Steps to Take for 5 Common Areas of Employee Workers’ Comp Fraud

When employees file fraudulent workers compensation claims, not only are they stealing from the insurance company, but also stealing from their employer, the shareholders of the employer if a publicly held company, and from their co-workers. The fraudulent workers comp claim is included in the claim history used by the insurance company to set the premium rates for the employer. When the employer pays higher insurance cost due to fraud, there is less money available to invest in the company and to pay the wages and pay raises of the employees of the company.

 

Nearly 25% of workers comp claims involve some element of fraud or malingering, whether it is an outright false claim or inflation of an otherwise legitimate claim. The Coalition Against Insurance Fraud estimates workers compensation fraud cost employers $6 billion a year. The National Insurance Crime Bureau recently reported the number of suspicious or questionable claims has increased as the economy has deteriorated. In fact, workers comp fraud is the second largest category of white-collar fraud only behind income tax evasion. Every employer must be vigilant in protecting themselves from the dishonest employees who will attempt to exploit the workers comp claim system.

 

 

There are five common areas of employee workers comp fraud:

 

  1. The false injury. The employee claims a hurt back or neck or other muscle problems for the sole purpose of collecting indemnity benefits.
  2. The inflated injury. The employee receives a real job related injury but then tries to extend his/her time off work by pretending the injury is worse than it really is so s/he can collect indemnity benefits.
  3. The prior injury. The employee has a real back, shoulder or knee problem from years ago, but now needs additional medical treatment for it.
  4. The at-home injury. The employee gets hurt at home, working for someone else or participating in a sports event, and claims s/he got hurt on the job.
  5. The malinger. The employee got hurt, got well, but got use to staying home and does not want to come back to work.

 

There are several courses of action the employer can take to combat workers comp claim fraud. One of the most effective things an employer can do reduce workers comp claim fraud is to have a well publicized and well used transitional duty or light duty return to work program. While a return to work program will not prevent all fraudulent workers comp claims, it will stop many of them.

The dishonest employee who got hurt at home but does not have medical insurance, or has medical insurance with a high deductible, will still file the fraudulent claim that he got hurt at work. However, the dishonest employee who wants to take an extended paid vacation with workers comp indemnity benefits, or the dishonest employee who wants to work at another job while collecting workers comp benefits, will be stopped from doing so by a strong transitional duty program.

 

 

Steps to Prevent Workers’ Comp Fraud

 

In addition to a strong transitional duty program, there are various other steps the employer can take to fight fraudulent claims including:

 

  1. Do not hire employees of questionable character or background. Prior to any offer of employment, thoroughly check the references of the potential employee and their background information.
  2. If an employee refuses transitional duty work, or tries transitional duty work for an hour or two, or a day or two and then stops, make an immediate inquiry into what part of the transitional duty job can’t be done. Make arrangements to alter the transitional duty job to fit the complaints. If the employee still refuses the transitional duty work, ask the insurer’s claims office to consider surveillance on the employee to be sure the limitations away from work are the same as when at work.
  3. Keep an ear open to the rumor mill. Disgruntled employees are far more likely to file a fraudulent workers comp claim then happy employees. Address any legitimate grips or complaints of the employees.
  4. Train your supervisors and department managers to recognize the characteristics of claims frequently indicating fraud. Provide the supervisors and department managers with a copy of our blog on Employee Workers Compensation Fraud
  5. Make sure all new and current employees are aware of your fraud policy of prosecuting workers comp fraud as a criminal offense. (And back it up! If you have an employee who commits workers comp fraud be sure to fully prosecute. If you want to see the number of your workers comp claims skyrocket, feel sorry for the employee or his family and not prosecute an obviously fraudulent claim).
  6. Make sure all employees understand that fraudulent claims come out of the employer’s pocket and reduce the pay raises or bonuses for everyone.
  7. When you suspect a workers comp claim may be fraudulent or when you have rumors or evidence that a claim has an element of fraud, contact the workers comp insurer’s Special Investigative Unit. They have the expertise and the connections with law enforcement to properly investigate and build the necessary proof to prosecute the fraud.
  8. Make it a requirement that the claims handling office of the insurer or third party administrator files an Insurance Services Office index report on every new workers comp claim and does a claims inquiry every six months as long as a claim remains open.
  9. Do not make it easy for the employee to file a bogus claim by having a loose safety program. By removing safety hazards from the work place, the employee has fewer options in creating a false injury scenario.
  10. Remember many fraudulent claims start out with a real injury. When the employee sees the television commercial with somebody holding fists full of money their attorney got them for their workers comp injury, the employee may be tempted to exaggerate his/her own claim. Anytime an employee hires a television attorney, you cannot discuss the claim with the employee, but you can advise the employee of the company’s policy to fight all claims vigorously when an attorney is hired.
  11. Make it a practice to reward fraud tips. Have a publicized program of paying a reward to anyone who reports a workers comp fraud resulting in conviction.

 

Fighting fraudulent workers comp claims is not easy, but it is absolutely necessary to protect your company’s bottom line. Make fraud prevention a component of your integrated workers compensation program.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

63 Items To Look For In Your TPA or Carrier Claim Report

Your company is self-insured and hired a Third Party Administrator (TPA) to handle your workers’ compensation claims.  As part of the servicing agreement with your TPA, the TPA agreed to complete a written report within 14 days of assignment on new workers’ compensation claim s with reserves over $10,000.   Here are some guidelines as to what the reports should contain.

 

All reports should be laid out in a consistent format for ease of reading. The reports should provide you with all essential information without you having to go on-line to read the entire claim file. The better adjusters will always use the same format, but if the adjuster does not, feel free to provide the following reporting sample outline for captions and sub-captions to the adjuster.   This is the minimum you should expect to see in the initial claims’ reports.

 

 

Coverage

 

Some adjusters will want to skip the coverage caption figuring your company would not have reported the claim if it was not covered. That can be a big mistake if your deductible, self-insured retention or other terms of coverage change at renewal or any other time).

 

  1. Policy number (if one is assigned) and policy dates
  2. Applicable deductible, self insured retention , endorsements
  3. Alternative or duel coverage

 

 

Description of Accident

 

  1. Date and time of day
  2. Place (Where the accident occurred on the premises, or other location if off the premises)
  3. What was the employee doing when the injury occurred
  4. Regular job for the employee or outside the norm for the employee
  5. Date the accident was reported to supervisor or manager
  6. Date the accident was reported to the claims coordinator for your company

 

 

Insured

 

  1. Name of Unit/Division/Branch
  2. Location (Street address, City & State), also the location code number (if one is assigned)
  3. The nature of the business/work performed at this location

 

 

Employee

 

  1. Full name
  2. Age/Date of Birth
  3. Number and relationship of dependents ( in states where dependents affect indemnity benefits)
  4. Detailed job description/occupation
  5. Length of employment, length of time in current job description
  6. Prior injuries, both work com and liability claims reported to the index bureau
  7. Summary of recorded statement or interview
  8. Social security (edited for confidentiality if required by state law)
  9. Education level of employee
  10. (If represented) Attorney for employee—name, address, expertise

 

 

Jurisdiction

 

  1. Statutory state benefits
  2. Federal (Longshore & Harborworkers Act, Federal Employment Liability Act, Jones Act)
  3. Potential Employers Liability exposure

 

 

Compensability

 

  1. Why the claim is compensable
  2. Why the claim is being controverted

 

 

Reserves

 

  1. Amounts for indemnity, medical, legal, rehabilitation and other expenses should be individually stated
  2. Adequacy for life of claim should be discussed

 

 

Indemnity Benefits

 

  1. Average weekly wage amount and how documented
  2. Compensation rate and how calculated
  3. Specific benefits due to permanent impairment, scarring (where allowed), etc.

 

 

Injury

 

  1. Nature of injury
  2. Attending physician(s) and specialists identified
  3. Hospitalization, discharged date or anticipated discharge date
  4. Type of future medical care and projected length of care
  5. Estimated length of temporary total disability
  6. Estimated Return To Work date, modified duty and/or regular duty
  7. Independent Medical Evaluation (if the jurisdiction allows more than one, if not the IME should be saved until the employee is at maximum medical improvement)
  8. Permanent impairment rating (expected or assigned)

 

 

Rehabilitation

 

  1. Vocational
  2. Physical
  3. Length of rehabilitation
  4. Facility or provider
  5. Reasons/justification for rehabilitation

 

 

Second Injury Fund (in states where it still exists)

 

  1. Nature of employee’s prior injury, disability or medical condition
  2. Statutory requirements to access the Second Injury Fund
  3. Self insurers’ rights of recovery

 

 

Subrogation

 

  1. Identification of responsible third party
  2. Negligence theory
  3. Expert testimony (if needed)
  4. Preservation of evidence
  5. Issues affecting pursuit of subrogation such as hold harmless agreements, contracts, business relationships, possibility of a cross-claim against your company
  6. Recovery amount
  7. Employee’s right of recovery

 

 

Litigation/Legal Expense

 

If the claim is being contested before a workers’ compensation board or in a court, the following information is needed:

  1. Defense attorney’s name, firm’s name, address
  2. Issue(s) in contention
  3. Probable outcome
  4. Legal budget

 

 

Action Plan

 

  1. Steps to be taken to move the file forward
  2. Barriers to resolving the claims

 

 

Diary for Future Reports

 

  1. Date an updated status report will be provided

 

 

Attachments

 

  1. List of attachments or documentation being provided, if any

 

 

Summary

 

The adjuster’s report should provide you with all the information needed to keep you totally informed about the claim in question.   If after reading the adjuster’s report you still have questions, add a caption or category to reporting format to answer your question on all future work comp claims.

 

The adjuster should provide status reports on a regular basis of 30 days to 90 days depending upon the developments on the claim. Status reports should not repeat the information provided in the initial reports, but only cover the categories where there has been a change or a new development that impacts the claim.

 

Proper reporting by the work comp adjuster will make your life easier in the management of your self-insured program.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Reduce Work Comp Costs Through Advocacy Based Claims Management

Claims management teams are constantly seeking innovative solutions to running an effective workers’ compensation program.  This includes providing quality services to employees who sustain work injuries and being a zealous advocate for their clients.  Part of the solution that has benefited programs in an “advocacy based” model of claims management.  Studies have proven this as an opportunity to meet program objective and reduce costs in the form of quicker return to work.

 

 

What is “Advocacy Based” Claims Management?

 

Under this model of claims management, the members of the claims team seek to empower employees to improve injury outcomes and get them back to work in a timely manner.  This process requires interested stakeholders to be active in assisting injured workers at all steps of the claim. It also requires them to “go the extra mile” and empathize with the situations someone experiences following a work injury.   Part of the process can include keeping the employee informed with details so they can in turn make decisions in their recovery.

 

 

It Starts with Words

 

Words mean things—especially when you are recovering from a work injury.  This is a crucial step in understanding the tribulations someone suffering from a work injury is going through.  It also helps with perception being reality in a positive manner.

 

Changing the vocabulary used during the claims management process is important.  This helps refocus conversations and processes.  Examples include:

 

  • Claimant/employee: By not using these words and instead referring to someone as “a person injured at work,” it helps humanize the person and what they are going though; and

 

  • Claims examiner: Use of these words is often outdated and reminds someone of a faceless bureaucrat sitting behind a desk.  By referring to someone as a “claims representative,” it again humanizes the process.

 

 

Finding Common Ground

 

While members of the claims management team have a fiduciary duty to their insureds, they can also find common ground with people suffering from a work injury.

 

  • Prescription Drug Abuse: There has been a lot said and written about prescription drug abuse in the workers’ compensation system.  The common denominator among many persons who end up dying from using these medications is a personal injury.  Even people with the best of intentions can become victims of abuse by not having a strong advocate.  This can include members of the claims management team who help control the number of drugs consumed and by educating the people they work with about the dangers of these substances.  Other activities such as monitoring a person’s intake and working with their doctors to minimize the chances of abuse are key.

 

  • Injury response: A fast an effective injury response is another method claims management teams can employ to be an advocate on the workers’ compensation process.  This starts with providing employers with the necessary tools to respond after an incident.  Regular, frequent and personalized contact with a person recovering from a work injury are also key.  While it might take extra time, being active in the care a person receives buys good will and breaks down barriers in an otherwise adversarial process.

 

  • Establish expectations for all: All the main actors in a workers’ compensation claim need to take ownership over the care and recovery of an individual.  For the employee, this includes concentrating on following their doctor’s instructions on rehabilitation.  Employer representatives also need to be engaged and coordinate care with the claims management team.

 

 

Conclusions

 

Effective members of the claims management team need to be an advocate for the person involved in their claims.  This starts with empathy toward the person suffering from the effects of a work injury.  It also includes avoiding excessive use of prescription drugs and responding to an incident in a proactive manner.  Taking these steps can reduce claims and still allow for the claims representative to look out for the best interests of a workers’ compensation program.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Inside Tips & Tricks for Effective Social Media Investigation

Fraud, waste and abuse (FWA) continue to be a significant driver in workers’ compensation program costs.  The result for many programs are higher costs per claim, which are passed along to the insured.  This trickle-down effect ultimately hurts the employees, which are the people served by workers’ compensation insurance programs.  Now is the time for interested stakeholders to employ innovative and creative investigative techniques used advanced techniques in claims investigation based on easy to use technology.

 

 

Social Media: Going Beyond the Basics

 

Social media investigation continues to be an area of initial research in every workers’ compensation claims investigation.  This is based on the continued growth in it is use over the last decade.  It is also an important area to investigate given its use with all generations.  The use of Facebook is a common example:

 

  • There are currently over 1.5 billion users of Facebook worldwide. The United States contains some of the most active users on this social media platform;

 

  • Over 72% of people who use the Internet are connected on Facebook; and

 

  • Nearly 10% of Facebook users do not change the privacy settings on their account. This means there is still a significant portion of users who allow all posts and updates to be visible to the general public.

 

Pictures posted to Facebook and other social media often contain hidden metadata.  This is information stored in the background due to the user failing to adjust the settings on their smartphone or other cameras.  The result is a treasure trove of information for the taking.  This includes:

 

  • Date and time stamp information as to when the photograph was taken; and

 

  • Specific longitude/latitude information as to where the photograph was taken.

 

Using this data, someone creates a “geofence,” which tells the world when and where a specific event took place.  It also limits the ability of someone to testify otherwise.

 

 

Vehicle Tracking and Sightings

 

State and local governments have employed millions of public security cameras across the country to capture real time images of what is taking place in their communities.  Part of this technology includes the use of license plate tracking information, which records when and where a particular vehicle passes a certain location.

 

While accessing and searching this information may be time consuming, it can establish a number of items that can be useful in a claims investigation.

 

  • The location where a claimant’s vehicle has visited;

 

  • Establish a pattern of locations visited by an employee;

 

  • Verify the testimony of an employee concerning the route taken to a certain location, which is important in “traveling employee” cases; and

 

  • Accessibility of information nationwide—it is used in every major city in the United States.

 

 

Keyword Search Technology

 

Most social media platforms are driven by “keyword” search technology.  This allows all users to use various terms and locate posts and other information from all users on the platform.

 

In the context of a workers’ compensation claims investigation, any user can ethically search to find information on where someone has been.  This includes postings by organizations or events listed in the platform that tag or record the names of attendees.  Although a user has set their privacy to limit the information from strangers, the fact someone else has a posting that includes a specific person’s name allows the public to obtain information.

 

 

Conclusions

 

Members of the claims management team have lots of readily accessible information at their hands based on today’s technology.  Proactive members will learn how to harness this information to advance and coordinate surveillance on workers’ compensation claims in a cost-effective manner.  The ultimate result is lower program costs and quicker claims resolution on troublesome files.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Where to Start For Best In Class Workers’ Comp Claims Management

All workers’ compensation claims management teams should have an attitude that seeks best in class when it comes to claims management practices.  This includes a focus on injury prevention, investigation and seeking to settle cases in a timely manner.  By taking proactive steps in these areas, any claims team will be set up for success and improve processes for employers and employees suffering from work-related injuries.  It will also reduce costs in the long run.

 

 

Start with Injury Prevention and Investigation

 

Injury prevention and investigation requires members of the claims management team to be proactive.  This includes creating partnerships with their clients on all workplace safety matters.  They also must be involved on the investigation of an injury and to ensure the correct reports are made in a timely manner.

 

  • Safety Recommendations: Members of the claims management team must be able to identify safety hazards and make recommendations regarding workplace safety.  This includes a review of safety equipment being used in the workplace.  Examples of this can include a review of workplace ergonomics and the rotation of job duties in repetitive lines of work or those that require heavy lifting.  It can also include the use of forensic experts who can dissect the anatomy of an injury and suggest improvements.  Injury avoidance measures also promotes employee satisfaction and positive morale within any company.

 

  • Primary Liability Determination: Time is of the essence when it comes to the investigation of any injury.  Claim handlers must be proactive on this issue to encourage their clients to obtain an injury report immediately and assist in the identification and follow-up with witnesses.  It is also important to understand and correctly apply the law.  Failure to make accurate primary liability determinations is an unnecessary cost and increases work for all interested stakeholders.

 

  • OSHA and Other Safety Compliance: Compliance with government and industry safety standards is an important component of any workers’ compensation program.  Claim handlers can help educate their clients on the basics of OSHA reporting.  This also includes information on state safety organizations tasked with injury investigations.  Failure to report any work injury in a timely manner can result in fines and other adverse consequences.

 

 

Promotion of Settlement Practices

 

The only good file is a closed file!  This is the mantra used throughout the claims management industry.

 

If a case is investigated and handled properly, it can be positioned for timely resolution.  Failing to do so can result in extra costs to any workers’ compensation program.  There are other additional considerations to be mindful of to save a program money and earn the respect of employer stakeholders.

 

  • Subrogation: This is the practice of seeking reimbursement from another party who shares in the legal responsibility for a work injury.  In order for any subrogation action to be successful, it is important to preserve physical evidence.  Common instances where subrogation recovery comes into play includes products liability actions, motor vehicle accidents and premise liability claims (slips/falls).  Examples of this can include a power tool or piece of machinery in a work injury.  Photographs of surface conditions or accident scenes are other forms of evidence that required for successful third-party recovery.

 

  • Independent Medical Examinations: In many jurisdictions, the defense interests have one opportunity to have an injured employee be seen for purposes of an IME.  Failure to prepare for this by recovering the necessary medical documents and obtaining other background information on the claim can result in a waste of time and money.

 

  • Medicare Secondary Payer Compliance: This is an area that continues to dominate workers’ compensation claims management given the increasing number of Americans on Medicare and/or Social Security Disability.  Part of any effective workers’ compensation program includes working with legal experts or other service providers who understand these complex issues.

 

  • Structured Settlement: Structured settlements are a stream of tax-free (IRC 104(a)(2) of (a)(3)) secure periodic payments providing income to an injured worker to settle a workers’ compensation claim. In addition to providing income for an injured worker, a structured settlement can provide income and up-front cash for attorney fees, medical expenses, and related liens. A structured settlement is a valuable piece of a comprehensive claim settlement strategy and creates a ‘win’ for all parties to a workers’ compensation settlement; the employer, the payer, the injured worker, and the attorneys

 

 

Conclusions

 

Claims management teams need to focus on high standards when it comes to assisting employers and other interested stakeholders in workers’ compensation claims.  Best-in-class should be the goal when developing a workers’ comp management program.  This starts with proactive injury prevention and investigation, as well as a firm understanding of settlement tools.

 

Learn more: The Step by Step Process to Master Workers’ Comp in 90 Days

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

How to Grade Your Workers’ Comp Adjuster

In school an “A” grade is the standard that everyone wants to meet. Whether you are in elementary school or working on your master’s degree, your performance results in a grade being given to the work you complete. To earn an A grade requires having at least 95 percent of the school work done correctly. Following the same basic grading principles – A, B, C, D, F – you can measure the performance of your workers compensation adjuster.

 

The following is a grading outline you can use to measure the performance of your workers’ comp adjuster on each claim. There are ten categories with 10 points each, or 100 points total. When you review your adjuster’s file on-line, grade each category against the measurements listed here. [If your Best Practices give the adjuster different time lines then what is given here, use your own Best Practice guidelines in grading your adjuster]. Give the adjuster the number of points (zero to ten) earned in each category.

 

 

Category 1 – Employee Contact:

 

The adjuster should contact the injured employee within 24 hours of the receipt of the claim (same day contact would be more points than next day contact). True contact entails an exchange of information between the adjuster and the employee, not just leaving a message on voice mail. If the adjuster was unable to reach the employee within 24 hours by telephone (or in person on severe claims), a contact letter should be sent to the employee along with a medical authorization or any state required forms. On any claim involving questionable compensability or subrogation, a recorded statement should be obtained from the employee. You’re looking for a “quality contact.”

 

 

Category 2 – Employer Contact:

 

The adjuster should easily score all ten points in this category by contacting the employer by phone (in person with extreme employee injuries) within 24 hours of receipt of the claim (same day contact would be better). On any claim involving questionable compensability or subrogation, a recorded statement should be obtained from the employee’s supervisor. Also, any witnesses to the accident should be contacted if the injuries are severe.

 

 

Category 3 – Medical Provider Contact:

 

The office of the medical provider should be contacted within 24 hours of the report of the accident to confirm the nature and extent of the accident, and the ability of the employee to return to work on modified duty/light duty. In the jurisdictions that do not require a medical authorization to obtain the medical records on the employee’s injury, the medical records should be requested during this initial contact.

 

 

Category 4 – Investigation:

 

If the adjuster has done a quality job in the three contact categories, earning points for completion of the investigation should be rather easy. The investigation should address all issues that impact coverage, the nature and extent of the injuries, the benefits owed, subrogation and subsequent injury fund (where applicable). An ISO Index Bureau search should be filed. If the investigation has been completed properly, the adjuster should be able to make a decision on the compensability of the claim. All of this should be accomplished within the first 14 days the claim file is open.

 

 

Category 5 – Average Weekly Wage and Benefits:

 

To earn points in this category, the adjuster should obtain from the employer the wage records or wage documentation on the proper state approved form. It is not acceptable for the adjuster to take the hourly rate off the Employer’s First Report of Injury form and estimate the average weekly wage. The weekly wage and the calculation of the indemnity benefit should be clearly documented in the adjuster’s file. In addition to calculation of the indemnity benefits with proper documentation of the wages, if owed, they are issued timely. Also, all medical bills are reviewed and paid timely.

 

 

Category 6 – Reserves:

 

The initial file reserve should be set by the adjuster within 72 hours of the file receipt, but after completion of the three contacts – employer, employee and medical provider. After the adjuster has obtained the initial medical records, within 60 days of file receipt, the reserves should be reviewed for accuracy. Throughout the course of the file the receipt of any information, medical or otherwise, that would impact the files, the reserves should be updated. On severe claims that remain open for an extended period of time, the adjuster should review the reserves every 6 months to verify their accuracy.

 

 

Category 7 – On-Going Contact:

 

A mistake that many adjusters make is not staying in contact with the employee, the employer and the medical provider. Consistent and on-going contact with the employee will maintain rapport with employee and eliminate many of the reasons that could delay the progress of the claim. The adjuster should maintain the file on diary to ensure all on-going contacts and necessary follow-up is completed. If the adjuster stays in contact with the employee at least monthly until the claim is resolved, and stays in contact with the employer and medical provider as needed, award all 10 points in this category.

 

 

Category 8 – Medical Management:

 

When the adjuster makes the initial medical provider contact, medical management begins. In the initial contact the adjuster should learn the diagnosis, prognosis, the treatment plan and the return to work status. The adjuster should coordinate with the employer and the medical provider to allow the employee to return to work on modified duty as soon as possible. If the injury is severe enough, the adjuster should provide the medical provider with the information on utilization review and pre-certification, plus a nurse case manager should be assigned to the claim timely. If a medical bill review service is used to audit medical bills, the adjuster should ensure all medical bills are sent to the appropriate audit vendor for review and processing.

 

Important note: To grade this portion of the score, have an MD review the file to make sure the injury is, in fact, work-related. Also analyze whether all medical reports are in the file, that complex medical language is recognized, and that medical care is appropriate, e.g. that nurse case management made a difference in the file and did not simply replace duties an adjuster should be doing. My view is that the best qualified person to review a medical file is a DOCTOR. Use TPAs that have appropriate MD resources for services such as peer-to-peer. If the nature of a claim is unrecognized or inappropriate, it won’t matter how many administrative details are done well, because the claim shouldn’t have been paid in the first place. Keep this in mind.

 

 

Category 9 – Litigation Management:

 

Any time a workers’ compensation board hearing or a court hearing is requested by the attorney for the employee, a prompt referral to pre-approved defense counsel should be done. The initial referral to defense counsel should outline the status of the claim, request a litigation budget and provide instructions to defense counsel on how the adjuster wants defense counsel to proceed. (If the adjuster does not instruct counsel on what the adjuster wants done, deduct at least 5 points in this category). The adjuster should continue to provide on-going instructions to counsel throughout the course of the claim.

 

 

Category 10 – File Documentation:

 

Every activity completed by the adjuster should have a clear, concise file note stating what was done and how it impacts the claim. All medical reports, reports from defense counsel and any other file development should be outlined in the file notes.

 

 

Bonus Points:

 

Occasionally, their will be other important activity in the file that is not included in the 10 categories noted above. For instance, the adjuster’s pursuit of subrogation to recover the cost of the claim deserves 5 or 10 bonus points based on your evaluation of how much extra effort the adjuster put forth to recover the subrogation.

 

Another area for consideration for bonus points would subsequent injury funds or other offsets. Any effort made by the adjuster to mitigate the cost of the claim should be recognizes by the award of bonus points.

 

 

Overall Grade:

 

Tally the number of points (from zero to ten) you gave the adjuster in each category. Compile the scores from all the claim files you review. Using the A, B, C, D and F grading system you had in school, does your adjuster deserve an “A”? If not, what category/area(s) did the adjuster consistently fail to earn all ten points? Identify the weak areas and ask your adjuster to strive to comply with your Best Practices in those areas. Some TPA’s grade their own adjusters; this can be valuable information for you to learn.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Poor Workers’ Comp Claims Handling Costs You Money

Each year you receive your bill for the next workers compensation policy year, and for many of companies, each year the bill is higher than the previous year. As you think about your work comp claims, you realize the claims for the current year were not any worse than they were for last year, or the year before. So why does your workers’ compensation premium bill keep going up and up?

 

When the underwriter at the insurer looks at calculating your premium, they use what is known as an experience modification factor. This factor is a calculation used to raise or lower your premium based on the loss experience your company has had. If the loss experience has improved, the premium charged to your company goes down. If you have had more claims than before or the claim cost has gone up, your premiums go up.

 

The loss experience is based on two factors, frequency and severity. The insurance company does not control frequency of claims, your company controls frequency through how well you manage the safety program. As you think back to the previous years, you think “wait a minute, our safety program is working, the number of claims has declined, so why has my premium gone up?” The answer is the other part of the experience modification factor – the severity of the claims.

 

 

Claim Cost Not Discounted Due to Poor Handling

 

There is one thing your insurance broker and your workers compensation insurer will never tell you about the cost of your workers compensation premium. If they do a poor job handling the claims, and spend more money than necessary due to a failure to properly investigate or to return the employees to work, you get to pay for their incompetence. The underwriting department does not discount the severity factor because the claims office did a poor job.

 

If your next thought is: “I’m no expert on how to handle work comp claims, so how would I know if the claims office is doing a good job?  There are ways you as the employer can gauge the effectiveness of the claims office.

 

 

Report Claim Immediately

 

The first thing the employer can do to reduce the severity of the claims is to report them to the claims office immediately. There have been numerous studies that show the longer the delay between the time of the accident and the adjuster contacting the employee, the higher the overall cost of the claim. By reporting the claim to the claims office immediately, you have reduced the amount of time between the accident and the adjuster contacting the employee.

 

Normally when the adjuster contacts the employee, the adjuster also contacts the employee’s supervisor or manager to verify the facts of the accident. If you have a claims coordinator, have the claims coordinator keep track as to when your company hears back from the work comp adjuster. If you do not have a claims coordinator, have the person who reported the claim to the claims office keep track of when you initially hear back from the adjuster. Same day contact from the claims adjuster is best, next day contact is acceptable.

 

 

Sign Adjuster Not Investigating Claims 

 

If your thought is: “We never hear from the adjuster after we report the accident,” that is a major sign that the adjuster is not investigating the claims. If the adjuster is not properly investigating the claims, you as the employer pay for it in your experience modification factor when claims that should be denied are paid, or claims that are fraudulent are paid.

 

There is a sure-fire way the employer can know if the adjuster was in contact with the employee the day the claim was reported to the claims office (or at least the next day). Pick up the telephone and call the employee. Ask the employee how the initial doctors office visit went and what the doctor thinks the employee’s prognosis will be. Then an “oh, by the way, have you heard from the insurance adjuster yet?” will quickly tell you if the adjuster has made timely contact with the employee. Do this on ten claims in a row and you will soon know if the adjuster is giving your claims the proper initial claims handling. [Bonus – by contacting the employee you show the employee that the employer does care about their well being, which builds rapport with the employee, and diminishes the chances of the employee hiring an attorney].

 

 

Lowest Price Often Precludes Service

 

Another definite tip-off that the adjuster is or is not handling the claims properly is when the adjuster calls your office trying to arrange modified duty so the employee can return to work.  If in the initial contact from the adjuster you are asked what light duty assignment you can provide the employee, you have an adjuster who is thinking about how to get the employee back to work, which lowers the amount of indemnity payments and the overall cost (severity) of the claim. A good adjuster will continue to explore light duty return to work until the employee is back at work. A poor adjuster will never ask about light duty return to work and will just pay the employee indemnity benefits until the doctor states the employee is fully recovered. When you bargain for lower-priced TPA or insurance claims adjusting services, consider that you want the adjusters to have the resources to DO this work, and offering the lowest possible price may preclude that  – no matter what they say at the official presentation.

 

An easy way to get your work comp adjuster(s) on the ball in their claim handling is to ask for a copy of their service standards (Best Practices) for workers compensation. Advise the adjuster(s) that you will be reviewing your files to see if they are complying with the Best Practices. If by chance you are told they do not have a set of service standards, it is time for you to talk to your broker about finding another insurance company who is concerned about doing a quality claims handling job.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

11 Red Flags of Workers’ Compensation Fraud

As an employer, you must be vigilant in your efforts to protect your company from the few employees who do commit workers compensation fraud.   Adjusters often refer to possible fraud in a workers comp claim as looking for “red flags.” A “red flag” is anything standing out from the ordinary.

Any one of the items on the following list of “red flag” do not prove a workers comp claim is fraudulent. However, if you have several “red flag” on a single claim, it’s a good idea to consult with both the adjuster and the SIU unit about the claim.

 

 

11 Red Flags of Workers’ Compensation Fraud

 

  1. Late Reporting
    1. If an employee is really injured on the job, it is unlikely the employee will wait days or weeks to report the injury.
  2. Accident Details
    1. The accident details are sketchy, vague or fuzzy.
    2. The employee has difficulty in recalling what happened.
    3. The employee changes the description of the accident when inconsistencies are pointed out.
    4. The nature of the injury is not consistent with the nature of the work done by the employee.
    5. The date, time and location of the accident is unknown or forgotten.
    6. The accident details are inconsistent with the employee job duties.
  3. More Than One Version of the Accident
    1. The employee gives completely different versions of the accident to the employer and the adjuster and to the doctor.
    2. The employee keeps modifying the story of what happened.
    3. The employee leaves out pertinent information.
    4. The accidents details vary from medical report to medical report.
  4. Witnesses
    1. There are no witnesses to the accident and the employee normally works around other people.
    2. There are witnesses but their version of the accident differs from the employee’s version of the accident.
    3. The accident occurs at a location away from where the employee would normally be working.
    4. The nature of the injury is unusual for the employee’s line of work.
    5. The employee’s co-workers express doubt that the accident occurred.
  5. Unhappy Employee
    1. The employee is disgruntled about some aspect of his/her job requirements.
    2. The employee was demoted or passed over for a promotion.
    3. The employee is on the list to be laid-off.
    4. The employee is on “positive improvement needed” status and is about to be terminated.
    5. The employee has had numerous prior employers.
    6. The “accident” occurs immediately prior to a strike, plant closing or the end of seasonal employment.
    7. The employee is a new hire.
  6. Monday Morning Claims
    1. The employee has an early Monday morning accident before the supervisor or other employees see him on the job (accident occurred off the job over the weekend).
  7. Injured Worker is Never at Home
    1. The injured employee is not at home during the normal workday.
    2. The employee is always sleeping when the adjuster calls or cannot be disturbed.
    3. The employee’s family member is vague or noncommittal about when you can reach the employee.
    4. The employee is “away” but quickly returns all calls from a cell phone, not the home phone.
    5. The employee uses the address of friends or family members and has no definite address or uses a Post Office box as an address.
    6. The spouse or other family members do not know about the workers comp injury.
  8. Financial Reasons
    1. The employee’s spouse is not working and drawing workers comp indemnity benefits, social security disability payments, welfare or unemployment insurance and the  employee wants the same life style.
    2. The employee inquires about a settlement early in the claim process.
    3. The employee was having prior financial problems.
    4. The employee is nearing retirement age.
    5. The employee files for benefits in a state other than where the accident occurred.
    6. In the states where an employee can collect workers comp indemnity benefits based on the amount of combined wages from both the workers comp employer and a second job employee.
    7. The failure to report other work income while drawing indemnity benefits.
    8. The employee took excessive time off just prior to the injury.
    9. The employee is in the middle of a divorce or other family disturbance.
    10. The social security number used by the employee belongs to someone else.
    11. The employee applies for Social Security benefits before the injury occurs.
    12. Income from workers comp, disability or other sources exceeds the employees prior after tax income.
  9. Medical Care
    1. All the injuries are subjective — pain without trauma, soft-tissue, emotional.
    2. The employee changes doctors frequently “doctor shopping” or changes doctors when released to return to work.
    3. The employee has excessive treatment for soft-tissue injuries.
    4. The medical treatment reported by the employee is different from the medical care stated in the medical reports.
    5. The nature of the medical treatment changes from one body part to another after the employee has been treating for a while.
    6. The employee misses medical appointments.
    7. The employee fails to show up for an independent medical examination.
    8. The employee refuses or delays diagnostic testing.
    9. Whiteouts, corrections, erasures on medical forms submitted by the employee.
    10. Exaggerated pain symptoms.
    11. The employee has a history of multiple workers comp claims and/or reporting subjective claims of injury.
    12. The injury relates to a preexisting medical condition or health problem.
    13. The medical reports provided by the employee appear to be second or third times photocopied.
    14. The length of recovery is excessive for the nature of the injury.
  10. Inconsistent Physical Ability
    1. The employee who has been off work for a while has calluses on hands or grime under the fingernails
    2. The medical reports reflect “muscular” “tanned” or other adjectives to reflect the employee is in good health.
    3. The employee is unable to work due to the injury but is seen painting his/her house, mowing the lawn, carrying heavy objects, etc.
    4. The employee has a high-risk hobby or does other physical exertion activities.
    5. Surveillance reflects physical activity greater than what is reflected in the medical reports.
    6. You learn the employee is working elsewhere while drawing indemnity benefits, especially where the work requirements exceed the capabilities reflected in the employee’s medical reports.
  11. Miscellaneous Red Flags
    1. The employee is unusually pushy to settle the workers comp claim
    2. The employee has extensive medical knowledge but no training in the medical field, or has extensive insurance terminology but no work experience in the insurance field.
    3. The employee was referred by a friend who name he does not know to a particular doctor or attorney.
    4. The employee is a part of a group of employees using the same doctor and the same attorney for their workers comp injuries.
    5. The attorney’s letter of representation is the same day of the injury or even dated before the “injury.”


Summary:

Remember, even if the employee’s claim has every one of these “red flag,” it still does not prove fraud. However, if the work claim has more than one of these “red flag,” you definitely want to bring in a fraud investigator to delve deeper into the claim. The more fraudulent claims you identify and deny, the lower your overall cost will be for workers compensation insurance.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

 

Workers’ Comp File Review Checklist for Initial and Subsequent Adjuster Action Plans

When you go on-line to review the adjuster’s file notes on your company’s lost time work comp claims, do you know what you should see in the adjuster’s Action Plan? If you have not been a work comp claims adjuster, it would be easy for you to miss items overlooked or missed by the adjuster. The adjuster’s file notes should state what was accomplished and what needs to be accomplished to move the file forward.

 

 

Each of the items that need to be accomplished should be given a due date and placed on the adjuster’s diary (calendar) for completion. You should see at minimum the date due and the date completed for each of the items in the adjuster’s Action Plan.

 

 

 

Initial Claim Handling Completed Day Claim Received

 

 

If your adjuster is following the Best Practices set by most insurers and third party administrators, the initial claim handling was completed the day the claim was received in the claims office. You should see file notes reflecting coverage was verified for the claim, that the employer contact, employee contact and physician contact was completed and the initial reserves were placed on the file.

 

 

All of these items should have been completed before the adjuster does the initial Action Plan. If for any reason coverage has not been verified, contacts not completed or the reserving cannot be done, the adjuster’s Action Plan should reflect the item(s) that are outstanding from the initial handling and provide the due date for the follow up on those items to be completed.

 

 

Initial Action Plan Checklist

 

Assuming the first day’s claim handling was completed, the initial Action Plan for the work comp claim should contain:

  1.  A follow up date for further contact with the employee (ability to return to work).
  2.  A follow up date for further contact with the employer (availability of a modified duty position if the employee is unable to return to full duty).
  3.  A follow up date to verify the receipt of the initial medical report.
  4.  A follow up date to verify the receipt of the documentation of the average weekly wage (should be within 14 days or less depending on the jurisdiction—in order for the adjuster to issue the first TTD payment or issue a denial of claim).
  5.  A follow up date to complete any further investigation of the claim (should be within 14 days of the date the claim was received).
  6.  If subrogation is appropriate based on the investigation, a date to put the responsible party on notice of the subrogation claim.
  7.  A date to verify the claim is accepted for compensability or the date the claim will be denied.
  8.  A date for the TTD benefit payments to be calculated and the first TTD check issued, if applicable.
  9.  A date for the completion of the ISO filing (within 14 days of the receipt of the claim).
  10.  A follow up date to verify all state required forms have been filed with the state work comp board.
  11.  If the file is reportable to an insurer, excess carrier or any other party, the date the reporting will be completed.
  12. A date for the next Action Plan to be completed (usually 30 days after the first Action Plan but the time frame can be shorter or longer depending on the severity of the claim).

 

 

Second Action Plan Checklist

 

By the time the second Action Plan is due, most or all of the items outlined in the first Action Plan were completed. Any items not completed are carried over to the second Action Plan with a new due date for each carried over item. Activities you can expect to see on the second Action Plan include:

 

  1. A date for reevaluation of the file reserves (usually 60 days from the date the claim was received in the claims office).
  2. A date for evaluation of the need for a Nurse Case Manager on the claim, if the employee has not returned to work, and assignment of the Nurse Case Manager, if needed.
  3. A date for coordination of the return to work full duty or modified duty, if needed.
  4. A date for the obtainment and evaluation of the disability rating.
  5. If the file is reportable to an insurer, excess carrier or any other party, the date the second report will be completed.
  6. A date for the next Action Plan to be completed (usually 30 days after the second Action Plan but the time frame can be shorter or longer depending on the severity of the claim).

 

 

 

Third & Subsequent Action Plan(s) Checklist

 

The third and subsequent adjuster’s Action Plans will vary more in the items that will be included in the Action Plan. Some things to look for in the subsequent Action Plans including their due dates, are:

 

  1. Medical records being obtained and evaluated for all on-going treatment.
  2. Regular scheduled follow-ups with the employee, the employer and the medical providers.
  3. Regular scheduled contact with the Nurse Case Manager when there is one.
  4. The completion and filing of all state forms.
  5. The scheduling and obtaining of independent medical evaluation or a peer review.
  6. Offsets and deductions being calculated and applied.
  7. Second Injury Fund (in the jurisdictions that still have one) being placed on notice
  8. A settlement evaluation that is explained and properly justified, including both the strengths and weaknesses of the claim.
  9. A Litigation Plan and a Litigation Budget, if the claim is in suit or in a contested board review.
  10. All required waivers and/or releases obtaines.
  11. CMS notification if a MSA is considered or needed.
  12. A re-evaluation of the reserving accuracy.
  13. Subsequent filing of the claim with the ISO/Index Bureau.
  14. If the file is reportable to an insurer, excess carrier or any other party, the date the next report will be completed.
  15. A date for the next Action Plan to be completed (usually 60 or 90 days after the third Action Plan but the time frame can be shorter or longer depending on the severity of the claim).

 

 

As long as the work comp claim remains open, the adjuster continues to have an Action Plan outlining the steps to take to bring the claim to a conclusion. The final entry on the adjuster’s last Action Plan for the claim is actually the activity the adjuster looks forward to doing. The final Action Plan activity should read: “Close file.’’

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

4 Things to Consider in Complex Work Comp Causation Cases

work comp causationMembers of the claims management team are challenged daily to run an effective operation.  One of these issues claim handlers confront are questions of medical causation before admitting primary liability on a workers’ compensation claim.  Unfortunately, most members of the claims management team do not have a medical degree, but they do have many resources at their disposal to meet these challenges and make even complex decisions with certainty.

 

 

To Admit or Deny Primary Liability

 

Questions of medical liability for a work injury are often more complex than those that involve a “legal” basis for denial.  When reviewing questions of medical causation, claim handlers need to consider the following issues:

 

  • Evidence of clinical medical findings to substantiate a work injury;

 

  • Evidence of the requisite workplace exposure—which are often complicated by claims or repetitive use allegations; and

 

  • Medical literature that connects or links the work activity to the alleged injury.

 

In many instances, claims handlers are left to rely on training, experience and gut instinct to make decisions.  Time is of the essence given statutory parameters following receipt of the First Report of Injury.  Failure to do so can result in admissions against interest and/or penalties.

 

 

4 Things to Consider in Complex Work Comp Causation Cases

 

Members of the claims management team need to be proactive when it comes to admitting or denying a workers’ compensation claim that boils down to issues concerning medical causation.  There are important steps one can take to make a reasonable and well-informed decision.

 

  • Investigate the mechanism of injury: This consideration includes the question of “how” an injury occurred.  The claim handler will have medical records that detail how the injury took place.  In other instances, they may have the opportunity to conduct a more in-depth investigation.  This can include a recorded statement from the injured worker or witnesses.

 

  • Determine the exact medical diagnosis: This includes obtaining as many medical records as possible immediately following the work injury.  This starts with learning where the employee received post-injury care and the names of prior medical providers.  In many instances, state and federal privacy laws allow claim handlers to receive medical records without a signed authorization.

 

  • Review all diagnostic tests and studies: Reviewing the reports from medical studies can provide insight into the origin of an injury.  Examples of this include injuries to the upper extremities, shoulder areas and cervical spine.  A review of EMGs, CT scans and MRI can narrow the point of injury and its origin.

 

  • Roundtable with the claims team: This is a value resource to review the facts and question the plausibility of a claim. Roundtable sessions with a claims management team are important for many reasons.  This includes the ability of claim handlers to learn from each other’s experience and plot claim strategy.  It can also be an opportunity to poke holes in the employee’s version of events and plan a defense.

 

 

Battle of the Medical Experts

 

In many litigated claims involving injury causation, there is a “battle of the experts.”  While the employee always carries the burden of proof, many jurisdictions view the evidence in a light most favorable to the employee.  The result in the need to provide the medical expert with as much information as possible prior to the adverse examination.  A well written IME report and excellent bedside manner for courtroom testimony is a must.

 

 

Conclusions

 

In every workers’ compensation claim, a strong defense starts with the claim handler working the file.  This requires that person to use their skills and resources to conduct a diligent investigation and examine the important issue of medical causation.  Claim handlers have many resources.  By using them, they can position their file load for success and reduce costs in their workers’ compensation program.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

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