Effective ERISA Recovery in Workers’ Comp Settlements

Effective ERISA Recovery in Workers’ Comp SettlementsMembers of the claims management team and workers’ compensation defense attorneys need to understand a number of issues to be effective.  In the area of resolving liens from workers’ compensation claims, it is important to recognize the complex issues associated with ERISA liens.  Failure to do so can result in added time handling a claim, as well as additional and unnecessary expenses.

 

 

What is ERISA?

 

The Employee Retirement Income Security Act (ERISA) was passed into law by Congress in 1974.  ERISA is codified in part at 29 U.S.C. §18, et seq., and establishes minimum standards for pension plans and other employee benefit plans.

 

ERISA claims arise when an employer-sponsored group health plans (GHP) provided by a private medical insurance company under the law pay for medical care and treatment arising from a workers’ compensation claims.  Given the unique nature of a qualifying ERISA plan, their ability to recover is defined by federal law and contractual language – not by state laws that would otherwise be applicable.

 

 

Determine ERISA Application

 

As a general rule, ERISA only applies to Plans created under the Act and “self-funded” by an employer who assumes the financial risk for providing health care benefits to its beneficiaries.  Generally, ERISA does not cover plans established for government agencies, churches or plans used to comply with state workers’ compensation laws, unemployment or disability matters.

 

The unique nature of ERISA Plans places additional burdens on parties to workers’ compensation claims.  The result is often an unwillingness of qualifying Plans to negotiate reduced settlements.  Due to the distinct nature of applicable Plans, federal law allows for them to bring a civil action to recover under 29 U.S.C. §1132(a)(3).

 

 

 

ERISA Plan Language: The Devil in the Details

 

All ERISA Plans have language explaining their rights of recovery in instances where medical benefits were paid on behalf of the claimant in a workers’ compensation and other personal injury claims.  Examples of Plan language with expansive recovery rights include the ability to be reimbursed “in full, and in first priority, for any medical expenses paid by the Plan relating to the injury or illness.”  In these instances, courts have largely ignored equitable arguments such as the “Made Whole Doctrine,” which limit recovery by an interested third party.  Due to the rejection of this and other defenses, ERISA Plans are allowed to recover first, and without the need to compromise.

 

 

Practice Pointers when Dealing with ERISA Plans

 

Federal pre-emption and judicially recognized contract interpretations often make it difficult for attorneys and members of the claims management team to resolve ERISA intervention interests.  Notwithstanding the special position of Plans, there are proactive steps one can take to resolve the claims effectively and efficiently:

 

  • Obtain a copy of the Plan contact and reimbursement language. Sometimes a Plan’s right to reimbursement may be favorable to quick resolution and not ironclad;

 

  • Present the facts of the case in a favorable light to your position. Each workers’ compensation claim is different and unique.  Although ERISA Plans have a “super lien,” they are often willing to take a reduced amount based on emotional appeals;

 

  • Keep the Plan administrator or their attorney posted on the status of a claim and include them on all procedural correspondence such as status conference and settlement negotiations; and

 

  • Although ERISA Plans may, in fact, have superior recovery rights, never be a jerk. Instead be respectful at all times.

 

 

Conclusions

 

The unique nature of ERISA often makes it difficult to settle a workers’ compensation claim.  Identifying the interests of the Plans is essential to deal with them productively.  There are also best practices one can implement to resolve claims and benefit the bottom line of a workers’ compensation program.

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Leverage Specialty Pharmacy Services in Complex Workers’ Comp Claims

Leverage Specialty Pharmacy Services in Complex Workers’ Comp Claims The increasing use of prescription medications places unique challenges on workers’ compensation programs.  Part of the problem is the complex nature of these issues.  This includes the use of “specialty pharmacy” to address the needs of complex matters.

 

 

What is Specialty Pharmacy?

 

The pharmaceutical business is always changing.  One of those changes is the rise in “specialty pharmacy,” which fills specialized prescription drugs, or those that are needed for small groups of patients with complex, chronic conditions. These prescriptions require additional care in their dispensing, handling, and delivery including patient education and training on side effects and self-administration of drugs beyond what is available at a typical retail pharmacy.

 

Specialty Pharmacy staff including nurses and pharmacists will be trained in complex conditions and treatments to offer patients additional education and resources.

 

 

Specialty Pharmacy and Its Impact on Work Comp

 

According to the latest Express Script’s Workers’ Compensation Drug Trend Report, specialty drugs account for 5.9% of total pharmacy costs, yet account for less than 1% of drugs used by injured workers’.

 

Specialty pharmacies focus on prescription medications that are not commonly used and dispensed.  These medications usually affect high-risk occupations that have unique challenges.

 

Some examples of conditions where specialty pharmacy come into play include:

 

  • Hepatitis C infections;
  • HIV/AID treatment;
  • Various cancers; and
  • High blood cholesterol­­­.

 

 

Common specialty prescription medications used include:

 

  • Harvoni® (ledipasvir/sofosbuvir): Antivirals (hepatitis C)
  • Enoxaparin sodium: Anticoagulants
  • Enbrel® (etanercept): Anti-inflammatories
  • Truvada® (emtricitabine/tenofovir): Antivirals (HIV)
  • Gleevec® (imatinib): Oncology drugs
  • Isentress® (raltegravir): Antivirals (HIV)
  • Xolair® (omalizumab): Asthma and allergy drugs

 

 

Implementing Specialty Pharmacy to Reduce Program Costs

 

Using a specialty pharmacy as part of your workers’ compensation program is essential for any workers’ compensation program administrator who seeks a competitive advantage in complex cases.  Use of this program can drive down costs and maintain a high standard of care for injured workers with the most complex and chronic conditions.

 

In the area of specialty pharmacy, the increasing cost associated with lifesaving prescription medications is primarily driven by two factors: an increase in the average cost per prescription, and increased utilization costs associated with specialty pharmacy medications.

 

Implementation of a specialty pharmacy program should be part of working pharmacy benefits manager relationship with expertise in this area.  Run a pilot program for 60-90 days to evaluate and compare your results to industry benchmarks.

 

 

Conclusions

 

To be successful with complex and chronic conditions, workers’ compensation program administrators and members of the claim management team should be aware of and utilize specialty pharmacies.  This will allow them to properly manage and reduce costs for specialized prescriptions that can cure and relieve the effects of uncommon workers’ compensation injuries.

 

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center.

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

The One Quick, Low Cost Activity That Produces Dramatic Work Comp Results

 

Hey there. Michael Stack here, CEO of Amaxx. We’re a couple weeks in now to 2018 and there’s a couple things that I hope you already have accomplished and you already have defined.

 

  • Number One is your goals.
    • Hopefully you’ve clearly defined what it is that you’re looking to accomplish this year in 2018, what that vision is for what that looks like for you and your organization.
  • Number two.
    • Hopefully you’ve been able to determine what metrics for you to track to know whether or not you’re on track to be achieving your goals.

 

If you haven’t done either one of those things then that’s where you start.

 

 

What Are The Required Daily Activities To Accomplish Your Goals?

 

Third piece of this then is what are the activities? What are the disciplines that you need to be doing on a daily, weekly, monthly, quarterly, and yearly basis that will moving you closer to accomplishing that very clearly defined vision which you set here in number one?

 

What I want to talk about today is an activity that will cost you the least amount of money. It will cost you the least amount of time and it will have the greatest impact on your work comp program, least amount of money, least amount of time, greatest impact on your work comp program, a very specific activity and discipline we could sending a get well card. Sending a get well card.

 

How long does it take to do that? Maybe three minutes, four minutes, five minutes if you have to get someone else to do it to write the note, maybe stick a little gift in it, put a stamp on it, and write the address and the envelope.

 

 

Impact on One is Profound, Impact on Your Program is World-Class

 

The impact that it can have on that one individual is profound. If you’re doing this consistently on every claim on a week in-week out basis you will build yourself a world class work comp management program. Visions, goals are what we’re looking to accomplish in this year of 2018 happens on a day-to-day basis. What are you doing on a day-to-day basis to achieve your goals? If you’re not doing a get well card it’ll cost you least amount of money. It will cost you the least amount of time and it will have the greatest impact on your work comp program.

 

I encourage you immediately after following this video to write one today, and then write one again next week and the week after that to build that discipline and build that habit.

 

Again, I’m Michael Stack, CEO of Amaxx. Remember your work today in workers compensation, it can have a dramatic impact on your company’s bottom line, but it will have a dramatic impact on someone’s life, so be great.

 

To Learn More: HOW TO MEASURE WORKERS’ COMP SUCCESS WITH 5 CRITICAL METRICS:
https://hw359.infusionsoft.com/app/orderForms/Instruction-Guide—5-Critical-Metrics

 

Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Top 5 Take Away Points from 2017 National Workers’ Comp & Disability Conference – Part 3

 

Top 5 Take Away Points from 2017 National Workers’ Comp & Disability Conference – Part 1

Top 5 Take Away Points from 2017 National Workers’ Comp & Disability Conference – Part 2

Top 5 Take Away Points from 2017 National Workers’ Comp & Disability Conference – Part 3

 

 

Hey, there. Michael Stack here, CEO of AMAXX. We’re about a month out from the conclusion of the National Work Comp and Disability Conference, held again this year in Las Vegas, back at Mandalay Bay.

 

 

Take Away #5: Blending Oversight and Empowerment to Maximize TPA Results.

 

Now, my fifth takeaway comes from a blending of a couple of different presentations at the conference. It comes from the Teddy Award winning presentations, and the risk management that described their programs in order to win those awards, as well as another presentation given by Caryl Russo from Barnabas Health and Carrie Burhenne from the PMA Companies entitled Blending Oversight and Empowerment to Maximize TPA Results.

 

“Don’t Go At It Alone”

 

The takeaway here is very simple. It’s the sentiment of, “Don’t go at it alone.” Don’t go at it alone. Workers’ compensation at its core is very simple, but as you lay around various stakeholders, claims handlers, vendors, biopsychosocial elements, state law reforms, it becomes extremely complex. The idea of don’t go at it alone is the fact that you will not be successful unless you bring on these partners. You develop this claims handling partnership with your TPA or a carrier. You develop these working relationships with your medical providers, with your adjusters, with your risk managers, with your attorneys, and all other stakeholders involved in the idea of creating these better outcomes for your injured workers, thus driving down your workers’ compensation cost.

 

If the Teddy Award winning companies and risk managers references this idea, if Caryl Russo from Barnabas Health who also won a Teddy Award a couple years ago is referencing this idea of not going at it alone, and that’s displayed and implemented in this idea, which Caryl does very well, of weekly meetings. If all of these companies are doing this tactic, working together, developing these partnerships, having this played out in strategy in the form of a weekly meeting, and in this weekly meeting you’re talking about what has happened in the past, what is currently going on in the claim, and what’s the plan going forward. It’s no more complicated than that.

 

Study & Follow Tactics of Best WC Programs

 

Jim Rowan says, “If you want to be happy, study happiness. If you want to be wealthy, study wealth.” If you want to have a successful work comp program, study successful work comp programs, and if all the successful work comp programs are doing this tactic, that’s a tactic you should be doing as well. If you’re not at the point where you’re ready to look at every single claim every single week, that’s fine. That’s not where you start. If you’ve never done this tactic, take one of your claims, take two, take three, take five of your most expensive open claims and look at them on a weekly basis. Bring in your stakeholders. Bring in your medical providers. Bring in your nurse case managers. Bring in the parties that are relevant to those specific claims. Talk about what’s happened in the past, talk about where you are now, and discuss the plan, and share ideas, share perspectives, share expertise in order to create that better outcome.

 

Takeaway number five is, “Don’t go at it alone, and be very intentional about developing those work comp management partner relationships.”

 

 

Education Without Implementation is Entertainment

 

That covers my top five takeaways for the National Work Comp and Disability Conference this past year. It was another tremendous conference with very valuable content and contacts, but as I referenced at the beginning of this session today, it’s not the content or the contacts that you receive at the conference itself, it’s what you do with that content, it’s what you do with those contacts, those business cards that you receive, that makes the most difference. If we’re not going to take the information and implement it, if we’re not going to be following up with those contacts and developing those relationships, and taking advantage of those opportunities, then the time that we just spent in Las Vegas is simply entertainment, and there’s a lot better ways, there’s a lot better shows to go see in Las Vegas than going to listen about workers’ compensation.

 

I encourage you to go back to your notes, develop your own top five takeaways, develop the one or two points that you’re going to implement right away. If you don’t have your own notes, borrow mine, and start to realize and implement to see those results.

 

Thanks again for your attention. My name is Michael Stack, CEO of AMAXX, and remember your work today in workers’ compensation can have a dramatic impact on your company’s bottom line, but it will have a dramatic impact on someone’s life, so be great.

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Top 5 Take Away Points from 2017 National Workers’ Comp & Disability Conference – Part 2

 

Top 5 Take Away Points from 2017 National Workers’ Comp & Disability Conference – Part 1

Top 5 Take Away Points from 2017 National Workers’ Comp & Disability Conference – Part 2

Top 5 Take Away Points from 2017 National Workers’ Comp & Disability Conference – Part 3

 

 

Hey, there. Michael Stack here, CEO of Amaxx. We’re about a month out from the conclusion of the National Work Comp and Disability Conference held again this year in Las Vegas back at Mandalay Bay.

 

 

Take Away #3: The Nordstrom Way: Boosting Injured Worker Engagement

 

Now, my third takeaway comes from the keynote presentation of the conference itself which was given by Janine Kral called The Nordstrom Way: Boosting Injured-Worker Engagement. Now, Janine did a tremendous job of describing their program at Nordstrom, the system that they use, their philosophy, as well as the positive outcomes that it has returned for their company.

 

Now, I have about six pages of notes from this one session alone. But, it’s not the system or describing the specific elements of the system that my key takeaway point to pass along. The key takeaway point to pass along is the idea that we all know Nordstrom for the idea of exceptional customer service. She described their handbook as having one rule: use good judgment at all times. We all know when we walk in to Nordstrom the difference between that retailer and another. We know their reputation for company service, customer service. We know their reputation for value. The key takeaway point to pass along isn’t the system that Nordstrom has implemented because I talk about the system and the proven methodologies in nearly every blog or training that I’ve ever done. But, it’s the importance of this key element of a vision, a clear goal, and mission for the company that resonates throughout every level of employees.

 

Now, one of my thoughts when I walked out of this session was tremendous system, fantastic job, Janine, in implementing it, in running it and achieving these results. But, my thought as a member of the audience was that people may look at that and say, “Well, we’re not Nordstrom. We’re not self-insured. We don’t have this tremendous culture of this idea of customer service. Our employee handbook is 300 pages thick. It doesn’t just say, ‘Use good judgment at all times.’ How can I possibly be successful? Great job for you but how can that even help me at all?”

 

 

Company Vision, Goal, & Mission

 

The key takeaway is not only recognizing the importance of this vision and importance of this goal, the importance of this mission of your company, but if you don’t have it and you recognize that, is to work to start to achieve it in some way. It doesn’t happen overnight. It starts with one very, very small piece of building that management commitment. If you don’t have that, that’s your first area of focus in order to start to achieve these results and start to build this system, and start to build that momentum in order to create those positive outcomes. Takeaway number three is start to build this vision, this goal and this mission and if you don’t have that currently, that’s the place for you start.

 

 

Take Away #4: Understanding Injured Worker Perceptions About Workers’ Compensation

 

Now, my fourth takeaway comes from a presentation entitled Understanding Injured Worker Perceptions About Workers’ Compensation. Now, this presentation was given by Michele Adams from Disney, as well as Dr. John Ruser from WCRI. Now, Dr. Ruser obviously presented the studies and the findings and the data, and Michele talked about how they use these studies and findings and data to create actionable items and improvements in their work comp system to create better injured worker outcomes, as well as drive down their workers’ compensation costs.

 

Very quick I want to run through some of the data that Dr. Ruser presented and some of the predictors of injured workers’ outcome. I want to through these fairly quickly. He talked about the main predictors of outcome being education, their fear of being fired, whether or not they have comorbidities, and the last thing is their understanding of the English language. Their amount of education, whether or not they have a fear of being fired which also can be equated to their trust in their employer-employee relationship, whether or not they have comorbidities and their understanding of the English language.

 

Michele then went into fairly good detail about how they take this information and use it to improve their system. I thought it was a tremendous presentation. I have a bunch of notes from this one presentation alone. But, the key piece and my key takeaway from this one particular session to pass along to you was a statement that Michele made about observational data. I think one of the things that we find so often in our world today is an overwhelm of data. If you can take this information and you have a sophisticated system and you’re advanced in your knowledge of being able to tweak things and understand this data and really create these actionable items that Disney had, you can really use this data extremely effectively to create these better outcomes. But, the reality is that not every company is there. Not every company is that sophisticated. Not every company is that advanced in their journey of workers’ compensation management to be able to take this information, put it into practice immediately and create these outcomes.

 

 

Understand Value of Observational Data

 

The takeaway that Michele mentioned that not only are they sophisticated in understanding this data and creating these actionable systems, but she talked about the value of observational data to go out and actually see what is happening with what they call their cast members in the parks. If you go out and you’re observing what is happening and you say, “Well, at the beginning of every shift, X, Y and Z happens. The employees come and we’re getting a number of these injuries.” Then you can use that observational data, go back and look at it from a very pragmatic and analytical standpoint to create these systems. From a very simplistic standpoint whether or not you’re going back and analyzing your own data and creating these sophisticated systems, if you can just physically observe what’s happening, you’re physically having these conversations with employees, the value that that can now bring to your program is tremendous. You can create a very comprehensive behavioral-based safety program based around this idea. But, the simplistic idea of observing what’s happening is a key piece to continuous work comp improvement.

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Top 5 Take Away Points from 2017 National Workers’ Comp & Disability Conference – Part 1

 

Top 5 Take Away Points from 2017 National Workers’ Comp & Disability Conference – Part 1

Top 5 Take Away Points from 2017 National Workers’ Comp & Disability Conference – Part 2

Top 5 Take Away Points from 2017 National Workers’ Comp & Disability Conference – Part 3

 

 

Hey there, Michael Stack here, CEO of Amaxx. We’re about a month out from the conclusion of the National Work Comp and Disability conference held again this year in Las Vegas, back at Mandalay Bay. It’s a great accommodation and I think they have right city to host this great conference every year. Now, I attended more sessions than I normally do. I was very interested in many of the topics that were presented. The general theme of the conference itself was really focusing on much of what, frankly, I teach and believe in, which is really the outcomes for the injured workers that drive down workers’ compensation costs, creating a true win-win scenario. I want to talk to you about my top five takeaways from the sessions that I attended.

 

 

 

What Have You Done With the Content & Contacts From Conference?

 

Before I get into the takeaways though I do have a question for you, particularly, if you attended the conference. I want you to answer this question honestly. What have you done with the content that you learned or the contacts that you received within this past 30 days since the conclusion of the conference? Did you take notes from the sessions? Have you read them over? Have you created your own top five takeaway list? Have you looked through those business cards that you received? Have you followed up with those individuals? Do you even remember the conversations even happening of what you were supposed to do?

 

What I find more often than not is that we run around crazy at these conferences. There are a couple of days our feet are hurting, we’re exhausted, we’re going to events, we’re attending sessions, we’re trying to get meetings scheduled in between, but when we come back to the office, we just kind of drop the ball and forget we even attended at all. So if there’s things that are left outstanding, if there’s things that you haven’t covered over the past 30 days that you meant to, I encourage you to take a look at them and take action with the next one to two weeks so that you can get the most value from attending that conference in the time that you spent.

 

If you didn’t come up with your own top five takeaways to implement because maybe you didn’t take as many notes as you would have liked or attended as many sessions as you’ve liked, I encourage you to use mine. Borrow the ideas that I’m going to be presenting today and implement those into your program even if it’s just one idea because you’re going to realize a lot more value from the time that you spent at the conference itself. Okay, so that’s my question. If you didn’t attend the conference then I encourage you to just leverage the information that I’m going to be talking about today.

 

 

 

Take Away #1: Alliance of Woman in Workers’ Compensation

 

Let’s talk about takeaway number one, which comes from the Alliance of Women in Workers’ Compensation Leadership Forum which was held the day before the official conference started. Now, the presentation was given by Margaret Spence. Margaret did a tremendous job at that presentation and at that leadership forum. To be frank, it had a fairly big impact on my own life in this past 30 days. Let’s talk about some of the things that she discussed and while this presentation was obviously directed towards women. Obviously, I’m not a woman, so I can’t fully appreciate and empathize with the experience of a professional woman in today’s environment or in the years past.

But I will tell you that the stories that she was describing, some of the challenges that women face, that she described both in the past and, currently, today in 2018 was a bit disheartening. It was a bit disheartening to hear that that still exists in our world, particularly, as I’m raising two young daughters. From my perspective, one of the underlying themes as it was given from the female perspective was to acknowledge and appreciate the struggles that women have come through and still face today, But having the courage and the confidence to break through it. One thing I’ll add from the male perspective and the perspective I think is very similar.

 

From the male perspective to appreciate and acknowledge the struggles that women have faced in the past and often continue to face today, but having the confidence and the courage to break through that, because while some of those prejudices may still exist in our world today, they should not exist in your world. If you take an honest and genuine look at yourself, and you see that those prejudices still exists in your world then you need to take the steps to correct it.

 

 

4 Questions to Take Charge of Your Own Destiny

 

So putting the issues of gender aside because I felt that Margaret’s message was very important for women, but it was also very important for men. It’s very important for African Americans, for Hispanics, for Mexicans, for Japanese, for Chinese, for Indians, for every race and creed. Her message was about having the confidence and the courage to take charge of your own destiny, regardless of the environment that you’re in. She walked us through an exercise which I’m going to relay to you now. I’ll tell you the answers that I came up with during that session, during that leadership forum, had a very important impact on my goal planning and business planning for my company, for 2018. Here’s a little exercise that Margaret walked us through. The first thing that she asked was what do you want. What do you want? She asked you to answer that question honestly and genuinely.

 

Second question to answer is why. Why do you want it? What do you want and why do you want it? Third question is what has held you back. What is holding you back from achieving this goal, from achieving this desired outcome? Number four is what do you fear. What do you want, why do you want it, what is holding you back, and what do you fear? If you can honestly answer those questions, it will help you develop that confidence, help you develop that vision, help you develop that courage to create this life that you both deserve and desire.

 

 

 

Take Away #2: Intersection of Medicine & Disability – A Doctors View

 

Let’s move on to takeaway number two. This comes from a presentation given by Dr. Marcos Iglesias, who’s the Chief Medical Officer at Broadspire.

 

The session was entitled The Intersection of Medicine and Disability, A Doctor’s View. Now, frankly, I felt that this was a strongest session and most valuable session that I attended at the National Work Comp and Disability conference. I could have taken probably all five of my top takeaways from this one session alone. Dr. Iglesias did give a very candid and simple explanation of the doctor’s viewpoint, of the clinical perspective. One of the things that we forget about so often in workers’ compensation is that every single claim is a medical injury. Every single claim needs some form of medical intervention to have that individual person recover to maximum medical improvement.

 

 

60-80% of Lost Work Days are Unnecessary

 

The better that we can understand that clinic perspective, that doctors perspective; the better that we can develop that working partnership is the better outcomes we’ll be able to provide for the injured workers. Thus, driving down our workers’ compensation cost. Let me go through some of the highlights that I took out from that session. Dr. Iglesias described that 60% to 80% of lost days in workers compensation of lost workdays are unnecessary, this idea of needless disability. There’s a number of psychosocial reasons for that but it’s important for us as non-medical professionals to understand and appreciate really the value of this one statistic as we’re looking at our own individual work comp management programs.

 

He talked about this idea of the injured worker often being in-charge of determining disability. He described that patient-doctor interaction. He also described some of the little tricks which I thought this was fairly interesting. If you Google doctor’s notes, you can get a very specific doctor’s note that looks very real, that has a phone number that you can call in order for the employer to verify your injury, verify the time needed out of work. The injured worker is often determining their own disability in many cases not coming directly from the doctor. He went into a much greater detail and I’m oversimplifying that point, but I think it’s important piece to understand how much of an impact the injured worker has on determining their own disability and the tools that that injured worker has at their disposal.

 

 

Redirect Conversation from Pain to Function

 

Next piece here then was redirecting the conversation from talking about pain to discussing function. Now, this was an impactful takeaway point for me because one of the things that I always recommend on the reports of injury is having a pain scale so that when you’re reporting that industry, you have that understanding of the current level of pain, and then you could re-look back at that later. Dr. Iglesias described this discussion of pain as being unproductive, that the more you focus on pain, the worse that pain becomes. Instead of talking about pain, talking about function, what can you do today, impacting these biopsychosocial elements that contribute to these unnecessary lost workdays.

 

So, takeaway here is redirecting pain to function. Next piece here then from this presentation was reframing this physician relationship, reframing the expectations of the physician relationship. So often we asked too much of our physicians. We asked, “Well, Joe got injured. Can he be back to work today or not?” The answer that Dr. Iglesias described was often from the physician’s perspective, “I don’t really know. I don’t really know the limitations that he needs. I don’t really know his job demands. I don’t really know the tolerance that Joe has for pain.” So when you reframe this doctor’s relationship, as Dr. Iglesias described it, he described to talk about things that can actually be measurable, the limitations, the capacity, and the actual restrictions themselves of the injured worker.

 

So rather than, “Can Joe be back to work today or not,” talk about what are the limitations of Joe, what is the capacity of Joe, and what are the restrictions of Joe, then it’s up to the employer to decide if Joe can be back to work or not, not the treating physician. That’s the discussion and that’s a framing that needs to be had with those treating physician relationships that you proactively develop. Last takeaway from this one session which I thought was a great clarifying question because not all the time do you have these great and interactive treating physician relationships, not all the time are your physicians on board, so if you’re working with a new physician or the relationship hasn’t developed quite so well going back to this point that injured workers are often the ones that are determining their own disability.

 

 

“If Your Patient Asked to Go Back to Work, Would You Allow It”

 

Asking this question that if your patient asked to go back to work, would you allow it. So, asking the treating physician the clarifying question that if your patient, if Joe asked you then, “Can I go back to work,” would that treating physician allow it? If the answer is yes then you know that there’s really no medical reason that Joe needs to be out of work. If the answer is, “No, I wouldn’t allow it,” then you need to further clarify what those medical reasons are. I thought it was a tremendous clarifying question to speak directly to this point of needless disability.

 

 

Top 5 Take Aways from 2017 National Workers’ Comp & Disability Conference

 

…to be continued

 

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

CMS Statement on Opioids and WCMSAs Provides Little Clarity as to Future Review Practices

CMS Statement on Opioids and WCMSAs

In a recent post on its website, the Centers for Medicare and Medicaid Services (CMS) acknowledged the opioid crisis in this country, but provided little clarity as to how it intends to address this crisis in its review and approval of Workers’ Compensation Medicare Set-Asides (WCMSAs).

 

The 12/14/2017 statement provides as follows:

 

CMS understands the concerns regarding the opioid crisis occurring in the United States. We are committed to ensuring the determination of Workers’ Compensation Medicare Set Aside Arrangement (WCMSA) amounts are an adequate projection of claimant’s needs for future medical services and prescription drugs. CMS continually evaluates all policies and procedures related to WCMSA amounts. Any changes that Medicare pursues related to this issue will be reflected in our WCMSA amount review process.

 

More information on the WCMSA process can be found in the WCMSA Reference Guide.

 

We assume the above statement may be, in part, related to the California Workers Compensation Institute (CWCI) study finding nearly 70% of CMS approved MSAs require funding of opioids over an injured worker’s life expectancy (See our article, Opioids in the MSA . . . Challenges and Strategies, where this study is discussed). While we credit CMS’s Office of Financial Management (the CMS department which oversees the WCMSA review program and contractor) with recognizing the opioid crisis, what is left uncertain is what specific actions CMS is to take to address this problem in WCMSAs. Instead, CMS provides a vague statement indicating any changes related to the opioid issue will be reflected in its WCMSA review process and then cites its WCMSA Reference Guide.

 

CMS does not cite to a particular section of the guide, but we assume the following would be the most pertinent:

 

 

Drug Weaning/Tapering

 

Drug weaning commonly occurs with pain medications, such as opioids, especially when claimants’ work injuries improve. The WCRC takes all evidence of drug weaning into account, although in most circumstances the WCRC cannot assume that the weaning process will be successful. Usually, the latest weaned dosage is extrapolated for the life expectancy, but again, they assess all records when making these types of determinations. Where a treating physician believes tapering is possible and in the best interests of the claimant, CMS will consider all evidence in making a WCMSA determination, including medical evidence of current actual tapering.

 

Based upon the Tower MSA CMS Reconciliation Module, which reviews all MSA determinations for the purpose of identifying trends in CMS WCMSA allocation practices, CMS consistently disregards any active weaning or tapering process or scheduled reduction to future medication use and instead takes the latest dosage found in the medical records and/or prescription history and extrapolates it over the claimant’s life expectancy.

 

The question then is whether this December 2017 statement signals a departure by CMS from these past practices to a policy which will now give more weight to a weaning or tapering schedule from the treating physician which translates into limitations on the allocation of opioids in the WCMSA. We will take a wait and see approach in this regard.

 

It should be understood though that even were CMS to limit the allocation of opioids in the WCMSA, this in no way prevents the claimant from using the WCMSA funds for filling opioid prescriptions in excess of what is allocated. The reason being is CMS rules for administering a WCMSA allow for the funds in the account to be used for any Medicare-covered injury-related treatment or medication. As such, with a valid prescription, there is nothing to stop a claimant from converting funds allocated to a surgery to pay for medications, including opioids. It will remain then in the hands of the claimant’s medical provider to wean the claimant off opioids and other medications not intended for long-term use.

 

 

Practical Implications

 

As always, we will monitor CMS WCMSA determinations for signs of any changes to their allocating practices for prescription medications, especially in regard to opioids. However, we have to assume that until we see any changes, CMS will continue to follow its policy of taking the most recent medication dosage and frequency and pricing it out over the claimant’s life expectancy.

 

What this means then is opioid misuse must be addressed prior to submission of a WCMSA to CMS with any actual elimination of opioids documented in the medical records prior to submission of the MSA. Tower MSA is committed to working with our clients on reduction and elimination of opioids prior to CMS submission. Our Pre-MSA triage service is uniquely designed to identify such MSA cost-drivers and recommend intervention strategies, including escalating the matter to our Internal Pharm. D. for direct contact with the treating physician. Resulting reductions in opioid use limit MSA costs to the employer and provide for a healthier injured worker over his or her lifetime.

 

 

 

Author Dan Anders, Chief Compliance Officer, Tower MSA Partners. Dan oversees the Medicare Secondary Payer (MSP) compliance program. In this position, he is responsible for ensuring the integrity and quality of the MSA program and other MSP compliance services and products. Based upon his more than a decade of experience in working with employers, insurers, TPAs, attorneys and claimants, Dan provides education and consultation to Tower MSA clients on all aspects of MSP compliance. Contact: (847) 946-2880 or daniel.anders@towermsa.com

Start the New Year Off Right With An Ergonomics Review

Start the New Year Off Right With An Ergonomics ReviewThe New Year provides employers an opportunity to re-examine the issue of ergonomics in the workplace.  Making sure that workplace ergonomics is in place for all employees not only improves workplace morale but can reduce the costs of workers’ compensation claims in the future.

 

 

What is Ergonomics?

 

Defined by Webster, ergonomics is the “the study of people’s efficiency in their working environment.”  This study includes a review of workstations and job functions to reduce muscle overuse, correct poor posture and eliminate injuries cause is repetitive work activities.  It can also include a review of policies and procedures that seek input from a varied of interested stakeholders—include the person perform a particular work function.  It is important to include a review of tools used on a daily basis and other intangibles including, but not limited to workspace lighting.

 

 

Implementing an Effective Review

 

A proper ergonomics review includes the use of different specialists and stakeholders.  Beyond using a qualified specialist, it is important to include input from company management and employees performing job functions.  This review can also include a review of available resources and budget constraints.

 

It is also essential to understand the demographics of your labor force.  Studies show that Americans are working into their later years.  This is resulting in more severe injuries from repetitive type injuries that lead to longer periods of disability.  Factors to consider when addressing this issue include:

 

  • Age discrimination laws that prevent employers from engaging in unlawful labor practices;
  • State and federal OSHA laws and regulations; and
  • Addressing injury and post-injury response.

 

 

Return-To-Work and Ergonomics

 

A successful ergonomics review will keep in mind issues employer, and employees face when returning to work following an injury.  Some important matters to consider include:

 

  • Modification of a pre-injury position to accommodate the restrictions of a recovering employee;
  • The ability of an employee under work restrictions to rotate positions on a frequent basis; and
  • Workstations that are easily modified to allow employees to move from one function to the next without disruptions in productivity.

 

These tasks are sometimes difficult to achieve.  Barriers to successful implementation include the inability of the claims management team to coordinate with employer representatives.  There is a need for all stakeholders to cooperate on these matters.  It requires clear communication and objective information from the treating physicians.

 

 

Injury Prevention

 

The prevention of injuries is a major feature of a successful ergonomics program that sometimes goes unnoticed.  Examples of this include adjustable workstations for employees that allow them to perform functions sitting and standing.  This not only leads to increased job satisfaction but is proven to reduce injury.  Some common injuries prevented from this type of modification include cervical spine strain, low back discomfort and upper extremity injuries such as carpal tunnel syndrome or ulnar nerve impingement.

 

 

Conclusions

 

An ergonomics review has many important benefits to all stakeholders concerned about workers’ compensation claim prevention or reduction.  This all starts with an effective implementation program.  Once this takes place, it is important to include all parties, including employees.

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Beware of Vocational Rehabilitation Costs

What is Vocational Rehabilitation?

 

Early workers’ compensation laws did not include vocational rehabilitation benefits.  The purpose of adding these benefits was to rehabilitate someone suffering from a work injury and return them to the labor market with an economic status as close as possible to that the employee would have enjoyed without the disability or injury.

 

 

Rehabilitation Eligibility and Initial Consultations

 

The guidelines for vocational rehabilitation vary in each jurisdiction.  The majority rule does allow for injured employees to receive vocational rehabilitation benefits if they are not able to return to their pre-injury employment without residual disability or work restrictions.  Additional threshold issues include possible affirmative defenses the employer and insurer may assert.

 

Once an employee is determined to be eligible for vocational rehabilitation services, one would undergo a consultation.  The purpose of this discussion performed by a vocational expert includes:

 

  • Understanding the employee’s injury and need for future medical care and treatment;

 

  • Discussion regarding work restrictions related to the employee’s condition(s); and

 

  • Develop a rehabilitation plan to return the employee to work.

 

Proactive members of the claims management team need to review all claims from the onset to determine issues of eligibility for rehabilitation services.  This review should never be limited to the physical limitations of an employee.  It is important to pay attention to issues concerning compensability, which include:

 

  • Notice and statute of limitations;

 

  • Intoxication;

 

  • Prohibited Acts;

 

  • Self-inflicted injuries; and

 

  • Whether the injury arose out of and within the course of employment.

 

 

Development of Rehabilitation Plans

 

Following the rehabilitation consultation, a vocational expert will prepare a rehabilitation plan for the injured worker.  Issues addressed in this Plan include:

 

  • Whether the employee will be permanently precluded or likely to be permanently precluded from engaging in their usual and customary occupation;

 

  • Whether the employee is reasonably expected to return to suitable gainful employment with the date-of-injury employer, or another employer; and

 

  • What additional rehabilitation services the employee may require. These services can include such things as physical reconditioning, job search assistance and the possibility of retraining.

 

It is important for claims handlers to remain engaged following the issuances of a rehabilitation plan.  This plan includes the monitoring of ongoing rehabilitation services and keeping in contact with the qualified rehabilitation consultant (QRC) working with the employee.  Failure to do so can result in prolonged disability and excessive or unnecessary charges related to vocational rehabilitation services.

 

 

Moving Injured Workers Back to Work

 

The goal of every rehabilitation plan should be returning the employee to suitable gainful employment.  Tools to accomplish this goal include:

 

  • Disability Status Reports: These are required reports QRCs are required to file with the industrial commission and all parties on a regular basis.  It is important to monitor and scrutinize these reports.  Claim handlers should demand progress in moving issues concerning job search and related re-employment activities forward.  If consistent progress is not seen, one should consider having the employee undergo an independent vocational evaluation (IVE).

 

  • On the Job Training Plans: Many jurisdictions allow vocational experts to use these plans to develop transferable job skills.  A defined plan should include information on a desired position for the employee, skills the employee will acquire through this training, tools, and supplies needed to accomplish the plan’s objectives and an expected average weekly wage upon completion.

 

  • Written Job Offers: This is an opportunity to encourage re-employment by the date of injury employer when one feels the employee is ready to return to work.  Examples of a well-written job offer details the position being offered, length and frequency of activities to complete a task and wages the employee will receive.

 

 

Conclusions

 

Proactive members of the claims management team need to understand vocational rehabilitation benefits and how it impacts a claim.  This understanding includes being fully engaged and seeking opportunities to return the employee to work effectively.

 

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center.

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Understanding Rights of Recovery: Dealing with Liens in Work Comp

Members of the workers’ compensation claims management team are faced with many challenges.  One of these tests includes the resolution of liens, intervention claims and other interests as part of settling a claim.  Failure to consider and resolve these interests can be detrimental to effective claims settlement and negatively impact a program’s bottom line.

 

 

What is a Lien? Why is it Important?

 

According to Black’s, a lien is “The principle under which an insurer (or another party) has paid the loss under an indemnity policy is entitled to take on all the rights and remedies belonging to the insured against a third party concerning any injuries or breaches covered by the policy.”  Under this legal principle, members of the claims management team need to proactively identify, provide notice to and resolve interested third-parties for medical care and treatment (or other benefits) related to a workers’ compensation claim.  Failure to take these important steps can result in the insurance carrier or insured being subjected to fine, penalty or future repayment.

 

 

Medical Providers and Health Insurance Liens

 

Some of the most common liens in a workers’ compensation claim include those asserted by medical providers or health insurance carriers.  These liens typically arise in the following situations:

 

  • Denial of primary liability;

 

  • Assertion of an affirmative defense after liability is accepted. Common situations include defenses related to the reasonableness or necessity of medical care, or treatment parameters issues; and

 

  • Payments mistakenly made by a health insurance carrier for treatment not properly submitted to the workers’ compensation carrier for payment.

 

 

Providing Notice to Interested Third Parties

 

In many jurisdictions, the parties to a workers’ compensation claim are responsible for including these interested parties in the claim, including taking the following steps:

 

  • Putting the medical provider or health insurance carrier on notice of their rights under the state workers’ compensation law;

 

  • Including the interested party on all pleadings served and filed during litigation; and

 

  • Making good faith efforts to resolve the intervention claims if the matter resolves before a hearing on the merits.

 

State laws that require notice of intervention rights typically include provisions where a party can extinguish recovery rights of non-responsive third party.

 

 

Adopting Best Practices to Lien Resolution

 

Members of the claims management team need to be proactive and scrutinize claims made by medical providers and health insurance carriers.  Part of the process includes affirmative defenses one can assert related to these claims.  It is important to be mindful of such issues as notice, statute of limitations, prohibited acts defense and employee intoxication to name a few.  Additional areas to consider include:

 

  • Recovery by the interested third party only in instances where the employee receives a settlement, judgment or award;

 

  • Requiring the third party to prove the medical bills are related to the workers’ compensation claim. This proof must include a close review of all bills and claims to ensure it is related to the work injury; and

 

  • Requesting a copy of an applicable health insurance policy. In some instances, the policies ability to recover may be limited by Plan language.  In some instances, a group health plan may be self-funded by the employer.  In these cases, the Plan may be willing to waive its entire claim.

 

In cases where there is a settlement, members of the claims management team should seek a settlement with the third party based on a reduced amount.  Arguments need to be made that include the strengths of defenses available to the employer/insurer and weaknesses of the employee’s claim.

 

 

Conclusions

 

Members of the workers’ compensation claims management team need to be proactive when it comes to the settlement of liens and intervention claims.  It is important to remain proactive on these matters and understand the recovery rights of all parties.  It is also important to treat all parties fairly and with respect.  Taking these steps can effectuate settlement and reduce program costs.

 

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center.

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

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