say about performing their jobs safely, and using that guidance to create safe working conditions. By listening to the employees and implementing safety recommendations, Honda created a safer working environment.
When Risk and Insurance magazine was considering various companies for the PreVent Award, it was looking for companies that implement safety programs to prevent work place injuries and provide a safe working environment. The magazine was looking for employers that were proactive in injury prevention beyond the traditional safety and loss control programs.
The criterion for the PreVent Award which is given each November includes
1.Total Injury Prevention Focus – which starts with recognizing all potential sources of workplace injuries including suboptimal equipment, inefficient work processes, excessive repetitive motions, poor body mechanics and/or ergonomically incorrect processes.
2. Risk Assessment – identifying all potential risk that can lead to injuries
3. Proactive Approach – comprehensive strategies to address losses and prevent them from reoccurring. (WCxKit)
We strongly support safety as a primary means of reducing workers compensation cost. For more information on how to improve your safety program, please contact us.
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
One of the least understood types of workers compensation claims is the psychiatric injury claim. Employers understand the physical injuries like a bone fracture or a laceration, but the mental injury claim is more difficult for employers to accept as a workers compensation claim. Employers are often befuddled, perplexed or doubt the validity of the mental injury claims.
Note: State statutes and case law which interprets state statutes varies so some things in this article may not apply to your company or your situation. Check with YOUR legal counsel before using this material as anything more than a thought-provoking article of interest.
With the psychiatric claim there are often no objective physical findings that can be measured. With subjective mental symptoms, the question of their validity is often influenced by the opinion the employer had of the employee prior to the claim. If the employee was known to be slacker prior to the psychiatric injury claim, the employer is less likely to accept the claim of a mental injury, then when the employee had been known as a dedicated hard worker. Regardless, whether the employer questions the validity of the mental injury claim or accepts it as valid, a detailed investigation into the medical documentation and the other non-work related factors that could affect the employee’s mental state is necessary.
The investigation into a psychiatric claim can be complicated by the fact that the courts and state legislative bodies keep changing the definition of a mental injury claim. The adjuster assigned to handle a psychiatric claim needs to be experienced in handling these changes and be up to date on recent changes in the law.
There are two types of mental injury claims, physical-mental and mental-mental. In a physical-mental psychiatric claim, the employee had incurred a physical injury at work, and as a result of the physical injury, has developed a mental injury. A common example is the employee who injured his back, and due to worrying about how he will support his family on his reduced income, develops a severe case of depression. Also, a recent trend, in physical-mental injury, by employees who are coached by a plaintiff’s attorney, is to develop post traumatic stress disorder after their injury.
In a mental-mental injury claim, the injury arises from fear, stress or anxiety. Due to the potential for abuse, most states have revised their workers compensation statutes to restrict or bar the mental-mental psychiatric claims. In the states where mental-mental claims are still permitted, there are four basic types, with each state setting their own boundaries as to what is accepted. From the strictest to the most lenient
1. The claim is compensable only if the employee is an eye-witness to a tragedy – for example, the employee sees another employee get run over by a train.
2. The claim is compensable only if the stress is caused by events beyond the ordinary every day stress of the job.
3. The claim is compensable if workplace stress, fear or anxiety causes it (except the fear of being disciplined, terminated, transferred, etc. do not qualify).
4. The claim is compensable if caused by any job-related stress.
The claim for a psychiatric injury is not simply based on the whim of the employee. There is a guidebook to identify what is an actual mental injury. The American Psychiatric Association has published the ‘Diagnostic and Statistical Manual of Mental Disorders’ which can be used to verify or disprove the fact the employee has a mental injury.
With psychiatric injury comes the issue of determining the cause of the mental injury. Usually the employee has other contributing causes to the mental injury. For the psychiatric injury to be a workers compensation claim, the employee must prove that work, and not some other event(s), is the primary cause of the mental injury.
To investigate the mental injury requires the adjuster or the defense attorney to investigate the personal life of the employee. The defense of the mental injury claim requires the adjuster to do an assets check, a background check on the employee, a credit investigation of the employee, a criminal background investigation and an investigation of prior mental health related issues. The employee may be having anxiety and depression, but if it is due to his arrest for beating up his wife and his house being foreclosed due to his gambling problem, the cause of the employee’s anxiety and depression is most likely not mainly work related. [WCx]
If the employee (usually through a plaintiff’s attorney) tries to expand his physical injury into a physical-mental claim, a good defense attorney, experienced in defending physical-mental injury and mental-mental injury, should be employed. An independent medical evaluation by a psychiatrist experienced in defending mental injury claims will be necessary, as well. An evaluation of the claim should be completed and a determination made as to whether or not to settle or to deny the psychiatric injury. The decision on how to proceed should be made in conjunction with the opinion of the defense attorney, the adjuster and the defense psychiatrist.
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.
WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com
VIEW SAMPLES PAGES
MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php
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.
Self-insured employers often get into trouble for not being knowledgeable of the requirements of the Unfair Claims Practice Act in the state(s) where it is being self-administered for workers compensation claims. The failure to act in a totally ethical manner can lead to litigation by the party wronged and to fines and/or the suspension of the self-insured’s authorization to be self-insured by the State.
The workers compensation adjuster, who is often dealing with attorneys out to maximize the cost of the workers comp claim, or with employee claimants who are attempting to commit fraud, may be tempted to fight fire with fire. The adjuster should always handle the claim in a totally ethical manner. If an adjuster is doing any of the following, stop everything and discuss the adjuster’s actions with the adjuster. [WCx]
Unfair claim practices by the adjuster include:
- Knowingly misrepresenting the benefits available under the state’s workers compensation law
- Failing to contact the injured employee (hoping the employee will not pursue the claim)
- Failing to investigate the claim properly
- Denying compensability without a valid reason
- Failing to file all necessary state forms
- Recording the employee’s statement when the employee is under the influence of medications or distracted by pain
- Failing to provide a copy of a recorded statement or written statement when one is requested
- Recording telephone calls without the other party’s knowledge of the call being recorded
- Knowingly documenting the file notes with inaccurate information
- Intentionally not returning phone calls of the employee or medical provider in an effort to discourage the claim
- Failing to pay indemnity benefits timely trying to coerce the employee in to returning to work prematurely
- Failing to authorize needed diagnostic testing without reason to not authorize
- Failing to pay for permanent partial disability
- Paying less than the workers comp statute calls for when settling a permanent partial disability
- Offering to settle and close out future benefits for an amount significantly less than what the adjuster knows to be fair
- Advising the employee not to hire an attorney
- Threatening to reduce the settlement of the claim if the employee hires an attorney
- Discussing any aspect of the claim with an employee known to be represented by an attorney
- Settling the claim before the extent of disability is known
- Overstating the damages and exposures so that the adjuster’s supervisor will extend excessive settlement authority, allowing the adjuster to make a quick (but overpaid) settlement
- Providing the employee’s personal information to parties who do not have a legitimate need to know
- Having a financial interest in any vendor utilized on the claim
Mistakes, oversights, and poor claim handling are not unfair claims practices. The workers compensation adjuster often has more work to do than it is possible to get done. With the telephone ringing constantly, the e-mail flooding in, having numerous deadlines for filing forms, numerous deadlines to prepare for mediations or conferences, and numerous other items that need to be completed, it is normal for some things to fall through the cracks. When the adjuster does not contact the injured employee timely, or does not respond to a settlement demand from the employee’s attorney, it is normally because the adjuster has more to do than is possible to get done. It only becomes an unfair claims practice when the adjuster intentionally decides not to take a needed action in an effort to impact the overall outcome of the claim. [WCx]
Almost all adjusters are honest and have the best interest of both the employee and the employer at heart. If you do notice any of the above 22 issues occurring, stop and discuss the issue with the adjuster. Often there is an ethical and valid reason for the adjuster’s action which will become apparent when you learn more about the reason for the adjuster‘s actions. Only when the adjuster sets out to act dishonestly should you be greatly concerned.
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.
WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com
VIEW SAMPLES PAGES
MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php
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.
These are dreaded words heard ‘round the locker room or break room table.’ They may start out as nothing, maybe a little one-liner about “some layoffs coming down the road” or maybe another guy said he saw Keith talking to Bob about “Immediate downsizing.”
Whether these are true or untrue, as a risk manager or someone involved in the claims process, be ready for the onslaught of the consequences of layoffs or downsizing. Not everyone will file a claim for workers comp, but bet the disgruntled employees will, along with a few unexpected employees to now report an injury of some sort in the past. (WCxKit)
How are these issues controlled and handled proactively? We discuss a few options below, and remember these may or may not apply in your jurisdiction.
Always consult counsel before implementing any of these ideas.
1. Go back to documentation
Keith just received his letter that his job was terminated and his last day of work will be in 10 days. Keith is nervous, because he has limited job skills, bills to pay. He lives in a small town and there are not a lot of jobs out there. Plus he does not have the greatest relationship with his supervisor, and he feels this is a personal assault coming directly from that supervisor who just does not like him.
What does Keith do? Well he decides to say he injured himself a month or so ago but was afraid to report it, because he heard that layoffs were coming. And he did not want to be one of the guys picked to be laid off.
This is a very common scenario. And this is where attention to documentation comes in to play. By now, everyone on the work floor should know that if any injury happens, whether they want treatment or not, the worker is to come to the risk manager’s office to complete some paperwork. And those who decide not to do this face the consequences associated with not reporting it.
The first question to Keith after he tells you he hurt himself a month ago should be “Why did you not tell me? You knew the procedure, right? Did you tell anyone? Did anyone witness your injury? Did you see your doctor? Why are you telling me this now?”
These are the first handful of questions to ask. Then call in his claim to the carrier/TPA immediately. And let them deal with it. If you still want to lay him off while his claim is under investigation, that is fine. If you want to wait until a decision has been made, that is fine as well. But documentation is key, and it always will be. You have to constantly tell the workers the responsibility to come tell you when something does not feel right, and an injury may have occurred. And if the employees do not do this then they face the consequences that can affect the claim’s compensability. Make it a reminder phrase every week.
2. Perform an exit interview
If a worker resigns from a position, or is laid off, chat with them a bit. Chances are the worker will come to you anyway to ask why it was them anyway. So now is a good time to see if the employee pulls out any angles to try and keep getting some income coming . Flat out ask if the worker is hurt, or had a workers comp claim, or is experiencing pain for example.
Common knowledge will reveal that this is a way to increase your own claims, since if it is not mentioned then why stir the pot? Actually, if employees are going to come forward and try being deceptive, better to confront it now versus 6 months from now. A claim will result regardless. Granted, most people will say “No” and move on, but there is always that handful of people that will try to claim an injury. Call the claim in to the adjuster, and let them handle it. That way you have performed your duty, and your responsibilities of reporting it are over and done.
3. Have a medical exam performed by an occupational medicine doc or a local clinic doctor to be safe
In order to be ultra-aggressive, get a doc to do an exit-exam. This will weed out all the fakers. It is not going to be free, but weigh the costs. If this is something to do to prove a point, then do it. Take time finding a doc that is also legit, and willing to do this. In the grand scheme of things I guess it is not fantastic to be laying off people due to expenses, and then have to spend $4,000 to have a doc say these workers are fine and show no signs of disability. This is about protecting your company from the unknown future of compensation claims, some of which can become incredibly costly no matter how insignificant they seem. So it is an option if that is preferred. Just make sure to have a credentialed doctor performing the exams in a private, professional setting (does this go without saying?), and that it is all HIPPA compliant.
4. Ask the employees to sign a release waiving liability (if legal in your jurisdiction)
Probably the most common is just the legal paper stating that the worker is not claiming any disability at this time. Depending on the jurisdiction, try inserting the word “future disability’ as well. But my advice is to thoroughly check with the employment counsel, as well as the workers comp counsel on permission. Or better yet have counsel draft the letter. Again it may cost something up front as far as expenses go, but it is all about protection down the road.
5. With a witness present, ask if the worker was or is hurt, or experiencing symptoms, and has been to the doctor for this. Ask is this is related to work or not.
This is similar to the doctor, but not as expensive. Have another HR person present for the exit interview, and ask the person about any disability relating to work. This will prevent the worker from coming back saying there were some problems swept under the rug and ignored. Check again with counsel on what can be and cannot be done, and then go from there. (WCxKit)
Summary:
With any type of employee reductions in the workforce, there are going to be some bitter feelings and resentment when reducing your number of workers. This article is about protecting your company, and protecting the future of potential comp claims. Any way to reduce exposure is always one worth researching, and implementing, sooner rather than later.
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
Vermont H 762 — a radical approach to workers compensation in Vermont
Noted WC writer Peter Rousmaniere writes that Vermont is set to pass a radical approach to dealing with the independent contractor problem in workers comp. “The problem is this: many businesses in the past, across the country, have chosen to define their workers as independent contractors, thereby saving themselves serious money in workers comp insurance, unemployment compensation insurance, and other benefits mandatory or voluntary, and leaving their workers exposed to the elements .(There are also other state labor protections that come to play),” he says.[WCx]
“The house bill 762 has a provision expressly designed to let workers define themselves as independent contractors!” he notes. “The intent comes out in the hearings: to let employers such as contractors hire them without having to worry about the risk of the engagement being seen as employment — even if the engagement looks, talks and walks like employment.”
Volume Three of the LexisNexis eNewsletter Available
Follow this link to see a summary of state and world news in the WC industry. This edition includes information on North Carolina’s reforms
, Retaliatory Discharge and an experts year-in-review among many other “goodies.” Check it out!
Broadspire Holds First Annual Rx Summit
Danielle Lisenbey, chief operating officer for the Medical Management Services of Broadspire announced its first annual Rx Summit here in Sunrise March 22. As a leader in the industry, Broadspire first Pharmacy Issues Summit should prove to be helpful. They write, “The purpose of the meeting is to bring thought leaders from various organizations together to discuss relevant topics and issues surrounding pharmacy benefits in the workers compensation setting. The intent is not to share the specifics of what various companies are doing, but rather to focus on the global industry issues themselves and what may be the possible trends and developments for the future. One key objective of the program will be to help to identify and define common threads that run through all components of the industry – across claimants, payors, employers and carriers. Defining some of these commonalities will help the consumer to maneuver through the market. This will be an opportunity to brainstorm and share ideas amongst industry peers that can help to influence positive impacts for all.”
TDI-DWC Launches Redesign of Homepage on the TDI Website
“In an effort to make online resources for workers’ compensation system participants more user friendly, the TDI-DWC homepage redesign features a new tab style menu with three sections to assist system participants in accessing workers’ compensation information. Topics A-Z features an alphabetical listing of workers’ compensation-related subject matter that directly links to website content. Online Services features direct links to services, including: safety violation reporting, employer coverage verification and attorney fee processing.
Resources features direct links to resources, including the Texas Labor Code, TDI-DWC rules, calendar of events and training and TDI-DWC forms,” they write.
There are many other helpful changes. Go take a look!
WCRI Releases Study of WC Laws
The Workers Compensation Research Institute (WCRI) and the International Association of Accident Boards and Commissions (IAIABC) just released a joint study, Workers’ Compensation Laws as of January 2012.
This tool allows users to compare WC system laws across U.S. and Canada. More information is available
here.
WCRI calls it, “An essential tool for researching and understanding the distinctions among workers’ compensation laws in all U.S. states and certain Canadian provinces.”
LRP Publications Announces New EEO/Federal Manager Book
To prevent age discrimination and sexual harassment complaints, managers need guidance. EEO complaints can be avoided.
Chapters include:
EEO Responsibilities
Sex Discrimination and Sexual Harassment
Race and Color Discrimination
National Origin Discrimination
Age Discrimination
Religious Discrimination and Accommodation
Disability Discrimination and Accommodation
Toward a Diverse Federal Workplace
Early MRIs Impact Outcomes Workshop March 14
Liberty Mutual Insurance knows that while MRIs are commonly used in workers compensation claims, their findings may or may not always be related to workplace injury. To this end, they are hosting a workshop March 14. More information is available here.
Among the topics to be discussed will be the results from a Liberty Mutual Research Institute for Safety study on the early use of MRIs as they relate to claims outcomes, case studies from the field and best practices around the use of MRIs.[WCx]
The company recommends people with claims, loss control, risk consulting, or managed care responsibilities should attend as well as risk managers interested in the latest issues and research associated with MRIs and claims outcomes.
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.
WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com
VIEW SAMPLES PAGES
MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php
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.
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