8 Steps to Obtain Faster, More Accurate Medicare Set-Asides

8 Steps to Obtain Faster, More Accurate Medicare Set-AsidesMedicare Set-asides can take time, money and valuable resources in the claim settlement process. Partnering with experts makes both financial and logistical sense to get your claims settled that much faster, and for the lowest cost.

 

Taking a proactive approach and truly engaging with your MSP vendor will help limit the costs and time to create the best possible MSA.

 

 

Action Steps

 

Strengthening your relationship with your MSP provider requires you to become involved, rather than taking a back seat and expecting the vendor to do it all. Here are actions that will help:

 

 

  1. Provide Complete Information

 

An accurate, defensible MSA report is dependent on the availability of all pertinent information and documentation. You don’t want to delay the process by having to revise the report because of missing information. While the MSA company may be able to access your claim system for relevant records, there may be older records and legal documents in a different system. At the time of referral the following information should be provided:

 

  • Complete referral form
  • Claim payment history
  • Two years of medical records for each
  • Accepted and denied body parts
  • Multiple dates of injury settling
  • Court orders and rulings
  • Depositions

 

 

  1. Read and Heed the Report

 

In addition to a projected dollar amount, the MSA report should include the basis for the number along with recommendations on ways to reduce the allocation and streamline the process. Failing to read through the report and follow the recommendations is wasting your money. For example, there may be suggestions to

 

  • Clarify ongoing medication use
  • Address open-ended treatment
  • Implement an action plan to reduce high opioid or other medication use

 

The vendor may have services that can address these and other issues that will better ensure CMS approval. Also, the report may include unintentional oversights or a misinterpretation of the records. Since you know the details of the claim better, it makes sense to read through the report and question anything that you don’t understand.

 

 

  1. Allow for Intervention

 

Missing medical reports, open-ended medication recommendations, and inconsistent physician statements are among the many hurdles that can increase the allocation or stall the approval process. The MSA vendor should provide an intervention plan to address any such issues that arise before the MSA report is completed and submitted to CMS. You should authorize the company to move forward with the plan and to meet with any attorneys involved if necessary.

 

 

  1. Work with the Compliance Team

 

A couple of questions are best left to attorneys, such as whether an MSA is even necessary and, if so, how state statutes, regulations or case law may affect the preparation and submission of the MSA. MSP vendors typically work with attorneys who are experts in MSP compliance. They can show you various tactics to limit the allocation amount. To do so, you need to provide the vendor with information on accepted and denied body parts along with relevant court orders, rulings or depositions.

 

 

  1. Agree to Escalation

 

A claims professional who neglects to respond to a recommendation from the vendor can create problems getting CMS approval. Conversely, the MSA vendor’s front-line personnel may not be giving you the information you need. Both you and the vendor should agree to have an escalation process in place. This will allow the vendor to bring the recommendation to a supervisor or manager, and lets you talk with a key contact at the vendor’s office to get a complete picture of any issues that must be addressed.

 

  1. Task Vendor as Gatekeeper

 

If your organization has many legacy or other claims that have been open for a while, you may want to conduct a settlement initiative. This typically involves many parties; such as defense attorneys, structured settlement brokers, professional administrator and a medical case manager. Have the MSA vendor act as the gatekeeper for this, by coordinating MSA development, clinical intervention, and CMS submission. That frees up the claims handler and defense attorney to focus on settlement negotiations and finalization.

 

 

  1. Include the Vendor in Finalization

 

The settlement terms must be consistent with CMS guidelines, including the proper inclusion of the MSA and defining Medicare conditional payment resolution. Also, CMS requires the MSA company to submit final, court-approved, settlement documents to make the approved MSA effective. Your defense attorney should, therefore, work with the MSP compliance team to avoid any problems later.

 

 

  1. Monitor Performance Metrics

 

You want to make sure your partnership with the MSA vendor continues to be successful and correct any areas that need improvement. The vendor should be able to provide performance metrics, such as

 

  • The number of MSA referrals
  • The turnaround time to write the MSA report
  • The CMS approval rate
  • Percentage of MSAs with prescription medications
  • Cost savings as a result of interventions
  • Percentage of MSAs with Development Letters from CMS

 

 

Conclusion

 

MSAs are complicated and can be expensive and time-consuming. Partnering with the right experts and staying involved with them can get you to a less costly settlement sooner.

 

 

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.

How Star Wars Nailed the First Step in Workers’ Comp Management

Hey there, Michael Stack here, CEO of Amaxx. So this past weekend my wife was gone for the weekend. She was visiting one of her good friends from college, from Lehigh University, who’s actually was the maid of honor in our wedding up in Saratoga, New York. So whenever she’s gone, I like to take the opportunity to watch some movies that maybe she wouldn’t really like quite so much. So I was able to watch The Godfather and then I also watched Star Wars The Last Jedi, the latest Star Wars movie that I hadn’t seen yet.

 

 

“Don’t Worry, We’re With The Resistance”

 

In that movie, in The Last Jedi, there’s one scene which encapsulates and demonstrates so well a critical, critical, element of worker’s compensation management. Actually when I work with a company, one of the first things that I often recommend that they do. So here was the scene, there’s two characters Finn and Rose, and they go on an adventure of course to save the galaxy. On their adventure, they encounter a little boy, and they need his help. The little boy of course is scared. One thing they say to him, is they say, “Don’t worry, we’re with The Resistance.” And they show the little badge and they show The Resistance icon. In that little statement, in that little exchange, they demonstrated a number of very important things.

 

 

Identify, Branding, Meaning

 

One was identity. They demonstrated their identity. Number two, was the branding. They had the logo in order to identify themselves and demonstrate that visually. Number three, most importantly, was the meaning behind it. Identity, branding, and meaning. In one little exchange they were able to get the trust and understanding of that little boy and demonstrate what it is that they’re there to do. In an instant.

 

 

ACME IPAR Program

 

If you take this concept and you look at your work comp management program, your injured worker is scared, they don’t know what to expect, they don’t know what is coming next. If you can demonstrate to them and create some branding, create this name around it. An example I love to use, is the Acme, if the Acme is your company, the Acme IPAR, the Acme Injury Prevention and Recovery program. You create an identity and a branding campaign around that, so that you can know and demonstrate in an instant the meaning of what is going to happen next to that injured worker.

 

If you can put some thought into that, if can brainstorm around that, if you can create this identity, create this brand, and attach it to that meaning of what to expect next, you will win the worker’s compensation battle. Again, I’m Michael Stack, CEO of Amaxx. Remember your work today in worker’s compensation can have a dramatic impact in your company’s bottle line. But it will have a dramatic impact on someone’s life, so be great.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

7 Reasons A Workers’ Comp Claim Should NOT Be Closed

7 Reasons A Workers' Comp Claim Should NOT Be ClosedA few years ago a large national third party administrator (TPA) got into a lot of trouble when a Fortune 500 client noticed some major irregularities in the closing and re-opening of claim files. The client noticed that an abnormal number of claims that were closed were being re-opened by the TPA. The risk manager of the client decided to find out why.

 

 

Salary Bonus Program Based on Closed Claims

 

The TPA had instituted a salary bonus program where adjusters who met different performance criteria received a small monthly bonus. One of the performance criteria was to close as many old claims each month as new claims received. The purpose of this particular performance criteria was to move files to closure as quickly as reasonable. What the adjusters figured out was a way to circumvent the intent of the performance measurement in order to make their numbers look good.

 

In the last week of each month, the adjusters who had not closed as many old claims as new claims received would select files that had little current activity and close them in the computer system.

 

 

Adjusters Game The System

 

The following week in the new month, the adjusters would re-open the claim files and continue to handle them. Obviously, this was not the proper way to handle file closings.

 

 

Only Close Claims When All Known Activity Is Completed

 

A workers’ compensation claim should not be closed for any reason other than when all known activity to be completed on the file has been completed. If any of the following situations exist on a work comp claim, it should be left open:

 

  1. the employee has not completed all medical treatment
  2. the temporary total disability indemnity has been paid and concluded, but the employee is continuing to treat with the medical provider
  3. the employee has completed the medical treatment, but all medical bills have not been paid yet
  4. the employee has temporary total disability benefits that have not been paid
  5. the employee has completed all medical treatment, and all medical bills have been paid, but the employee is still receiving weekly or bi-weekly payments for permanent partial disability or permanent total disability
  6. the widow(er) is still receiving weekly, bi-weekly or monthly death benefits
  7. the medical bills have all been paid, all indemnity benefits have been paid, but there are still outstanding bills on the claim for the defense attorney, nurse case manager or other provider of service.

 

If there is a possibility that another dollar can be spent on the claim, the file should not be closed.

 

During a recent claim file audit, the worker’s compensation claims manager wanted to argue whether or not claims with all indemnity benefits paid, but with on-going medical maintenance treatment should be classified as open or closed. The claims manager had several old-dog files where the employees had permanent medical problems and occasionally went to the doctor. In several of the old-dog claims, the employee was making a once a year visit to the doctor. The claims manager had closed the files and was making payments on the closed files each year. This was another situation where the manager’s performance was being evaluated based on the number of files closed.

 

 

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.

 

 

 

Tips to Understand OSHA Rights and Responsibilities to Drive Safety

The Occupational Safety and Health Administration (OSHA) was created at the federal level on December 29, 1970, with the goal of assuring “safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education, and assistance.”  Since its creation, the agency has evolved and become commonplace in the workers’ compensation scene as a means of investigating work injuries and providing information to interested stakeholders.  Parties seeking to reduce workers’ compensation program costs should understand OSHA and view the agency as a partner in making workplaces safe for employees.

 

 

Understanding OSHA Basics

 

There are many misconceptions about OSHA.  It is important to those seeking to provide a safe workplace to understand better the requirements and how the agency is responsible for enforcing safety standards.

 

OSHA standards and agency overview covers most private sector employers.  While it does not cover many state and local government agencies, employees of these entities are subject to protections by the federal act and applicable state programs.

 

The federal act also allows states to create their own OSHA programs.  In these jurisdictions, the state agency receives funding from the federal government to run its program.  This allows states to develop their own standards, provided they meet the federal minimums required under the Act.  There are currently 22 OSHA approved programs that include: Alaska, Arizona, California, Hawaii, Indiana, Iowa, Kentucky, Maryland, Michigan, Minnesota, Nevada, New Mexico, North Carolina, Oregon, Puerto Rico, South Carolina, Tennessee, Utah, Vermont, Virginia, Washington, and Wyoming.

 

 

OSHA Rights and Responsibilities

 

OSHA mandates the creation of a series of rights and responsibilities that impact covered employers and their employees.  These issues are governed by the basic premise of OSHA – employees have a right to a safe workplace.  It is the responsibility of the employer to provide this environment.  Basic guidelines include the following:

 

  • Employers – Requirements to inform employees of workplace hazards and provide training on how to avoid injury. This includes information people are able to understand, which can include written information in multiple languages.  Accident information needs to be posted in common work spaces.  Prompt response to employee complaints and OSHA corrective action are required.

 

  • Employees – The ability to voice concerns without fear of retaliation. They also should have access to important safety information.  This includes information concerning chemicals and other harmful materials in the workplace.  All employees need to understand how and when to report workplace incidents.

 

 

Using Workplace Safety Committees to Drive a Culture of Safety

 

There are no federal requirements for employers to have an established and functioning safety committee.  However, many state-based OSHA programs require these committees based on the size of the employer.  Even if one is not required by a state program, employers have found them to be effective in identifying issues, mitigating the danger and implementing cost-effective changes that promote worker safety and injury reduction.  Important steps for a committee to take include:

 

  • Prepare a plan for a safe workplace and best practices;

 

  • Create a safety program and written forms;

 

  • Prepare and present annual training on safety-related issues;

 

  • Initiate a workplace “self-inspection” program to review all safety practices and identify corrective action; and

 

  • Generally promote a safe workplace through legal, compliance and human resources departments. Be creative.  Consider hosting events such as a companywide “safety week” to make all employees aware of safety issues and foster a workplace environment dedicated to safety.

 

Additional information and guidance can be found in federal regulations, which are located at 29 C.F.R. §1960.36 et seq.

 

 

Partnering with OSHA for Workplace Safety

 

All OSHA agencies have resources available to employers concerned about safety.  While the nature of these services varies, it does offer stakeholders seeking to create a culture of compliance to work with OSHA on preventing workplace injuries.  Resources commonly found include the following:

 

  • Seminars and education sessions: These workshops are typically offered to employers free or at a nominal cost to educate parties on common workplace safety hazards.  They also offer tips on cost-effective improvements.

 

  • Safety Partnerships: This is an opportunity for employers to have a OSHA safety inspector visit their worksite or location to identify risks without being subject to fines.  The employer is then given a reasonable amount of time to correct any identified safety issues.

 

Conclusions

 

The goal of OSHA is to promote a safe workplace.  By understanding how the agency operates, interested stakeholders can foster an environment of compliance and provide safety to its employees.  In turn, this can reduce workers’ compensation program costs.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Pick Up The Phone To Dramatically Reduce Your Workers’ Compensation Costs

Pick Up The Phone To Dramatically Reduce Your Workers’ Compensation CostsOne of the biggest reasons injured workers hire attorneys is because no one has contacted them since the injury. They are in pain, not sure what to do or expect, and no one from the company has bothered to see how they are doing or even say ‘hello.’ They feel ignored and alone.

 

Attorney involvement is a huge cost driver, often more than doubling the cost of a claim. It makes sense to do everything possible to eliminate this reason a worker would contact an attorney — especially when it is as simple as making a phone call.

 

 

Why It’s Important

 

A worker who has been injured is suddenly thrust completely outside his comfort zone. His employer can easily allay his fears and concerns by contacting him. Calling the injured worker as soon as possible after the injury sets the tone for the claim.

 

 

Who Should Call

 

The most effective way to set a positive tone for the claim is by having a trusted colleague connect with the injured worker. In most cases, it is the supervisor. That person typically knows the injured worker well and is also in the best position to provide information about the company’s disability management process.

 

In some cases the supervisor may not be the best person to contact the injured worker; he may be unavailable or may have a frictional relationship with the employee. In those cases, someone else should be designated to communicate with the worker. It could be another manager who has a positive relationship with the employee or even a coworker who clearly understands the workers’ compensation process.

 

 

What to Say

 

A big reason some supervisors don’t contact injured workers is because they are not sure what to say. The conversation can be simple and friendly. With some basic, short training, the first-day phone call can be the most important aspect of handling the claim.

 

It’s important to understand the most immediate concerns of an injured worker are:

 

  • How and when he will get paid
  • How he will receive medical treatment
  • Whether and how he will be able to work

 

The conversation should address those issues, and answer any additional questions the worker has. The tone of the discussion should be friendly and easy, expressing concern and understanding. It is also imperative that the caller convey the message that the company wants the employee back at work.

 

Here are examples of things to say to the injured worker:

 

 

Show caring and concern:

 

  1. How are you? How is it going?
  2. How are you feeling?
  3. How was your first medical appointment?
  4. Did you like the doctor?
  5. Are/were you able to get the prescriptions you need?

 

 

Express support and understanding:

 

  1. We are really sorry you got injured.
  2. Is there anything we can do to help?
  3. Would you like me to contact your family?
  4. Do you need me to pick up any of your clothes, your materials, anything from the office?
  5. We want you back at work.

 

In addition to asking questions, the caller should actively listen to what the injured worker is saying. That means letting him speak without interrupting him, even if he is angry and upset. What is important is that he is heard and that the caller expresses his understanding of the situation — even if the caller does not agree with what the worker is saying.

 

 

Conclusion

 

Workers’ compensation claims close quicker when the injured worker heals faster and gets back to work sooner. Engaging the worker in his recovery will expedite the process. Injured workers who feel their employer cares about their well-being and maintains a connection are more engaged than those who feel alienated.

 

 

 

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.

Mentoring Millennials Is Key, RIMS 2018, and Other Top News Tidbits

Mentoring Millennials Is Key

by Neil Lentine, President of Broadspire USA.

 

As a Baby Boomer, it has been an interesting process learning to interact with millennials who are just getting started in their careers.

 

I’ve had to keep in mind that the millennials have been shaped by social networks, where everyone is perceived to be on equal footing and immediate feedback is constantly sought. Growing up in the dawn of the digital age, their view of the world is, in many ways different than my own, so learning where they’re coming from is important to help guide them in a direction where they can be successful.

 

 

Rapid Advances In Technology Outpacing Risk Management: Marsh/Rims

Emerging technologies continue to rapidly change the way businesses operate and interact with customers, yet risk management processes are not keeping pace with the associated risks, according to a new report published today by Marsh, a global leader in insurance broking and innovative risk management solutions, and RIMS, the risk management society™.

 

The 15th Annual Excellence in Risk Management report delves into risk professionals’ knowledge of and role in managing technology innovation such as artificial intelligence (AI), blockchain, and the Internet of Things (IoT). According to the findings, 59% of respondents said their organizations are currently using or exploring the use of IoT systems; 47% are using or exploring the use of AI; and 24% are using or exploring the use of blockchain. Despite the growth, only 14% said they strongly believe they have a clear process in place for addressing disruptive technology risks. Nearly half could not say there was a clear process at all.

 

 

Force Behind Industry’s First Cost of Risk Survey Berry Griffin, Jr. Inducted into The Risk Management Hall Of Fame

RIMS, the risk management society™, and American International Group, Inc. (AIG) today announced Berry Griffin, Jr. as the 2018 inductee into the Risk Management Hall of Fame (RMHF).  The RMHF serves as a means to maintain the history of the field of risk management and recognizes risk practitioners who have made significant contributions to advancing the discipline. Mr. Griffin was officially inducted at RIMS 2018 Annual Conference & Exhibition in San Antonio.

 

 

RIMS 2018 Awards & Honors

RIMS, the risk management society™, today announced the winners of its series of industry awards presented during RIMS 2018 Annual Conference & Exhibition Awards Luncheon in San Antonio.

 

RIMS’ most prestigious honor, the Harry and Dorothy Goodell Award, was presented to Ward Ching, Managing Director, Western Region at Aon Global Risk Consulting. Named in honor of RIMS’ first president, the award pays tribute to an individual who has furthered the goals of the Society and the risk management discipline through outstanding service and achievement.

 

 

University of Wisconsin-Madison Wins 2018 Spencer-RIMS Risk Management Challenge

At the Spencer Educational Foundation reception, case-study provider Andrew Bent, risk manager at Sage Group plc announced University of Wisconsin-Madison (UWM) student team as the winners of the 2018 Spencer-RIMS Risk Management Challenge. The team, comprised of four risk management students, competed against 26 other universities and delivered the award-winning risk management presentation in front industry leaders at RIMS 2018 Annual Conference & Exhibition in San Antonio.

 

 

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.

 

 

7 Ways Your TPA May Be Underpaying Your Company Workers’ Comp Payments

7 Ways Your TPA May Be Underpaying Your Company Workers Comp PaymentsIf you ask any workers’ compensation adjuster how to calculate the amount of the temporary total disability check for an injured employee who is unable to return to work, you will get a quick answer like “it is two-thirds of their average weekly wage.” {While all states do not use two-thirds of the average weekly wage, for this blog, we will}    In most cases, the adjuster will be correct, but in a small percentage of the disability checks, the employee is underpaid.

 

The component of what constitutes “wages” is an area of workers’ compensation that has almost as many variations as there are states. While the adjuster normally includes vacation pay and holiday pay in the indemnity calculations, many other types of compensation get overlooked.

 

Buried deep in the work comp statutes, or in some cases, court decisions, is a definition of what constitutes wages. For the employee who is paid $15 per hour, and never works anything but a 40 hour week, the adjuster’s calculation of a weekly disability benefit of $400 ($15 x 40 x 2/3) is correct if none of the following exceptions come into play.

 

 

1. A Second Job:

 

In about half of the states, if the employee is working a second job for another employer, the employee is entitled to two-thirds of the income lost from the other job. Let’s say the above employee is making $15 an hour from your company and works from 8:00 a.m to 4:30 p.m for your company. When the employee get’s off work, he goes down the street and starts his part-time janitorial job that is from 5:00 p.m to 9:00 p.m where he earns $12 per hour. Due to his part-time job, the adjuster will need to add another $160 ($12 x 20 x 2/3) to the weekly indemnity check. This hypothetical employee would get an indemnity check of $560 ($400 + $160) per week, assuming that the $560 per week is below the state cap for weekly indemnity checks.   [I know it doesn’t seem right that your work comp coverage is paying for lost income from work at another employer, but that’s the law in many states].

 

 

2. Training Pay:

 

Closely kin to the second job compensation is training pay. If the hypothetical employee above did not have a second job but was attending a night class where he was being paid by your company $75 per week to attend, in some states the lost income is owed if he could no longer attend the class due to his on-the-job injury. The adjuster would need to add $50 ($75 x 2/3) to his week check. If the nightly class had only 4 more weeks to run, then after the fourth week, the adjuster could remove the extra $50 per week from the indemnity check.

 

 

3. Freebies:

 

An area of compensation that a lot of adjusters miss (and for that matter, attorneys representing the injured employee) is the value of freebies. If the employer routinely provides free meals or free housing as part of the compensation (think migrant farm worker in a state where migrant farm workers are covered for workers’ comp), and the employer no longer provides the free meals or free housing after the injury, the value of the freebies has to be added to the calculation of the weekly indemnity check.

 

 

4. Commissions:

 

The calculation of the weekly indemnity check for the salesperson would seem to be easy like the calculation of hourly workers indemnity check – two-thirds of the average income over the period of time used to calculate the weekly check. This works if the salesperson income is steady, but not with the new salesperson whose income is steadily increasing each week or month. In most states that is too bad for the salesperson with no projection of future earnings being allowed. However, a few states will allow “equitable estimation,” and the work comp boards will award it.

 

Another area of disputes with salespersons on how much their indemnity check should occur when the salesperson earns additional commissions or overrides. If the salesperson who sells over and above X number of units per year gets an additional percentage of commission for exceeding the goal but will come up short of the goal due to an on-the-job injury, does the adjuster still owe an indemnity payment on the additional percentage? It varies tremendously from state to state. It will normally take some research on the part of the adjuster to answer that question. The same issues apply when the salesperson receives overrides from recruiting additional salespeople but is unable to recruit due to the on-the-job injury.

 

 

5. Bonuses:

 

Bonuses are another area where the employee often gets shortchanged on the indemnity check. For instance, let’s say the employee works in a state where only the previous 13 weeks of income (some states use 26 weeks of income, other states use 1 year’s income) is used to calculate the average weekly wage. The employee gets hurt on November 1st, and is still off work at the end of the year when the employer passes out the year-end bonuses. If the employer does not have the employee on the payroll, and the employee does not receive the bonus, the work comp adjuster would owe two-thirds of the bonus amount. This is only if the sole reason the employee did not receive the bonus is that the employee was not working due to the injury at the time the bonuses were passed out.

 

 

6. Tips & Gratuities:

 

One area where the employees often receive less money than what they should receive on the indemnity checks is the employees who earn tips and gratuities in addition to their base pay. When the employee is injured, the employer reports the income amount that is on the employer’s record. When the adjuster tells the employee what the amount of their indemnity check will be, they often hear from the employee “that’s not right, that does not include the tips that I did not report”.   When the waiter, bell-hop or taxicab driver tells the adjuster they cheat the government out of tax revenue by under-reporting their income; there is nothing the adjuster can do about it. [What the adjuster is thinking but won’t say – ‘if you are willing to cheat Uncle Sam on your income tax, you are probably willing to cheat the insurance company on your work comp claim’].

 

 

7. Benefits:

 

In some states, the employer is allowed to discontinue contributions to 401k plans, health insurance, and other benefits when the employee is off work for an extended period of time. If the employee has to pick up the tab for the health insurance or other benefits, some states require the work comp adjuster to consider the value of the lost benefits in the calculation of the weekly indemnity check amount.

 

 

Summary:

 

The calculation of the indemnity check depends on what the state statutes require. Both the employer and the workers’ compensation adjuster need to know the lesser known points of what is considered a part of the employee’s compensation in their own state.

 

CHECK YOUR STATE LAW!

 

 

 

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.

 

7 Types of Workers’ Comp Claims That Raise Questionable Red Flags

7 Types of Workers’ Comp Claims That Raise Questionable Red FlagsMost workers compensation claims are legitimate. Unfortunately, there will be times when an employee will try to take advantage of the workers’ comp system. When an employee has a workers comp claim with the following characteristics, it is time to be extra diligent in your approach to the claim.

 

 

  1. The Monday Morning Claim

 

When an employee reports an injury within the first few minutes of being on the job on Monday morning, there is a good chance the accident did not happen within those first few minutes but over the weekend while the employee was doing household chores or participating in a sporting activity or other physical exertion. This is especially true if the employee, who does not normally come in early, gets in and gets hurt before anyone else arrives on the job.

 

 

  1. The Unwitnessed Accident

 

A disproportionate share of back injuries, neck injuries, and other musculoskeletal injuries seem to occur when no other employees are in the immediate area. Often these unwitnessed injuries occur to people who have degenerative disc disease, arthritis, or other musculoskeletal issues bothering them before the unwitnessed accident occurs.

 

If your “injured” employee works typically around other employees, and the employee is in an area where the employee normally does not work, when the unwitnessed accident occurs, an in-depth investigation will be needed.

 

 

  1. The Late Report of Injury

 

When an employee is injured on the job, unless there is some really compelling reason to not report the injury, the accident will be reported the same day it occurred or at the latest the following day. When the employee reports an “accident” that occurred last week, last month, or longer, it most likely did not occur at work.

 

 

  1. I Forgot the Details

 

When the employee tells the employer that the back injury happened to carry a box of parts, and then tells the emergency room doctor the injury occurred picking up a heavy piece of equipment, and then the lawyer claims the back injury happened while the worker was using a jackhammer, which version of the accident do you believe? If the accident version varies from medical report to medical report, most likely none of the accident versions are correct. The employee who forgets the details of the accident is most likely having workers’ comp take care of the aching back or another body part when the worker should be paying and submitting bills to the worker’s own health insurance.

 

 

  1. The Unhappy Employee

 

Workers compensation is often abused by an unhappy employee. Sometimes employees may use a workers’ comp claim to keep from being laid off following a disciplinary action or to maintain a source of income when the union calls a strike, or when the factory is closing, or at the end of seasonal employment. When an employee is disgruntled about some aspect of the job, workers comp is often seen as a paid vacation.

 

 

  1. The Cheat

 

While some of the fraudulent workers’ comp claims are to have workers’ comp pay for a real, but not work-related injury, many fraudulent claims are based solely on greed. For example: The employee is offered a temporary “under-the-table job” paying cash. Claiming workers comp indemnity benefits while working under-the-table is a good way of getting additional income while maintaining a job to go back to when the temporary work ends. Other variations of the cheat is the employee who has been working two jobs, but is ready to give the second job up. A workers’ comp claim drawing indemnity benefits from two jobs greater than what is made on only one job provides the excuse needed to make a phony claim.

 

 

 

  1. The Migrating Injury

 

The migrating injury claim is often missed by an employer or adjuster. The employee starts out with a very real, very well-documented injury such as a falling object breaking a foot bone. The employee gets acquainted with the doctor and after several visits advises the doctor there is wrist pain. The doctor starts treating the wrist for carpal tunnel syndrome. When the doctor starts treating a body part that was not injured on the day of the accident, the additional medical treatment needs to be promptly identified and denied.

 

 

Any time you feel there is something just not right about an employee’s workers comp claim, your instinct is often correct. Any time a questionable claim is reported, do not just accept it. Report it to the claims office as questionable and explain why you think so. Ask for a complete investigation and involvement of the SIU (Special Investigation Unit) in the claim. Defeating the questionable claim will have a positive impact on your workers’ compensation costs.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

5 Tips – How to Use Surveillance to Prove Workers’ Comp Fraud

There are jurisdictions where workers comp is very employee-friendly, and it seems the employee can do no wrong. In the mind of a judge, it is the employee who suffered a great loss while working for your company. They are in daily pain because of injuries suffered on the job site. They are trying to make ends meet on reduced wages.

 

 

For the most part, this is correct. But every adjuster has a few cases where there is that gut feeling that something is not right. But, if the medical adds up to supporting ongoing disability, and a nagging feeling still exists, then it is time to run surveillance. But how does it work to help in a specific case? There is no question the claimant is injured. More than 10 seconds of video of the claimant getting the mail is needed. Here are 5 ways to think about surveillance and its benefits.

 

 

 

  1. Use a Surveillance Firm that Boasts Results

 

There are many surveillance firms available. Some of them specialize in legal backgrounds in law enforcement, some with military backgrounds, and some with insurance backgrounds to name a few. Whatever the case may be, a reputable firm must be chosen.  Video evidence of the claimant doing something outside of the medical restrictions must be obtained. Showing this as repeated behavior is key.

 

 

Obtaining this kind of evidence to help the case is partially due to luck. But this is where a skilled investigator plays a huge role. Through a background search including social media and understanding the person’s habits, one can begin to theorize how and when the subject will be active.   For example, if the claimant has pictures of deer on a Facebook page, it can be reasoned the Fall season is likely an outdoor time for the worker to be active.

 

 

Feedback from peers in the specific industry and carriers is helpful. Some carriers now have their own surveillance unit, and it can be considerably less costly to use a carrier’s firm than to go outside of the network. This is a large expense. But if good video is recorded, it can save so much more in overtime cost and is a wise investment.

 

 

  1. Plan on 3-5 Days Worth of Surveillance

 

As mentioned above, the person must be shown breaking medical rules. If the claimant has restrictions of no lifting over 15 lbs and is caught at the grocery store lifting 2 bags of groceries, that is not exactly case-changing evidence. But, if the worker is lifting groceries one day, then going home and doing yard work for 2 hours, helping a neighbor the next day cut a tree down, then waxing the car a day later followed up by working with a friend to remodel a kitchen, now potential evidence is building to show a pattern. It shows the worker living a normal life with little to no medical problems.

 

 

The scenario of finding evidence is probably not going to happen on every file, but it is amazing to discover what people are doing on their spare time. Some people hole up in houses and only stick arms out to retrieve mail from the bin by the front door.  Those people may have experienced having surveillance used on them! While others are out golfing, playing softball, deer hunting, or boating with a shoulder injury to name a few scenarios. Whatever it may be, the employer needs enough video to justify the person breaking medical restrictions as often as possible. This is especially helpful when an IME supports an ongoing disability. Then after video is successfully recorded, it is sent to the IME doctor for review. And the doctor may change an opinion to show no ongoing medical disability. If there is a suspicion that a claimant is not 100% truthful with a disability, and the right video and doctor’s opinions coincide, then the adjuster’s suspicions are justified.

 

 

 

  1. Be Sure Reports Detail All Activity

 

Just the video alone can be enough to swing an opinion to deny ongoing benefits. In addition to the video, record every activity, action by action. Sometimes the events unfold before the investigator can get the camera rolling. Or the investigator cannot get a shot due to location. Investigators should still document the activities of the subject in great detail. Chances are the agency may be deposed on the case at a later date, so most reputable firms are extremely detailed in every fact and activity on the case. In these cases, it is preferred to have too much information than not enough.

 

 

 

  1. The Video Obtained Has to be Clear

 

Getting video of the claimant is very important, but it can be worthless if the claimant is out of view or the picture is fuzzy. A lot of this comes down to the investigator’s experience and the quality of the equipment the firm uses. Ask for examples of video and reports to gain an idea of how a case is handled.

 

 

 

  1. The Subject Has to be Violating their Restrictions Frequently

 

We mentioned above getting 3-5 days worth of video to show the subject breaking restrictions on multiple occasions.  There are cases of a judge viewing a video of the claimant breaking restrictions on one occasion and then turning to the subject and saying “Why were you lifting 40 lbs when your restrictions state you should only lift 20 lbs?”   The response is usually something like, “Boy I must have been having a good day that day because I could hardly lift anything at all.”

 

 

It may seem unbelievable, but depending on the jurisdiction, some judges believe it.   Show the judge the worker’s behaviors are not just a one-time thing. The person is violating restrictions on a daily basis for 4 straight days. Imagine if surveillance could be done for 30 days in a row, so much evidence of restriction violation would exist. Malingering would be simpler to prove.

 

 

And that is the goal and challenge when recording a person doing the wrong thing more than one time. It shows a pattern and makes the point the person is leading a normal, pain-free life, despite reporting otherwise to the doctor. If blatant disregard is evident through the use of video on multiple occasions, there is a great chance of getting the desired result — terminating the fraudulent claim.

 

 

Summary

 

Surveillance can be a useful tool to help confirm a claimant’s honesty. But to benefit from it fully, certain guidelines must be followed. First, a reputable firm must be used making sure the firm is descriptive and up on the latest technology. Try to obtain as much video as possible and then tie it into the case defense. Although not every person “doing fraud” will be caught, chances are those violating the medical restrictions and working second jobs under the table will be caught.

 

 

 

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.

4 Foundational Elements of Return to Work Success

 

Register for Live Stream WC Mastery Training:

 

When worker’s compensation was created over 100 years ago as the first form of social insurance in America, the number one reason and goal of the program was to return employees to their pre-injury state. Number one reason and number one goal of worker’s compensation was to return employees to their pre-injury state, both medically and from an occupation standpoint, their ability to work.

 

Hello, my name is Michael Stack, CEO of Amaxx. And if that is the truth, which it is, the number one goal of worker’s compensation is to return employees to their pre-injury state, the best way to do that is with a very effective return to work program. Now there’s a lot we could talk about with return to work. There’s a lot of different nuances, but what I want to discuss today is where I see companies falling down the most. And that’s right out of the gates in the policy, in the transitional duty policy, and the strategy and the philosophy as to how an organization even looks at setting up a return to work in the first place. Because if you’re not doing this right out of the gates, then you’re setting yourself up for failure, or at least you’re setting yourself up to not be as successful and have things run as smoothly as they could.

 

 

4 Foundational Elements of Return to Work Success

 

We’re going to cover four critical elements to return to work or transitional duty policy that you need to have implemented at your organization to set things up properly. Let’s talk about what these are.

 

Temporary

First thing is it needs to be temporary. Return to work needs to be temporary, and this should be no more than 90 days. The vast majority of healing should be occurred in most injuries … of course, you need to be flexible on this in order to accommodate for the ADA … but as you’re communicating this, as you’re setting this up, the vast majority of cases, temporary transitional duties should last no more than 90 days. And if you’re not on that path, then you need to bring up some other claim interventions to get things going in the right direction. So number one is temporary.

 

 

Similar to Employee’s Current Position and Flexible

 

Number two is it needs to be similar to their current position. As you’re looking at creating a transitional duty job, the first place to look is that it’s similar to their current job. Look at the functional abilities that you get from their provider, from the medical provider, and match that up to what they do. Make sure that they can continue to be productive as an employee. The first place to look is that modifying and making it similar to their original job. But you also need to be flexible in this same breath. Ask that employee what part of your job can you do today? Get those functional abilities from the medical provider, and maybe you can’t modify their original job, which happens. You also need to have the ability to possibly move them to a different division within your own organization or possibly at a different charity so they can get back to work right away, doing something that’s productive as for the society as a whole, helps their healing, as well. So temporary, similar and flexible.

 

 

Occurs During Regular Business Hours

 

Number three then is that it’s during regular business hours. Transitional duty occurs during regular business hours, and this is a typical workday. Regular business hours, Monday through Friday, 9:00 to 5:00 or 9:00 to 6:00, whatever your hours are at your organizations. So there’s no overtime that happens with a transitional duty job and no second shift, as well. So no overtime, no second shift. If someone’s on a transitional duty job, it’s happening during regular business hours. It lets you be able to monitor that individual employee, lets you be able to communicate with them better, and really puts them in and taps them into the ability to tap into medical providers, etc.

 

 

Condition of Employment

 

And the last thing here, element number four is that it’s a condition of employment. Return to work is a condition of employment. Now you think about this as if this person wasn’t injured, do you require them to come to work every day? What if they just said, “Well, I don’t feel like coming to work. I don’t feel like going in today. I’m not really feeling that great. I don’t feel like coming to work.” That’s unacceptable from an employment standpoint. Being paid as an employee, you have to come to work. The same thing is true in a transitional duty policy, as well.

 

Again, I’m Michael Stack, CEO of Amaxx, and if you can incorporate these four elements into your transitional duty policy, you will be well on your way to success in the most critical element to worker’s compensation management. Remember your work today in worker’s compensation can have a dramatic impact on your company’s bottom line. But it will have a dramatic impact on someone’s life. So be great.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

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