Your Adjuster Has a Critical Role in Legal Defense Management

 Your Adjuster Has a Critical Role in Legal Defense Management With the public bombardment of attorney advertisements, it is becoming harder for the claims adjuster to work directly with an injured employee.  The plaintiff attorney advertising is designed to get the public to think that they need attorneys for everything. However, with proper claims handling, the claims adjuster can still control the workers’ compensation claim.

 

 

Once Attorney Hired, No Further Contact with Employee

 

Once the employee has retained counsel the adjuster can have no further direct contact with the employee.  The adjuster cannot advise the employee to terminate a relationship with their legal counsel.  The adjuster cannot tell an employee not to retain legal counsel.  While some employees can be very difficult to deal with and extremely demanding, the adjuster can never tell an employee to get an attorney.  If asked about getting an attorney, the adjuster should tell the employee it is their decision on whether or not they hire an attorney.  The adjuster should request a letter of representation from the employee’s attorney as soon as notified of their existence.

 

The adjuster may reevaluate the claim when an attorney appears, but the adjuster should not be stampeded into an excessive change of opinion.  Claims have been settled for less with attorneys than they might have been settled with the employee direct.

 

The adjuster will price the settlement values of the workers’ compensation claim based on the facts and exposures regardless of legal representation.  The injured employee will determine after the disposition of the claim whether or not the attorney was worth it and needed.

 

 

Adjuster to Maintain Positive Contact with Employee Before Attorney Representation

 

Prior to an attorney representation, the adjuster should maintain a direct dialogue and interface with the claimant.  This is accomplished by showing empathy and concern for the person and injury.  The adjuster should not allow sympathy to overrule the facts and necessities of the loss.

 

The adjuster can maintain control of the claim by prompt contact, kept promises, returned telephone calls, and questions answered with fact, law, and honesty.  Explanation of all steps as to what will happen, when it will happen and how it will happen, builds confidence of the employee in the adjuster’s professionalism.

 

All of these steps may not keep the employee away from an attorney.   Nor may it prohibit a request for a hearing, even if the adjuster works in the same professional manner with the claimant’s attorney.  Many attorneys receiving such consideration will usually delay filing for a hearing and are more apt to be receptive to a prehearing resolution of the claim.  (Some jurisdictions have hearings in front of an official from the work comp board, while others will have an industrial commission, and others used the court system of their state).

 

 

First Notice of Claim Could Be Request for Hearing

 

On the other hand the first notice of a claim may be by a request for a hearing.

 

Regardless of when or how a hearing request arrives, the adjuster is under the gun to process the legal papers as fast as possible.   Most hearing requests must be answered in a specific time frame, often 30 days, but some jurisdictions have a shorter time frame of 20 days from the date the employer is notified.  If the answer period is going to expire before an answer can be given due to investigation needs, the adjuster should request an extension of time from the employee’s attorney.  The adjuster should attempt any disposition that might be possible before referring to defense counsel.

 

The hearing request should be sent to defense counsel at once by the adjuster.  The adjuster will need to keep the claim file on a daily diary until the employee’s attorney agrees to an extension of time, or until the adjuster has employed defense counsel to respond to the hearing request.

 

The adjuster should send defense counsel a copy of the file with a covering letter outlining legal steps to take, and the adjuster’s summary assessment of the file.  The adjuster should provide written litigation management guidelines to the defense attorneys. The adjuster should request a litigation plan and a litigation budget. The adjuster should set a legal reserve for the defense cost. The legal plan should be the guide for setting the legal reserve.  However, until a litigation plan arrives from defense counsel, the adjuster can use an average of past legal costs for similar losses to set the legal reserve.

 

 

Stay with File Before and After Referral is Made to Defense Counsel

 

The adjuster should keep the file on a daily diary until the claim referral is acknowledged by defense counsel and an answer has been filed.

 

The adjuster should not abandon the file handling and management to defense counsel.  The adjuster is responsible for gathering the facts for the defense counsel.  If the file has recorded statements from the injured employee and other employees as witnesses, the adjuster should defer expensive depositions until absolutely necessary.  The adjuster should prevent needless litigation steps and not allow the defense attorney to use outside investigation without prior approval and need.

 

All specialist investigation or experts needs the adjuster’s approval. They are to be coordinated with the adjuster, the employer and the defense counsel.  The adjuster should control cost by the pre-agreement of fees and cost.  The adjuster should audit the billing by outside investigators or experts to be sure it is in keeping with the agreements.

 

If defense counsel needs information from the employer, the adjuster should obtain it. When a meeting or conference is necessary, the adjuster should be present with defense counsel and the employer.  If the self-insured employer needs to be contacted for disposition authority, it should be done through the adjuster.

 

Good adjusters know the value of the claim, can negotiate the settlement themselves, and should try to keep defense counsel out of settlement negotiations to limit legal fees.  However, when a case is in a hearing, arbitration, or statutory judgment the attorney may have to settle on the spot.  The adjuster should provide defense counsel with the necessary settlement authority. Telephone discussions for additional authority can prevail in these situations. If the self-insured employer input is required, the adjuster should comply.

 

The adjuster should control defense counsel reporting. It is not necessary for the attorney to parrot back factual information already in the file.  All that is necessary for the attorney to do is state how the facts will be used in the litigation process.  The attorney’s report should contain an opinion as to disposition.  A request for any additional investigation is necessary.  A time frame and necessary legal steps should be in the report.

 

 

Adjuster Critical in Management of Attorney Costs

 

Once the initial assessment report is completed by defense counsel, it is necessary for the adjuster to receive supplemental reports for current activities and opinions.  If legal research is necessary the attorney must discuss and get the adjuster’s approval.  Limitations must be set to avoid runaway costs.

 

The adjuster should have defense counsel eliminate from their reports all, or at least surplus copies of interrogatories, pleadings, depositions, and other legal information.  The attorney generally reports on the contents of these items and their impacts, so it is seldom, if ever, necessary for copies to come to the adjuster’s file.  Not only will this save attorney copy cost, it will reduce a cumbersome file.  If a need arises for these actual documents, the adjuster can always request them.

 

All defense counsel legal billings should be reviewed and approved by the adjuster.  The adjuster should check the defense counsel bill line by line to be certain there is no duplicity, overlap, or non-authorized handling.

 

The adjuster should be cognizant of excessive telephone and other uses.  The adjuster should supply photocopies of documents to counsel when possible so they do not have to copy.  The adjuster should before sending any file to defense counsel go through the file page by page and eliminate any duplicates, or needless paper.

 

When a case goes to a hearing and an adverse decision gives grounds for appeal, the adjuster should handle the appeal response period on daily diary until the defense counsel has filed the appeal.

 

 

 

Multiple Defense Relationships Should be Engaged

 

The adjuster should develop relationships with several defense counsel firms. It is recommended that the different firms be used simultaneously. This generates competition between the firms, allows for spreading work, and keeps the assignments on a fresh approach for service and thinking.

 

 

 

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 Power of a Good Settlement Consultant

The Power of a Good Settlement ConsultantWhich unappealing situation would you prefer?

 

A. You must seek permission to see any medical provider; then, you may have to wait and/or travel far distances to visit the physician. Any medications, surgeries, or procedures must first be approved, and there’s a good chance some will be denied.

 

B. You have to navigate a complex healthcare system yourself — meaning you’re on your own to find the right specialists and ensure they charge according to your state’s ‘fee schedule.’ You pay full retail prices for doctor visits and all medications and treatments. You must fully comply with the myriad Medicare requirements or risk ultimately losing that benefit. You are extremely worried you won’t have enough money to pay for your medical care, your mortgage and send your child to college. Short of paying excessive fees for expert advice, there is no one to guide you.

 

 

Complex Issues Can Prevent Settlement

 

Neither scenario is appealing; yet, those are the choices facing many injured workers with long-standing, complex workers’ compensation claims. While many would like to settle and finally leave the workers’ comp system; issues such as lien resolution, financial planning, legal issues, and insurance concerns are just some of the challenging hurdles which are seemingly too difficult to overcome.

 

Fortunately, a solution to these challenges can often be found that meets the injured worker’s unique needs, along with those of the attorneys, employer, payers, and others involved.  Finding the right people to work with can get claims off payers’ books and ensure the injured worker’s financial and medical needs are taken care of throughout his lifetime.

 

 

The Settlement Consultant

 

A settlement consultant is a settlement expert with knowledge and access to various settlement tools to address the most challenging workers’ compensation claim issues. For example, a consultant that works with insurance planners can provide comparative information on insurance products, such as disability or long-term care insurance. Having the benefit of an expert in Medicare Set-Asides available can ensure compliance and reporting issues are addressed, so future benefits are not put at risk.

 

These experts can be brought into the process early on, so the settlement is set up appropriately. Rather than just running quotes, the settlement consultant should act as the general contractor in identifying, bringing and managing the best experts to the table to address the issues preventing a positive outcome for all parties in the case.

 

 

Settlement Consultant as General Contractor

 

If you were building a house, you would need workers to lay the foundation and put up the walls, electrical and plumbing specialists, roofers, and HVAC professionals. You might want a home theater with the latest equipment and would need an expert for consultation and installation. Maybe you’d opt for a decorative pond on the property, and would need someone experienced in grading the land.

 

You would want a general contractor to oversee the entire project and make sure things were done according to your specifications and timeframe.

 

A settlement consultant should function as a general contractor who coordinates all the moving parts to the settlement. Just like the best general contractors, a settlement consultant should be able to identify and coordinate all the right players needed to create a truly win-win settlement.

 

Among the qualifications of the best settlement consultants are:

 

  1. Vast experience and deep connections. The best settlement consultants have vast experience and deep connections with many vendors. They can find the right ones for each injured worker.

 

  1. Whole-person approach. Superior consultants look beyond the amount of the settlement. They work closely with the injured worker, to ascertain not only his medical needs, but other considerations; such as unique legal issues to be resolved, insurance concerns; retirement needs, and college funding for children or grandchildren.

 

  1. Ability to uncover lifetime needs. The most qualified settlement consultants spend time getting to know the injured worker and identifying his needs; then bringing in experts to address them.

 

  1. No cost to the injured worker. The consultant’s services should also be completely fee transparent, and come at no cost to the injured worker.

 

 

Use Settlement Consultant Early

 

A settlement consultant should be brought into the case as early as possible, even before the worker has agreed to settle the claim. By forming a relationship with the injured worker and understanding his needs, the consultant can present a variety of customized solutions to focus on his particular situation and help reach an optimal settlement

 

 

Conclusion

 

Settling a workers’ compensation claim can be a nerve-wracking experience for an injured worker, especially one who has been in the system for an extended period of time. Working with a truly qualified settlement consultant can help settle the claim and empower the injured worker to lead the life they deserve.

 

 

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.

Know Two Types of Functional Capacity Evaluations (FCE)

Know Two Types of Functional Capacity Evaluations (FCE)When a physician is treating an employee for a back injury or other job related injury, the decision on when to return the injured employee to work is often a subjective decision. The physician who is unsure of the employees physical capability will often turn to the physical therapist for an objective opinion of the employees ability for work. The physical therapist will provide a Functional Capacity Evaluation (FCE) by administering various tests to determine the employee’s functional capacities and limitations.

 

 

Comprehensive Examination and Evaluation

 

The FCE is a comprehensive examination and evaluation by the physical therapist that objectively measures the employees level of functioning. The testing will document the employees ability, or the lack of ability, to perform the essential job related task over a specific time frame. The FCE will provide objective information to the physician in several areas:

 

  1. the employee’s functional abilities and job demands
  2. the disability evaluation
  3. when to return the employee to work
  4. whether or not the employee can return to the job held prior to the injury
  5. the employee’s functional abilities away from the job
  6. to information to design a rehabilitation plan, if needed
  7. the need for other medical intervention and/or treatment

 

While most workers compensation adjusters and employers will look at a FCE as a way of proving the employee is able to return to work, it serves a much greater function.   The results of the FCE will often limit the disability rating of the employee, preventing the physician from assigning a higher disability rating than is justified. Furthermore, the FCE will determine physical limitations the employer will need to know to modify the employee’s job, preventing a needless re-injury of the same body part.

 

 

Job Specific & General Purpose FCE

 

There are two types of FCE, the Job Specific FCE, and the General Purpose FCE. The Job Specific FCE measures the employee’s ability to perform the task and physical demands of a specific job. It can be performed at the physical therapist’s clinic, but the physical therapists can go with the employee to the actual job site and evaluate the employee’s ability to do the essential task of the employee’s job. The job-specific FCE will determine if the employee can safely do his prior job or if modifications of the required work are needed.

 

The General Purpose FCE is normally used when there is no longer a job for the employee to return to or when the job functions have not been determined. The General Purpose FCE consists of a group of standardized test and measurements that can be used to establish the employee’s overall physical capabilities. The results of the General Purpose FCE can be used to evaluate the employee’s ability to perform specific jobs that may come available to the employee.

 

 

Determine Medical Status of Employee 

 

Prior to starting the FCE, the physical therapist will review the medical records of the employee to determine the medical status of the employee. The physical therapist will establish a baseline for the employee based on the known job demands. The job demands of the employee will be characterized per the US Department of Labor’s “Selected Characteristics of Occupations as Defined in the Revised Dictionary of Occupational Titles” as:

 

  1. sedentary – exerting up to 10 pounds of force occasionally,
  2. light – exerting up to 20 pounds of force occasionally or up to 10 pounds of force frequently
  3. medium – exerting 20 to 50 pounds of force occasionally or 10 to 25 pound of force frequently
  4. heavy – exerting 50 to 100 pounds of force occasionally or 25 to 50 pounds of force frequently
  5. very heavy – exerting in excess of 100 pounds of force occasionally or in excess of 50 pounds of force frequently or in excess of 20 pounds of force constantly

 

Both the Job Specific FCE and the General Purpose FCE measure the employee’s ability to perform various motions, movements, and skills. The ability to do the accomplish the physical demands of the job will be measured in these areas:

 

  1. Balancing           Carrying                  Climbing                 Crawling
  2. Crouching          Far vision                Feeling                   Finger dexterity
  3. Fingering           Handling                 Hearing                   Kneeling
  4. Lifting                Manual dexterity   Motor coordination Near vision
  5. Pulling               Pushing                  Reaching                Sitting
  6. Standing            Stooping                 Talking                    Walking

 

Again, using the US Department of Labor guidelines, the employee’s tolerance level during an eight hour work day for the above activities is categorized as:

 

  1. Not Present (Never) – The activity does not exist in the job (example: Crawling could be classified as Not Present in the job)
  2. Occasionally – The activity exists less than 1/3 of the time (example: Climbing – occasionally)
  3. Frequently – The activity exists from 1/3 to 2/3 of the time (example: Carrying – frequently)
  4. Constantly – The activity exists 2/3 or more of the time (example: Walking – constantly)

 

Document Evaluation Results 

 

When performing the FCE, the physical therapist is responsible for ensuring the test are appropriate for the employee and the test can be done safely. The physical therapist will review the musculoskeletal condition of the employee as reported by the treating physician.   The physical therapist will screen the employee for any underlying medical pathology that would limit or prohibit the employee from participating in the FCE.

 

Upon completion of the FCE, the physical therapist will document the evaluation results. The FCE report will confirm the employee can return to work without job modifications or will confirm the employee can return to work with specific job modifications, or the need to delay the employee’s return to work.   The FCE may also address the need for work hardening or other interventions that would improve the employee’s physical abilities. Properly utilized, a FCE can provide the treating physician with the necessary information to return the employee back to work.

 

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the co-author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:.

Contact: RShafer@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.

 

 

 

5 Ways to Relieve and Prevent Chronic Low Back Pain

5 Ways to Relieve and Prevent Chronic Low Back PainExperiencing low back pain is common among adults. And as one of the most pervasive and expensive causes of workers’ compensation claims, it makes sense do everything possible to prevent LBP.

 

Our industry could prevent needless disabilities and save employers and payer’s a significant amount of money if armed with the latest research and some simple exercises.

 

About LBP

 

The biggest risk factor for a second episode of LBP is having a first episode. New research out of Australia shows that more than any other risk factor – whether it is obesity, smoking, or some other comorbidity – a single occurrence of LBP is the main commonality among those who have a second occurrence.

 

Specifically, one-third of people who have LBP will have a second episode within a year, and the chance of another recurrence triples after that. The researchers were surprised, given that preventing a recurrence of LBP is fairly easy.

 

Studies indicate that doing exercise can reduce the risk of a LBP episode by 35 percent, and combined with education about LBP, the risk drops by 45 percent.

 

That said, treatment for acute back pain is different from chronic LBP.

 

Acute LBP. This is short-term, generally lasting no more than six weeks.

 

  • The best treatment is to stay active, but avoid overdoing it. Keeping up with activities such as work is advised, and no bedrest!
  • Almost all episodes of acute back pain will resolve spontaneously, even when there is evidence of disc herniation and sciatica. So conservative measures are called for and appropriate.
  • An MRI prior to 6 weeks of persistent pain is not recommended unless various red flags are present suggesting a serious or progressive condition. Premature MRIs have a high likelihood of showing incidental chronic changes which are common in adults and are not related to the patient’s complaints.
  • Psychosocial factors play a major role in LBP and should be addressed, g., stress, job dissatisfaction and sleep disturbances.

 

Chronic LBP.  LBP is label as chronic when it persists for at least three months and is a major cost driver in workers’ compensation.

 

  • One in four injured workers with chronic LBP is out of work for up to six months, increasing the chances of permanent disability.
  • The estimated direct costs exceed $14 billion annually.

 

 

Treatment

 

While most episodes of LBP resolve themselves within a few weeks, there is no quick fix for chronic cases. The best advice is to do exercises that target specific areas, although no one exercise is ‘best.’ The best exercise is the one the injured worker does consistently.

 

Ideally, the injured worker should do movements that increase mobility and range of motion, since that will reduce their pain. Tight, weak muscles don’t allow the joints to move properly.

 

Pilates and Yoga are great ways to reduce pain and prevent LBP. Here are additional exercises that can help LBP

 

  1. Strengthening. Exercises that help strengthen muscles in the front and back of the spine are best. They should focus on the deeper, transverse abdominis that support the spine. Planks are a good example. They also help the intrinsic, tiny muscles that attach to each vertebra and provide postural support, which is important.

 

  1. Practicing good posture is key to improving stability. The goal is to have a neutral spine. Workers who sit all day put increased pressure on the spine.

 

  1. Body mechanics. Proper lifting techniques, for example, help protect the spine and prevent recurrences of LBP.

 

  1. Flexibility. Exercises that target the lower extremities are important. The hip rotators, hamstrings, and hip flexors can tighten up and cause pain. Movements that increase flexibility can relieve chronic LBP.

 

  1. Stretching. Taking the stress off the lower back can greatly relieve LBP. Gentle stretches can provide the fastest relief for LBP. The ‘cat/cow stretch’ is especially effective and easy to do. The worker is on the floor on his hands and knees, with hands under the shoulders and knees under the hips. He rounds the back, stretching the mid-back between the shoulder blades, similar to how a cat stretches. After 5 seconds, he relaxes and then arches his lower back and holds for another 5 seconds. Another is the ‘knee to chest stretch.’ In this one, the worker lies on his back with knees bent and feet flat on the floor, with his hands behind the knees or just below the kneecaps. He then gently brings both knees toward the chest, using the hands to pull them; and holds for 20 to 30 seconds.

 

 

Conclusion

 

Any worker of any age can experience LBP. Older workers typically have degenerative changes, while younger employees tend to experience soft tissue problems. Treatment will vary depending on the specific pain generator and be customized according to specific evidence-based medicine guidelines. The key is to make a correct diagnosis, and then target the best therapy beginning with conservative measures.

 

 

 

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.

6 Strategies to Determine Workers’ Comp Causation

6 Strategies to Determine Workers’ Comp CausationCausation is one of the most challenging concepts in the claims community. Causes of low back pain, carpal tunnel syndrome, and other soft tissue pain are often a matter of conjecture on the part of treating physicians, leaving claims managers scratching their heads.

 

But that doesn’t mean you have to blindly accept the doctor’s diagnosis on a claim with obvious red flags. Partnering with the right experts can better ensure payers don’t end up footing the bill for a non-work related injury.

 

 

The Problem

 

The back is the most common body part facing the claims community, and causality is the challenge. That statement during a recent webinar speaks to an all too familiar problem in the workers’ compensation system: determining the cause of an injury where there is often no clear-cut answer.

 

Unfortunately, many treating physicians are not focused on causation and instead seek only to help their patients. They take the word of the patient that the pain is work-related.

 

Many payers are apt to simply accept the treating physician’s determination, figuring da challenge of the doctor’s opinion will likely end up costing more money in the end. However, the problem is often not limited to one or two such cases. “Contagious syndrome,” a term coined by attorney Stuart Colburn, refers to the phenomenon where other workers see a colleague receiving benefits for soft tissue injuries and claim their own.

 

 

Scenarios

 

A 35-year old worker files a claim for a lumbar strain he says he sustained at work. Additional facts are; he is overweight, has a new baby at home, and has expressed an interest in becoming a dispatcher on light duty.

 

In another example, an older woman claims carpal tunnel syndrome in her right wrist, has surgery and returns to work. Six months later, she says her wrist never fully healed and files a claim for CTS on her left wrist. She says both were caused by her repetitive motions at work. Her supervisor has alluded to potential psychosocial factors.

 

In both cases, comorbid factors are clearly evident. In addition to being overweight, the male with low back pain is likely losing sleep due to the new baby (an evidence-based factor for low back pain) and has indicated he would like to be transferred to a less-intensive job on light duty. The other worker has at least two comorbid factors that are indicative of CTS: being female and older.

 

 

Solutions

 

  1. Know the risk factors. Evidence-based medicine identifies clear risk factors for developing soft tissue injuries, both work-related and non-occupational. For example, CTS may be work-related if there is a combination of force and either repetitive motions or awkward posturing. But repetitive motion on its own is not an evidence-based cause of CTS. There are few work-related causes of low back pain. Job dissatisfaction is perhaps the biggest.

 

  1. ID appropriate physicians. Where possible, you want to work with physicians who understand the issues surrounding occupational injuries, such as the importance of determining causation and return-to-work. In rural areas where there are few or no occupational physicians available, payers need to educate physicians on workers’ compensation-related issues

 

  1. Provide job insights. Physicians faced with a patient in pain want to help the person and tend to believe what they are told. The worker who says he injured his back because he is routinely lifting heavy objects and/or is in awkward positions may be misrepresenting his actual job duties. Payers can clarify job duties in several ways:

 

 

  • Invite the physician to the worksite to see what the job entails.
  • Videotape someone doing the job so the physician can see the actual tasks involved.
  • Provide a thorough, detailed job description so the doctor understands what the worker does on a day-to-day basis.

 

  1. Review the history. The claims adjuster should look at the worker’s

 

  • Previous work history; i.e., what he did before working at your company. This may reveal activities consistent with his current complaint.
  • Check medical records. There could be prior injuries in the same or nearby body locations, indicating the injury is not new. This may also show comorbid conditions that could be factors.
  • Determine employment start date. See if the worker is a long-time employee or a new hire, which may be a red flag for a preexisting condition.

 

  1. Approach the physician. If your reviews uncover several red flags, your claims adjuster may be able to convince the physician to take a closer look.

 

  1. Use peer review. The insurance carrier or third party administrator who is managing the claim can request a peer review. An independent medical reviewer can look at the records, test results, etc., and may have a different opinion from the treating doctor. The peer reviewer probably stands a better chance of persuading the treating physician to consider revising his initial determination, since it is a physician to physician discussion.

 

Ideally, you should have established relationships with peer review physicians. If not, the insurance carrier or third-party administrator may have some available.

 

 

Conclusion

 

Identifying causation for a soft tissue injury is often as much of an art as a science. But following evidence-based medicine and working closely with treating physicians can get you that much closer to the true cause.

 

 

 

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.

Medcor Announces the Acquisition of TalisPoint

Chicago-based Medcor, Inc., the leading health navigation firm, has acquired San Francisco-based Talisman Systems Group, Inc., the leading provider of network management services for workers’ compensation and other industries. Talisman will operate as an independent subsidiary of Medcor, retaining its leadership and TalisPoint brand and will remain based in San Francisco.

 

Medcor navigates patients to optimal care through onsite clinics and virtual health services, using evidence-based medicine, proprietary clinical systems and patented processes. Medcor clients include employers from a wide range of industries and insurance carriers. The TalisPoint system validates, updates and manages network data and produces referral documents for insurance carriers, claims administrators, provider networks and employers.

 

Through this acquisition, Medcor expands its innovative health navigation services. These begin with rapid, convenient access to health assessment at the onset of symptoms or injury, followed by guidance to appropriate care. Often, Medcor can provide the care directly or guide patients in self-care. When referrals into the healthcare system are necessary, Medcor’s systems help ensure patients receive the care they need and avoid overtreatment and unnecessary costs. Sophisticated algorithms help Medcor identify serious cases quickly. TalisPoint data helps connect patients with the right provider in the proper network to improve clinical and financial outcomes.

 

Medcor President and CEO Philip Seeger explained, “We are combining two best-in-class businesses whose services are very complementary to one another. This is a powerful way to bring more value to our clients; the fact that we already have mutual clients shows that our customers have independently come to the same conclusion. The high-quality network information that TalisPoint provides will help us more efficiently navigate patients to the right place, at the right time, to receive the right level of care.”

 

Talisman President and CEO Monique Barkett said, “TalisPoint allows for fast, accurate and up-to-date access of vendors and medical networks. This facilitates Medcor’s service delivery by providing person-specific information and pinpointing the exact facility and provider called for by Medcor’s care protocols. To stay at the forefront of our industry, we prioritize innovation to ensure our systems will continue to be best-in-class in the years to come. With Medcor, Talisman now has a proven information technology partner to help us develop the next generation of TalisPoint.”

 

The two companies share reputations for transparency, high customer service, and operating without conflicts of interest. For more information, watch the short video at this link https://youtu.be/AvAFzJJqjSI, contact media@medcor.com or call 815-759-5442.

 

 


 

Medcor operates 240 clinics at or near client worksites and provides virtual health services to over 309,000 worksites throughout the United States and Canada. Medcor serves clients across a wide range of industries, including private firms and government agencies. Medcor helps employers and patients navigate the complexities of healthcare to achieve better clinical and financial outcomes. Learn more at medcor.com.

 

Talisman’s core product, TalisPoint, offers web-based customized network management tools to assist users in selecting medical providers and other vendor types. Access to verified provider data is a key to effective communication between patients, providers and employers. Learn more at talispoint.com.

 

 

 

The Intersection of Medicine and Disability: A Doctor’s View & Other Top WC Tidbits

The Intersection of Medicine and Disability: A Doctor’s View

Whether we are a health care practitioner, an employer or a claims professional, disability is something we deal with on a daily basis. What are the nuances of a disability claim and how can the roles and responsibilities within these claims be better understood?

Dr. Iglesias breaks down what goes into a disability determination and how employers, claims administrators, and physicians can make better and more timely disability determinations that will benefit all the stakeholders in a disability claim.

 

 

Facetime With Phil — Introduction To Analgesics

What are the different drugs available and how does a prescriber make a choice? Join myMatrixx Chief Clinical Officer Phil Walls as he begins a discussion on Analgesics. In this vlog, Phil covers the basics on this topic and begins a deeper dive into the treatment of pain management.

 

 

 

Dan Anders: Building a Better Relationship with your MSA Vendor

Let’s face it. When you realize that settlement of a workers’ compensation claim will require a Medicare Set-Aside (MSA) you may let out an audible groan or even a choice profanity. An MSA will no doubt add cost and time to settlement of a claim. This is why it is so important to partner with a Medicare Secondary Payer (MSP) compliance vendor that can effectively work with you to limit those costs and reduce the time involved with the MSA to the greatest extent possible while still ensuring you are compliant with Medicare requirements.

 

 

 

Opioid Litigation Update

Two-thirds of the deaths from drug overdoses in the U.S. involve opioids. This has been declared a crisis in America. On this Ringler Radio podcast, host Larry Cohen and co-host, Heather Anderson discuss how the Beasley Allen law firm’s attorney Rhon Jones is joining forces with the Attorney General of Alabama in litigation to put a halt to this devastating crisis that touches so many lives today.

 

 

 

Workers’ Compensation Cost Reduction Starts with Better Medical Care

Seek the best possible care for employees with workers’ compensation injuries, because better care will result in fewer treatments and ultimately lower costs. So said Margaret Spence, president and CEO of C. Douglas & Associates in West Palm Beach, Fla., during a June 20 concurrent session at the SHRM 2017 Annual Conference & Exposition in New Orleans. Spence recalled one employer in the panhandle of Oklahoma whose workers were told they had to use doctors in the rural area. When Spence got involved with the handling of the firms’ workers’ compensation claims, the company concluded that the doctors in that area were less qualified and every employee was sent to Oklahoma City for treatment.

 

 

 

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.

Seven Sections of Documentation For A Properly Organized Workers’ Comp Claim File

Seven Sections of Documentation For A Properly Organized Workers' Comp Claim FileThe workers’ compensation claim file should have Seven Sections of documentation that relates to the claim in a properly organized manner.

 

 

1- Claim Investigation:

 

The claim investigation section of the file should contain the adjusters claim file notes on everything that has occurred during the entire course of the claim. This includes a summary of each telephone call and a summary of all medical reports, state forms, letters, attorney reports, etc.

 

The claim investigation section should also contain either the transcript of the employees recorded statement or the claim file notes should contain a detailed review of the employees recorded statement. If a recorded statement was not obtained, the details of the employee’s initial interview should be summarized in the claim file notes. The claim investigation section should also include the employer’s supervisors recorded statement or a detailed review of the supervisor’s version of the accident.

 

A copy of the Employers First Report of Injury should be included in the claim investigation section for a comparison of the claimants version of the accident with the insured’s version of the accident.

 

When there is the potential for subrogation, for example – injuries involving an automobile accident or injuries involving a machine malfunction, documentation to support the subrogation should be included in the file investigation. This can include anything from a police report to a mechanical engineers evaluation of the machine that malfunctioned.

 

If there is a question of compensability or subrogation, the claim investigation section of the claim file should also include the recorded statement of witnesses or others who have detailed knowledge of the accident or occurrence.

 

If the claim lingers and there is a question of malingering by the employee, the claim investigation section will also contain the surveillance reports on the employee.

 

 

2- Medical Documentation:

 

The medical documentation section of the claim file should be divided into two categories, medical bills, and medical reports. Each of these two areas should be further divided into medical providers, with all medical bills by each medical provider grouped by date of service, and all medical reports by each medical provider grouped by the date of service.

 

Miscellaneous medical documentation – ambulance bills, prescriptions, durable medical equipment, etc., should be grouped by the category and organized chronologically.

 

 

3- Indemnity Documentation:

 

The employer’s wage statement reflecting the total compensation (over the state determined pre-injury period for benefits calculations) should be clearly identified in the claim file. Attached to the wage statement should be the calculations used to determine the temporary total disability benefit. If the disability benefit rate for permanent partial disability or permanent total disability is different from the disability rate for temporary total disability, the calculations used to determine the permanent partial disability or the permanent total disability rate should be shown.

 

Any documentation submitted by the employee to claim a higher rate of indemnity benefits should also be included in this section. This could include W-2 forms, copies of previous bonus checks or commission checks, etc.

 

 

4- State Forms:

 

A copy of every form submitted to the state by the employer, the employee or the insurance company should be included in this section of the claim file. State forms can be organized either numerically by the state form number, alphabetically by the state form name or chronologically by the date the state form was submitted to the workers’ compensation commission/bureau/agency/department, etc.

 

 

5- Hearings & Legal:

 

If any party requests a hearing, trial or other legal determination of benefits, this section would contain the documentation of the legal proceeding. This can include petitions for benefits, request for hearings, discovery documents and transcripts of depositions or transcripts of hearings.

 

This section of the claim file should also contain all correspondence between the work comp adjuster and the employee’s attorney, all correspondence between the work comp adjuster and the defense attorney, and all correspondence between the employee’s attorney and the defense attorney. If outside experts have been brought into the claim, the correspondence between the outside experts and any other party would be included in this section of the claim file.

 

 

6- Medical Management:

 

The medical management section of the claim file should include all correspondence and communications between the triage nurse and any other party. It should all obtain all reports, correspondence and communications between a nurse case manager assigned to assist the employee and any other party.

 

 

7- Vocational Rehabilitation:

 

The vocational rehabilitation section of the claim file will contain all the reports and activities of the vocational counselor assigned to the employee. This can include a broad range of information from vocational testing results, to available jobs in the community, to vocational retraining of the employee.

 

 

Summary:

 

The properly organized workers’ compensation claim file will prevent mistakes in the claim handling. It will also reduce the amount of time the adjuster works on the claim file by eliminating time spent searching for specific information. When the claim file is complete and well organized, everyone – employee, employer and insurer – benefit by having all aspects of the claim handled and concluded timely and properly.

 

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the co-author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:.

Contact: RShafer@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.

 

 

 

Avoid High Cost of Denied Claims With Solid Investigation Strategy

Avoid High Cost of Denied Claims With Solid Investigation Strategy

There are many reasons for members of the workers’ compensation claim management team to deny a claim.  This includes denials of primary liability based on a lack of medical support, evidence of a pre-existing condition, idiopathic claims, intoxication defenses and statutory reasons such as notice and statute of limitations.  While the facts of the case may look good at the time of the denial, studies indicate that these denied claims can become costly in the long run.  To better manage claims in a cost-effective manner, it is essential even the most seasoned claim handler think twice before issuing a denial.

 

 

Program Efficiency and Denied Claims

 

Various studies indicate that from 2013 to 2017, claims denial rates have increased from 5.8% to 6.9%.  Reasons for a workers’ compensation claim to be denied include lack of medical evidence, information indicating the injury is not related to one’s work activities, and documentation supporting the contention the person injured was not an employee.  While there has been an increase in workers’ compensation claims denied, this has not translated into program savings.  Instead, these same studies indicate that approximately 67% of all initially denied claims will convert to admitted claims within 12 months.  The result is over a 50% increase in money eventually paid out to fully resolve the matter.  This adds $15,000 to each claim.  Multiple this by many claims and workers’ compensation programs end up paying out a lot of money.

 

 

Barriers to an Effective Claim Investigation

 

Members of the claims management team face many challenges when reviewing a claim and making a determination as to primary liability – and other issues of compensability.  One of the driving factors is the rigid framework many jurisdictions place on insurance carriers.  These barriers are numerous and include the following:

 

  • Inability to issue a retroactive denial of primary liability: In some jurisdictions, members of the claim management team are not able to deny a claim once payment of medical or indemnity benefits has been made. Paying anything on a claim may also diminish the chances of obtaining a $0 Medicare Set-aside allocation under the voluntary review/approval by CMS; and

 

  • Administrative penalties for the late issuance of a denial: Paying administrative penalties does not promote program efficiency.  It also does not make a workers’ compensation insurer look attractive to prospective clients as most states publish statistics on penalties issued by a state industrial commission.  Penalties can also be cumulative, which result in a system of graduated costs for throughout the year.

 

The result of these barriers should also have an increased urgency to deny a claim if it does not pass the proverbial “smell test.” While this may seem like a good strategy, the result can lead to decreased program efficiency.  Now is the time to implement change and take a more reasoned approach to denying a workers’ compensation claim.

 

 

Improving the Claims Process — Making Better Decisions

 

Studies indicate that claims converted from denied to paid are particularly high in California, Florida, and Texas.  Claim management teams who handle claims in these jurisdictions should take note.  Additional education and coordination with other interested stakeholders such as employers and defense counsel can mitigate the payment of unnecessary benefits and reduce the percentage of converted claims.  Other strategies can include:

 

  • Better communication with insureds regarding accident reporting and injury investigation;

 

  • Education and training on workplace safety and injury prevention; and

 

  • Improvements in the claims handling process via the utilization of analytics and technology. This includes making the claims process more accessible to employers and other stakeholders through web and app-based reporting features.

 

 

Conclusion

 

The only good file is a closed file – but this does not mean files should be closed by simply denying primary liability.  Claims management teams seeking to reduce workers’ compensation program costs must make better decisions when denying workers’ compensation claims.  This needs to include better communication and involving all interested stakeholders.

 

 

 

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.

School System Summer Break – 4 Proactive Work Comp Tips

School System Summer Break - 4 Proactive Work Comp Tips

Interested stakeholders in the workers’ compensation process are constantly seeking ways to reduce program costs.

 

One area includes the discontinuance of workers’ compensation benefits for school employees and teachers suffering from the effects of a work injury during the summer break period.  While statues and case law interpretations vary in each jurisdiction, employers and insurers are generally limited in their ability to discontinue or suspend various workers’ compensation benefits for school employees during this time of year – even if they have no plans of looking for work while under restrictions on their activity.

 

 

Schools Out – Time to Discontinue Work Comp Benefits?

 

While the school year typically runs from late August through late May, employees of school districts around the country sustain work-related injuries every day.  The ongoing effects of those work injuries do not magically disappear for summer break.  Sadly, those hot summer days a teacher, paraprofessional or administrative staff employee would like to spend at a beach, can be spent at home convalescing.  Proactive members of the claims management team might view this as an opportunity to discontinue ongoing wage loss and vocational rehabilitation benefits.  Unfortunately, this is often not consistent with many state workers’ compensation laws via case law interpretation.

 

One case on point comes from Minnesota, where a school district sought to discontinue ongoing wage loss benefits at the conclusion of a school year.[1]  The rationale for the discontinuance was based on the premise the employee did not intend to work during the summer months, and the result was no loss in wages.  A compensation judge rejected this argument and affirmed by the Minnesota Workers’ Compensation Court of Appeals.

 

In affirming the reinstatement of wage loss benefits, the court noted that “A teacher who has no summer school duties is presumably free to pursue other part-time or short-term employment.  Therefore, a teacher with a work injury might be entitled to continuing wage loss benefits through the summer if the teacher is totally unable to work for medical reasons attributable to the injury or has injury-related restrictions that affect is his or her ability to secure other employment.”

 

In sum, wage loss benefits are typically payable as long as the employee has a disability related to the work injury. The basis for this decision is also applicable to other forms of workers’ compensation benefits, including vocational rehabilitation.

 

 

Staying Proactive to Avoid the Summertime Claims Blues

 

Being away from work can cause the summertime blues in anyone – especially people who work in an educational environment.  Now is the time for claims professionals handling claims related to school employees to be proactive on these matters to reduce their exposure and ensure improper discontinuance of benefits is not made.

 

  • Investigate whether the school employee is engaged in seasonal employment. People who work in a school environment may be likely to work seasonal jobs during the summer months.  This can include individuals suffering from work-related  Efforts to investigate these matters may also include the use of surveillance if there is credible information the employee is working and not reporting their work activities.

 

  • Make efforts to return the injured school employee to work. Proactive return to work efforts should be made on every claim.  This is especially the case for school employees where wage loss benefits could be paid for an extended period of time.  Suggestions include developing a “Work on Loan” relationship a local non-profit, volunteer agency, or other light duty work inside school district buildings and facilities.

 

  • Monitor the status of claims involving school employees and stay in contact. Lack of communication between the employer/insurer and employee leads to conflict, fear and  Staying in contact with the injured worker provides for effective communication and minimizes problems.

 

  • Determine if the school employee is cooperating in vocational rehabilitation efforts. Summer break and time off from school does not give an injured school employee a vacation from their recovery and achieving their vocational rehabilitation goals.  Various workers’ compensation benefits can still be discontinued or suspended for failure to cooperate with a rehabilitation plan.

 

 

Conclusions

 

School employment and summer breaks create an opportunity for interested stakeholders to stay engaged with employees and reduce workers’ compensation program costs.  While most benefits typically remain payable during summer breaks, there are opportunities for motivated members of the claims management team to engage injured employees and minimize their exposure.  This includes claim monitoring, engagement and ongoing efforts to return an employee back to work.

 

[1] Qualy v. Special School District No. 1, 1994 WL 421773 (MN WCCA).

 

 

 

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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