Leverage Pharmacy Controls to Reduce Opioid Spending 13.4%

The workers’ compensation industry has been a leader in addressing the national opioid epidemic. Nevertheless, medical providers continue to prescribe these drugs for chronic pain, despite research and recommendations that caution against using them as a first line of treatment.

 

The good news is that payers can take steps to reduce the unnecessary use of opioids. In its latest Drug Trend Report, Express Scripts said its clients saw an average 13.4 percent decrease in spending for opioids — even though the drugs continue to be the most expensive and highly utilized class for work-related injuries.

 

Armed with more evidence of the dangers and with increased persistence, payers can further reduce the prescribing of opioids for injured workers.

 

 

The Problem

 

The Centers for Disease Control and Prevention ( CDC)  released a new study that shows the more days for which opioids are prescribed, the more likely a person would become a chronic opioid user. The risks for chronic opioid use increases with each additional day of prescription. The days most associated with chronic use of the drugs were the 3rd, 5th and 31st days of the prescriptions.

 

Starting a patient on a long-acting opioid showed the highest probability of continued opioid use at 1 and 3 years. Patients who were started on the drug tramadol were the second most likely to have continued opioid use.

 

Additional potential triggers for abusing the drugs were:

 

  • A second prescription or a refill. Authorizing a second opioid prescription was shown to double the risk for opioid use one year later.
  • A morphine equivalent cumulative dose of at least 700 milligrams.
  • An initial supply of 10 or 30 days.

 

Opioids cause changes to a person’s brain. They have a chemical structure similar to a natural substance in the body. The drugs go to the pleasure center of the brain and release dopamine, a neurotransmitter that can cause depressed breathing, blood pressure and alertness, as well as decreased pain and a euphoric effect. Eventually, the drugs can result in a compromised ability to regulate unsafe or risky behaviors.

 

Over time, the body can become tolerant and dependent on the drug, meaning the patient must take more of the drug to achieve the same pain relief results.  Some people then become addicted to the drugs.

 

Opioids can be life threatening, even for a first time user, due to depressed breathing. Other side effects associated with opioids include depression, constipation, confusion, insomnia, and sexual dysfunction.

 

 

What to Do

 

Adoption of strategies addressing morphine equivalent dose (MED) led to significant decreases for Express Scripts’ clients, the company said. “Payers who adopted the MED program had a 32.7% reduction in cumulative MED >100 and a 24.7% overall decrease in cumulative MED,” according to the Drug Trend Report.

 

The company also uses a proprietary “point-of-sale and concurrent drug utilization review (DUR) edits to identify dangerous drug combinations (such as benzodiazepines and/or skeletal muscle relaxants with opioids) or other therapy concerns (duplication, use of long-acting opioids as a first choice and more).” Benzodiazepines in combination with opioids “should be avoided whenever possible due to respiratory depression and greater risk for potentially fatal overdose.”

 

Additional best practices to control over use and abuse of opioids are the following:

 

  • Real-time monitoring of MED and payer notification prior to any opioid fill that exceeds predefined MED thresholds.
  • Patient education and prescriber outreach for certain prescribing patterns, dangerous combinations and MED thresholds.
  • Leveraging opioid prescriber and patient trends with sophisticated reporting and analytics to identify fraud, waste and abuse and other risky behavior.
  • Coordinating efforts among providers, governments and law enforcement.
  • Ensuring providers prescribe opioids for the shortest duration possible when used to treat acute pain. Three days or less is ideal, while more than 7 is rarely needed.
  • Inform providers and discourage them from unnecessarily prescribing tramadol for chronic pain.

 

 

Summary

 

Opioids have a place in the nation’s healthcare system. However, their use for chronic pain has clearly been exceeded in recent years.

 

Payers that stay abreast of the latest research findings and establish protocols based on the information can go a long way to help prevent an injured worker from developing chronic opioid abuse, and save significant dollars.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

9 Questions to Ask Injured Worker’s Treating Physician

Leaving no stone unturned is critical to managing your workers’ compensation costs. With the number of steps from injury to resolution; the number or people involved from physicians to adjusters; and the number of possible outcomes from a band-aid to a large insurance settlement you cannot leave any single step to memory.

 

 

Create System to Ask All the Right Questions

 

Certain questions must be asked, forms must be filled out, and precautions should be taken. Your injury management system should ensure all the questions one should ask the physician on the telephone to be sure every “i” is dotted and ever “t” is crossed.

 

Formalize your questions in a checklist so these questions are asked uniformly; it’s not something that should be done on an ad hoc basis.

 

9 Questions to Ask Injured Worker’s Treating Physician

 

  1. Introduce yourself and give the injured employee’s name, mentioning the employee has authorized you to speak with the doctor
  2. Get and give all contact information.
  3. Offer to email authorization so the doctor may discuss the employee’s condition.
  4. Ask for diagnosis and whether it is work related.
  5. Ask how the employee is responding to treatment.
  6. Ask if prescribed medications could interfere with the employee’s job.
  7. Does the physician recommend any significant limitations?
  8. Can the employee perform a transitional duty job? If yes, obtain the employee’s work restrictions.
  9. Is there anything else that I should know, that would help our employee recover more quickly?

 

This open-ended question gives the doctor an opportunity to provide information that is additional and helpful to the employer or the employee.

 

Keeping up with all these details assists your company in getting your employee healthy and back to work.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Broadspire® Names Dr. Marcos Iglesias Chief Medical Officer

ATLANTA, June 22, 2017 (GLOBE NEWSWIRE) — Broadspire®, a division of Crawford & Company®, and a leading global third-party administrator, today announced that Dr. Marcos Iglesias has been named the company’s new chief medical officer, effective June 26. Dr. Iglesias assumes the position from Dr. Jacob Lazarovic, who announced his retirement after 18 years with Broadspire.

 

“Providing appropriate clinical oversight for injured employees is a critical aspect of the services we provide, and so we are excited to have Dr. Iglesias join Broadspire to provide strategic leadership in this area; his extensive medical and business background, particularly in injury management, makes him an excellent fit for us,” said Neil Lentine, chief operating officer at Broadspire.

 

Dr. Iglesias brings with him extensive practice and administrative experience in a number of medical areas, including occupational medicine, workers compensation, utilization management and disability management. Prior to joining Broadspire, Dr. Iglesias practiced medicine for 16 years and then held a number of senior management positions with insurance companies; most recently he served as vice president and medical director at The Hartford Insurance Company. Prior to that he held the positions of medical director at Midwest Employers Casualty Company and Lincoln Financial Group.

 

“Broadspire is known in the industry for its successful medical management approach, which includes making certain that injured workers receive clinically appropriate and cost effective care,” said Dr. Iglesias. “I am excited to join a company that has always been at the forefront of managed care thought leadership, and I look forward to working with the entire clinical team, as well as Broadspire customers, as we work to provide the best care for those affected by injury.”

 

Among his professional achievements, Dr. Iglesias is Board Certified in Family Medicine (ABFM) and Utilization Review and Quality Assurance (ABQAURP). He is a Fellow of the American Academy of Family Physicians (AAFP), the American College of Occupational and Environmental Medicine (ACOEM) and the American Institute of Healthcare Quality (AIHQ). He is also certified in Health Care Quality and Management (CHCQM).

 

Dr. Iglesias received his medical degree in Medicine and Family Medicine from the University of Toronto and later received a master’s in Medical Management from the Marshall School of Business at the University of Southern California.

 

 

About Broadspire®

Broadspire®, a leading global third-party administrator, offers casualty claim, medical management, accident and health, and disability and leave management solutions, helping increase employee productivity and reducing the cost of risk through early intervention, professional expertise and data analytics. As a Crawford Company, Broadspire is based in Atlanta, Ga. Services are offered by Crawford & Company under the Broadspire brand in countries outside the U.S.

 

 

About Crawford®

Based in Atlanta, Crawford & Company (NYSE:CRD‐A) (NYSE:CRD‐B) is the world’s largest publicly listed independent provider of claims management solutions to insurance companies and self‐insured entities with an expansive global network serving clients in more than 70 countries. The Crawford Solution® offers comprehensive, integrated claims services, business process outsourcing and consulting services for major product lines including property and casualty claims management, workers’ compensation claims and medical management, and legal settlement administration. More information is available at www.crawfordandcompany.com.

 

For more information please contact: Nancy Hamlet/404.300.1918 Nancy_hamlet@us.crawco.com

 

 

6 Minimum Expectations For Employer Involvement in Workers’ Comp

6 Minimum Expectations For Employer Involvement in Workers’ CompWe all know it is the employer’s responsibility to purchase workers’ compensation insurance coverage and to report a claim to the claims office when an accident occurs. Unfortunately, way too many employers end involvement in workers’ compensation at this point. It’s expensive to be passive about workers’ compensation.

 

However, being an active, responsible participant in your work comp claims process improves the employer’s financial picture.  Here are the minimum expectations of employer involvement in workers’ compensation:

 

A Safe Work Environment:

 

It is your responsibility as an employer to provide a safe work environment. By doing so, you eliminate many work comp claims because the injuries never happen. A strong safety program in which the employees are actively involved in preventing accidents has a major impact on the financial cost of workers’ compensation.

 

Know the Law:

 

Post in a convenient place state required notices for all employees to see. Notices include their rights under the work comp laws, a list of approved medical facilities (in states allowing the employer to select the medical provider), post OSHA posters and anything else required in your state.

If an employee is injured, allow the employee to seek medical care as quickly as possible. Do not do anything appearing to interfere with the employee’s right to medical assistance.

 

 

Report the Claim At Once & Accurately:

 

It is not enough to report the injury claim to the claims office. Report the injury immediately to the claims office  – just as soon as the employer becomes aware the injury occurred. Not next week, not in a couple of days, not when you “get around to it,” but NOW – when the employee is seeking medical treatment for the work comp injury.

 

All employees and all their supervisors should know that it is a requirement for every work comp claim to be reported to your work comp claims coordinator as soon as medical treatment is needed. The claims coordinator then promptly completes the Employer’s First Report of Injury and immediately sends it to the claims office. Immediately means, “stop whatever you are doing” and report the new injury/claim.

 

All supervisors should be trained on the information needed to complete the Employer’s First Report of Injury form so it is accurate when it is received in the claims office. It is well established in the claims field that fast and accurate reporting of the claim has a positive impact on the outcome of the claim.

 

 

Cooperation with the Insurance Company:

 

The employer who takes the hands-off approach to work comp claims will see a steady increase in their work comp insurance premiums. The smart employer takes the approach of being actively involved in the work comp claims.

 

It is your responsibility as an employer to assist the work comp adjuster in their handling of the claim. As the adjuster investigates the claim, there will be a need for documentation from you as to the employee’s payroll history. The adjuster may need to speak with the employee’s supervisor or co-workers who witnessed the injury. In some situations, the adjuster may need to see the employee’s personnel file or health benefits file. If you are contacted by an attorney for the employee, be sure to notify the adjuster immediately. By providing whatever assistance the adjuster needs on a timely basis you can help to mitigate the cost of the work comp claim.

 

 

Employee Contact:

 

One of the most often over-looked responsibilities of the employer in work comp claims is the human element. The employee’s supervisor or the work comp claims coordinator or both, should stay in contact with the injured employee while that person is off work. By letting the employee know your company is concerned about his/her well-being and by keeping the lines of communication open, the risk of the claim becoming adversarial or the employee employing an attorney, guaranteed to delay resolution of the claim, is diminished.

 

 

Return to Work Program:

 

Study after study show the quicker the employee is returned to work, the lower the overall cost of the workers’ compensation claim. It is imperative the employer have a Modified Duty Program or a Light Duty Program available for all injured employees.

 

In most states you can contact the employee’s medical provider and ask for the conditions under which the employee can return to work. You have the right to know the employee’s medical condition and to have the worker return to work on a light duty program with the medical provider’s agreement.

 

By bringing the employee back to work on a modified duty program, the employee benefits and the employer saves money (remember the more the insurance company pays out, the higher your eventual work comp premium).   When the employee is off work, the insurance company is paying benefits to the employee, but the employer is not receiving anything of value. By returning the employee to work, the benefits being paid by the insurance company stop. While an employee on modified duty may not be as productive as an employee on regular duty, the employee is still producing some benefit to the employer.

 

 

Summary:

 

The more pro-active the employer is in the work comp claim process, the lower the overall cost of workers’ compensation. Employers who provides a safe work environment, knows the requirements of the workers’ comp laws in their state and who reports their work comp claims quickly and accurately will lower their cost for work comp coverage. The employer who cooperates with the insurance adjuster’s investigation, keeps in contact with the employee and assists the employee to return to work quickly experiences a positive effect on the cost of workers’ compensation.

 

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Use A Medical Advisor To Maximize Value of Independent Medical Exam

Use A Medical Advisor To Maximize Value of Independent Medical Exam A company medical advisor can be one of the most effective tools for reducing workers’ compensation costs as there is often a need to address specific health issues in regard to an injured employee’s case.

 

 

Leverage Medical Advisor for Independent Medical Exams (IME)

 

An example is leveraging your company’s medical advisor regarding an Independent Medical Exam (IME). Follow these steps:

 

  1. Accompany your adjuster’s letter with a signed cover letter from the medical advisor or director. Doing so results in more comprehensive and conclusive independent medical evaluation and examination (IMEs) reports.
  2. Be sure to include claim number and all relevant addresses and contact information on the letter.
  3. Welcome the physician to ask questions.

 

 

Be sure to ask the independent medical evaluation physician (IME) to answer the following questions or types of example questions:

 

  1. What is the patient’s present diagnosis and work status since it is X months since the original injury?
  2. Has s/he achieved maximal result?
  3. Can s/he perform the job as a painter (or whatever is the usual work task)?
  4. Specifically, please address whether s/he would have difficulty simply walking on a flat surface and going up and down a ladder?
  5. Since the latter involves flexion and extension of the ankle, would the lateral sprain affecting primarily pronation and supination really interfere with performance?
  6. If the worker uses an ankle support, would it be sufficient to allow work performed as a painter?

 

For example, this may be necessary when documentation states:  “Patient may have trouble walking.”  and your company needs to know how long the worker can walk for, at what inclination and duration.  These specifics can be determined by the independent medical examiner but may require some slight prodding to get documented.

 

 

Medical Advisor Often Overlooked

 

As part of an overall workers’ compensation cost-control program, hiring a medical advisor to work proactively on claims is an important, but often overlooked step.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

How to Tell If You Need a Nurse Case Manager for Your Workers Compensation Claim

How to Tell When You Need at Nurse Case ManagerNurse case managers (NCMs) coordinate medical care and determine extent of disability.  However, there are times when the NCM doesn’t serve a specific purpose and is assigned to the claim to get the claim moving.  At times, NCM’s are used to do some of the tasks adjusters are supposed to do. Your job is to clarify when nurse case management is warranted and useful.

 

The injury coordinator can evaluate these aspects of both telephonic case management and field-based case management first of all by emailing the adjuster and stating the above.

 

Also, the injury coordinator should know whether your NCM is an RN or a Licensed Practical Nurse (LPN). You should be charged less for a LPN or a NCM with less experience or fewer credentials.

 

  • Require the NCM to provide you with frequent updates. If you review the insurer’s file notes online and do not see NCM notes, contact the NCM to provide an update.
  • Ask your third party administrator or adjuster to work with you to determine when the use of nurses serves to resolve claims quickly and ensures good quality medical care for the employees.

 

 

Ask the following:

 

  • Do you have any suggestions of when we should use nurses, what types of claims?
  • Can we get a list of all claims which have NCM assigned?
  • Shall we touch base about this on our regular risk management conference call?

 

 

Make use of a Nurse Case Manager:

 

  1. In complex cases with multiple provider coordination.
  2. In new lost-time claims if the length of time out of work is disproportionate to the injury.
  3. When an employee is missing medical appointments.
  4. When surgery, including arthroscopy, is anticipated.
  5. For all hospitalizations.
  6. If there is diagnostic testing including MRIs, CAT scans, or myelograms.
  7. For severe injuries including: severe eye injuries, severs lacerations, back and knee injuries, cumulative trauma cases and severe sprains, strains or dislocations.
  8. And remember:  Not all nurse case managers are equally effective. If your assigned NCM is not effective, ask for a replacement.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

8 Part Email To Send When Transitional Duty Doesn’t Work

8 Part Email to Send When Transitional Duty Doesn't WorkDespite your best efforts to get medical restrictions from all treating physicians and evaluate your employee on a weekly basis, there are times when the medical provider says the injured employee can do more than s/he thinks s/he can.

 

  • For example, a bus driver injured his right arm in a work-related accident. The doctor finds the muscles and bones have mostly healed and the patient should no longer be feeling pain and may return to work for four, rather than an eight-hour day.
  • But in your weekly reviews, the employee complains that opening the bus door is still so painful he cannot drive home at the end of the day.

 

In this situation, write an email from the injury coordinator to the adjustor asking if a functional capacity evaluation (FCE) may be needed. Also, consider options for alternate work for a while longer.

 

 

8 Part Email To Send When Transitional Duty Doesn’t Work

 

  1. Be sure to include claim number and all relevant addresses and contact information on the letter.
  2. Include the supervisor in any discussions.
  3. Clearly explain the situation: who is injured, what the injury is, what the current complaint is and what the physician says the worker should be able to do
  4. Explain the company’s medical advisor reviewed the reports and the employee’s complaints do not mesh with the current medical diagnosis.
  5. Acknowledge the pain could be imagined (but without judgment) or the result of the employee being fearful of additional injury. Be aware that the pain might be very real also, and don’t minimize the likelihood of this possibility. Anyone who has ever had repetitive arm injury knows how painful it can be and often even a small amount of use can trigger painful symptoms.
  6. Ask your adjustor if an (FCE) is needed and, depending on results, perhaps an off-site work hardening program is in order.  In work-hardening the employee is allowed to build up to his regular job capacity in a supervised setting, removing the fear of re-injury.
  7. Ask the adjustor for suggestions of work-hardening centers in the area.
  8. Acknowledge the difficulty of this claim and ask the adjustor for a timely response.

 

Real or imagined, pain while doing one’s job benefits neither the company nor the employee. There are programs designed to help your employee work through these issues.

Vigilant attention to the employee will ease this process.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Two Very Important Steps When Managing A Catastrophic Injury Claim

When you say catastrophic injury, many people in the insurance field think of brain injuries, spinal cord injuries, severe burns, amputations, loss of eyesight or neurological injuries. While these are the more common types of catastrophic injuries, any injury requiring extensive medical treatment and has a long-term and/or permanent impact on a person’s life can be a catastrophic injury.

 

Catastrophic injuries make up only a small fraction of the total number of workers’ compensation claims but account for a significant portion of the dollars spent on medical care and treatment of employees. The proper management of these high dollar claims makes a significant difference in the cost of the workers’ compensation program.

 

 

Here are two very important steps to take to minimize the financial impact of the catastrophic injury claim, as well as create best outcome for the injured worker.

 

 

Step #1: Immediate Attention

 

When the work comp adjuster receives an obvious catastrophic injury claim, it is imperative for the adjuster to act immediately. The adjuster needs to drop everything else and concentrate on the catastrophic injury claim.

 

  • The work comp adjuster contacts the employer and interviews the supervisor and/or other employees who were present at the time of the injury to get a comprehensive understanding of what occurred.
  • Then the adjuster contacts the employee if the employee is able to speak with the adjuster. If the employee is unable to speak, the adjuster must make immediate contact with the spouse or another family member who represents the employee’s interest.
  • The adjuster makes arrangements to personally meet with the employee and/or the employee’s family member at the hospital, preferably the same day of the injury. The adjuster also arranges for the nurse case manager assigned to the claim to attend the initial meeting with the employee and/or employee’s family.
  • Contact by the work comp adjuster and the nurse case manager with the employee or family member the same day as the accident is reported is critical to the outcome of the claim.
    The employee’s most pressing concern is surviving the injury.
  • Once the employee is reassured by the medical facility s/he will live, the next thoughts are: “Will I be able to work in the future and how will this accident impact my life with my family and my family’s life?

 

 

Attorney Alert!

 

  • It’s at this point the employee or a family member remembers the late night television commercial for the local attorney. If the work comp adjuster or the nurse case manager reassures the employee and/or the family the injured person will receive all the medical care needed, and that indemnity benefits will be paid, the probability of the employee hiring an attorney to represent the employee is greatly diminished.
  • Hence, it is critical the work comp adjuster meet with the employee and/or family and establish rapport with them while reassuring them all their medical needs will be meet and the indemnity benefits will be paid.

 

 

Step 2: Medical Management

 

The intensive involvement of the work comp adjuster in the initial stages of the catastrophic injury claim is of paramount importance. However, as the claim progresses, and new work comp claims arrived on the adjuster’s desk, the need for a medical specialist to continue to assist the employee becomes necessary.

 

  • Early medical management is essential to achieve the best possible medical outcome. The highly trained nurse case manager (NCM) who was with the adjuster at the initial meeting with the employee and/or the employee’s family takes over the day to day medical management of the claim.
  • The NCM becomes responsible for insuring the employee receives proper medical care throughout the life of the claim. This continuity of the medical care is critical to the best possible medical outcome for the employee. It also prevents the medical care from drifting and prevents the work comp claim from becoming an even bigger claim.
  • The NCM works with the employee to guide the employee and the employee’s family through the significant life changes following a catastrophic injury.
  • As the employee goes through hospitalization, rehabilitation, return to home and community and, hopefully, an eventual return to work, the NCM controls the pace of the step-downs in medical facilities and medical care.
  • Along the way to recovery, or maximum medical improvement short of recovery, the NCM continues working with the treating physicians, medical specialists, consultants, therapists, rehabilitation provider and life-care planners, if the employee is unable to return to work.
  • For those employees who are permanent and totally disable and never able to return to work, the continuing involvement of the NCM is necessary. The expertise of the NCM in managing the medical aspects of disability and in determining the appropriate home-based care will impact the overall cost of the catastrophic work comp claim.

 

 

Summary:

 

Catastrophic injury claims not appropriately managed by the work comp adjuster and the nurse case manager quickly spiral out of control, drastically increasing the overall cost of the claim.

 

Immediate attention to the employee’s medical needs by the work comp adjuster and the nurse case manager, along with the continuing control of the medical care by the nurse case manager, has the positive impact on the overall cost of the work comp claim.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Is Your TPA Recovering Every Subrogation Dollar It Should?

Do you ever wonder if the claim handling quality of your insurer or third party administrator (TPA) is as good as it should be?

 

  • Do you ever find your insurer or TPA making large reserve changes just before it settles a work comp claim?

 

  • Is your insurer or TPA recovering every subrogation dollar it should?

 

  • Is your insurer or TPA doing everything it should to resist fraudulent claims?

 

If you have any of these concerns, you can consider four types of file review for workers’ compensation claim files .

 

 

1 – Claim File Quality Audits

 

Your company’s service agreement with your insurer or TPA should specify the claim handling standards — the Best Practices– that apply to all of your workers’ comp claims. An audit of the work comp claim file quality focuses on the components of claim handling that optimize the claim resolution results.

 

The work comp claim file review compares your files against the Best Practices standards you agreed to with your insurer or TPA. The experienced auditor reviews and analyzes how the various aspects of the file interrelate to give your company a total picture of how each individual file is/was handled.

 

When the audit is concluded, your auditor provides you with an Executive Summary Report outlining the audit findings.  The Executive Summary Report outlines your claim handlers strengths and weaknesses. The report provides you with valuable information and recommends solutions allowing your company to avoid future difficulties. The completed claims audit provides your risk management department with peace of mind, or it assists your company to know where your claims are deficient, allowing you to take the appropriate action before you incur extra claim cost.

 

 

2- Reserve Audits

 

When reserves are set too high on your work comp claims, your company’s ability to undertake new business is unnecessarily limited and it may impact your company’s ability to get financing. When reserves are set too low, your company’s available assets are overstated, eventually resulting in unanticipated shortfalls.

 

Reserves need to be state accurately and they need timely adjustments —  soon as information impacting the reserves becomes available. The independent claims auditor evaluates the reserve accuracy and timeliness of reserves for individual claim files and for the entire work comp claim inventory.

 

Whether you need a reserve audit for underwriting and renewal, retro premium adjustment, a merger/acquisition, collateral adjustment, the professional claims auditor provides you with the accuracy of reserves you need. The reserve audit gives you an objective analysis of your financial funding needs.

 

 

3- Subrogation Audits

 

Every dollar recovered by subrogation is a dollar added to your firm’s bottom line. Often busy adjusters overlook subrogation opportunities. Subrogation must be looked for in every work comp claim. While your work comp adjuster knows to pursue subrogation on clear-cut automobile accidents, the work comp adjuster often does not have the liability expertise to recognize the potential for recovery when the work comp claim involves elements of general liability or products liability. The professional claim auditor identifies these potential recovery opportunities and maximize your recoveries.

 

Subrogation audits are considered for all open files and for closed files still within the statute of limitations. Subrogation audits pay for themselves by bringing in otherwise missed recoveries.   When the subrogation audit can be done electronically, your independent work comp claims auditor may often perform the audit for a percentage of the identified file review recoveries.

 

 

4- Fraud Audits

 

Nothing hurts the bottom line of your business more than a fraudulent claim, as it is a theft of the amount of money paid on the claim and, as we all know, the company’s loss history is used as the basis for future premium charges.

 

Separating the fraudulent claims from the legitimate claims can be difficult. The professional auditor can assist in identifying those claims where more can be done to disprove the fraudulent claim.

 

 

Summary

 

The professional claims auditor provides your company with the information you need to determine the claim handling quality of your files. The auditor assists you in verifying or correcting the accuracy of file reserves.   A subrogation audit pays for itself in additional identified recoveries, while a fraud audit save your company from paying fraudulent claims. All four types of audits improve the financial status of your company.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Develop Defense Attorney Relationships to Settle Work Comp Claims

Leaders of claim management teams are constantly seeking solutions to solve problems.  This includes surrounding themselves with like-minded individuals who have a mindset that empathizes with the injured worker while at the same time advocating for the bottom line.  When seeking to accomplish this goal, interested stakeholders should evaluate their program and settlement procedures.  Another area of focus should include the development of relationships with defense attorneys that share the same vision as the claims management team.

 

 

Evaluate Cases Early and Attempt to Settle

 

All members of the workers’ compensation claim management team needs to develop the skill of evaluating a case and driving it toward timely settlement.  This involves several steps that need to be taken before referring a case for legal assistance.  Necessary steps include:

 

  • Conducting an effective initial investigation and, if necessary, issuing a denial of primary liability grounded in the facts of the claim and the law. Failure to do so in a timely manner will only add to the cost of each claim;

 

  • Accurately calculate the average weekly wage (AWW) to determine properly the employee’s benefits and future exposure. Most workers’ compensation benefits are grounded in the AWW.  Failure to calculate it correctly can significantly increase the time and money spent on a clam; and

 

  • Obtain the necessary background information on the claimant and work injury. In many instances, even seasoned claim handlers are not able to settle a case given their lackluster efforts in doing basic research on a claim.

 

 

Identify Defense Counsel with Similar Values

 

Members of the claims management team need to expand their horizons and continually develop relationships with members of the defense bar.  This investigation needs to go beyond where an attorney went to law school or the name of their law firm.

 

  • Build relationships: There are countless opportunities to meet defense attorneys.  This can include bar association functions, claims association meetings or involvement in community programs.  Claim handlers serious about seeking creative solutions need to be proactive when it comes to finding the right attorney.  A factor should not include who is offering a free lunch or tickets to the big game.

 

  • Ideals Consistent with Your Program: Part of getting to know a defense attorney needs to go beyond that person’s favorite restaurant.  Members of the claims management team who want to find the best fit for their program need to understand the defense attorney’s strengths, opportunities to become a better lawyer and their views on how to handle claim.

 

 

 

Claim Updates and Consistent Status Reporting

 

Knowing what is going on in a case is important for anyone involved in handling workers’ compensation claim.  This is due to the speed at which claims are handled, litigated and moved toward final resolution.  Effective claim handlers need to seek out attorneys dedicated to keeping them involved and apprised of claim developments.

 

  • One effective tool to do this is a status report. A typical status report should include information on the facts of the case, a clear and concise legal analysis and proactive recommendations for further handling.  There should be no surprises.  This includes matters concerning case evaluation, the exposure of a claim and what likely will happen.

 

 

Conclusions

 

Running an effective claims management team and handling individual claims is demanding work.  This requires the individual claim handler to be proactive in the early part of a case as they investigate the injury and make determinations regarding liability.  Another important point is for claim handlers to develop relationships with attorneys to drive claims to settlement.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Professional Development Resource

Learn How to Reduce Workers Comp Costs 20% to 50%"Workers Compensation Management Program: Reduce Costs 20% to 50%"
Lower your workers compensation expense by using the
guidebook from Advisen and the Workers Comp Resource Center.
Perfect for promotional distribution by brokers and agents!
Learn More

Please don't print this Website

Unnecessary printing not only means unnecessary cost of paper and inks, but also avoidable environmental impact on producing and shipping these supplies. Reducing printing can make a small but a significant impact.

Instead use the PDF download option, provided on the page you tried to print.

Powered by "Unprintable Blog" for Wordpress - www.greencp.de