9 Steps to Get the Best Out of Your Workers’ Comp Adjuster

Having a great claims adjuster can be invaluable. Claims are processed smoothly, timely, and satisfactorily.

 

But getting the ideal adjuster is not always possible, and employers often blame adjusters when things don’t go as efficiently as they could. Should you seek a different adjuster, or just accept that you’re stuck with a dud? Actually, you may be able to avoid both. By taking a step back to gain some insight into the adjuster’s world and using a few simple strategies, you may be able to turn things around.

 

 

Set Realistic Expectations

 

The adjuster’s role is the fair and reasonable settlement of claims. First step is to figure out what that means to you and how it fits in with your company’s claims handling plan. Setting up expectations is important. If there are no clear directions or goals, you really can’t blame the adjuster for failing to meet your expectations.

 

For example, do you want the adjuster to be in constant contact with you, or do you want communication only when absolutely necessary? You need to determine that and let the adjuster know.

 

If you expect the adjuster to resolve claims within a certain period of time, are you doing all you can to facilitate that? How soon are injuries reported? Is that on a consistent basis? Do you have a timeframe for when and how investigations are performed?

 

Other factors can also affect the resolution of claims. Not having a return-to-work program or light duty/transitional work can make more work for the adjuster, along with the lack of a fraud prevention program. Make sure your actions and goals are in line with your expectations of your adjuster.

 

 

Understand the Adjuster

 

It can be upsetting when the adjuster doesn’t get back to you when you think he should, or denies treatment on a claim with no explanation or approves a questionable claim. But seeing things from the adjuster’s standpoint can help.

 

Instead of lambasting the adjuster, consider what is happening on his end. Being an adjuster can be a thankless job;

 

  • There are constant questions, emails and phone calls, often from disgruntled employees, employers or others.
  • His caseload may be overwhelming.
  • There are constant deadlines that may or may not be achievable.
  • The turnover for the profession is such that his office may be understaffed at any given time.
  • While you might be easy to work with, others may not be.

 

You can find out what’s going on by talking with the adjuster.

 

Build a Relationship

 

Developing a bond with the adjuster can go a long way toward having a better connection with him. Working better with the adjuster can involve a few simple steps:

 

  1. Pay him a visit. A ‘chairside visit’ is a great way to establish a good relationship with an adjuster. For this informal meeting, you literally sit at his desk to understand the demands of his day. You can also take the opportunity to learn how he handles claims; the intake process, medical-only and lost-time claims, and catastrophic claims.

 

  1. Get to know him on a personal level. While you don’t need to be best friends, you can find out a little about him — his home life, kids, hobbies, etc.

 

  1. Realize he is the expert. Even if you don’t like the way he’s handling a claim show him respect. That said, find out his expertise level. If he’s new to the profession, he’s probably not the right person to handle complex claims. On the other hand, a highly experienced adjuster might be bored handling simple, medical only claims.

 

  1. Ask questions. There may be good reasons for the way he’s handled certain aspects of a claim. Don’t just get angry, find out why. Ask open-ended questions that are not accusatory. Putting him on the defensive won’t help your relationship, and it likely won’t get you answers.

 

  1. Give praise when warranted. If the adjuster does a particularly good job with a claim, tell him so. He’s probably much more used to hearing negative comments than true appreciation. Doing so will make things much easier when you later have concerns about a claim.
  2. Listen to what he says. You may have ideas to solve some of the challenges he’s facing.

 

  1. Offer to help. There may be things you can do that would help him expedite the claims process.

 

 

Conclusion

 

If you’re having problems with your adjuster, first look at your own program. Having an organized plan for claims handling and relaying that sets up realistic expectations.

 

Then, work with the adjuster. Develop a bond so you can easily find out the reasons for any problems and set up strategies to avoid future challenges.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

4 Items Claims Handlers Want From Their Defense Attorney

Workers’ compensation defense attorneys may lay awake at night wondering what their claims handler really wants.  Besides getting their files closed in a timely manner, they want to work with defense attorneys committed to a zealous defense of the file in an ethical and cost-effective manner.  Here are some tips that can help defense attorneys sleep better at night knowing they are giving their claims handler what they want.

 

 

Calculate the Average Weekly Wage (AWW)

 

The AWW is the basis for most indemnity benefits in a workers’ compensation claim.  Failing to calculate it correctly can increase the cost and exposure of the claim.  A seasoned defense attorney needs to communicate with the employer and receive additional explanation from the employee on a number of issues.  The list can be endless, but some special considerations include:

 

  • Whether the employee was a full or part-time worker;

 

  • Whether the employee was working any additional jobs outside the employer involved in the claim;

 

  • Investigation into the nature of any fringe benefits the employee was receiving. This includes tips, bonuses, insurance benefits and other forms on potential income; and

 

  • Special circumstances concerning the employee’s employment. This is especially the case when the injured worker in a seasonal employee, construction worker or part of a union collective bargaining agreement.

 

 

Calculate and Evaluate the Indemnity Exposure

 

Once the AWW is correctly calculated, the defense attorney can provide an accurate analysis to the claims management team about wage loss exposure.  This includes information on the following benefits:

 

  • Temporary Total Disability (TTD)—Benefits paid when the employee is temporarily off work due to injury or disability;

 

  • Temporary Partial Disability (TPD)—Benefits paid when the employee returns to work, but at reduced hours or rate of pay;

 

  • Permanent Partial Disability (PPD)—Typically a hybrid benefit based on the AWW and the number of weeks disability assigned by statute or rule to an injury; and

 

  • Permanent Total Disability (PTD)—Benefits paid when the employee is permanently precluded from returning to gainful employment based on their age, training and experience, and the type of work available in the geographical area. Various presumptions may apply concerning an employee’s receipt of Social Security Disability benefits.

 

 

Aggressive Defense Strategy That is Cost-Effective

 

Members of the claims management team also appreciate an aggressive defense strategy that moves a case toward settlement in an efficient and cost-effective manner.  Considerations for such planning include:

 

  • An immediate status report upon receiving the claims file, with periodic reports that are robust and evaluate the strengths and weakness of various defenses, a reasonable strategy and probable outcome;

 

  • Identification of missing information that needs to be discovered in order to provide an accurate analysis and defense. This includes a plan on how to uncover this information and whom might be a witness at hearing; and

 

  • Recommendations on how to move a case toward settlement. This includes information concerning the timing of an independent medical examination or independent vocational evaluation.

 

 

Medicare Secondary Payer Compliance

 

Medicare Secondary Payer compliance is an important part of any workers’ compensation claim analysis.  This includes recommendations on the following topics:

 

  • Whether a service provider should be utilized to prepare a Medicare Set-aside allocation;

 

  • If the Medicare Set-aside should be included for review and approval under the voluntary CMS process; and

 

  • Matters concerning conditional payment identification and repayment.

 

 

Conclusions

 

The wants of a workers’ compensation claims handler are quite simple.  They expect professionalism and responsive defense counsel to assist them on all claims.  While the defense attorney might not have all the answers, they need to assist the claims handler in discovering the information and reporting on it timely.  This also includes a reasonable analysis, while being a zealous advocate.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

The Reality of the Biggest Myth Regarding Your Third Party Administrator

The Reality of the Biggest Myth Regarding Your Third Party AdministratorMYTH: The best way to reduce workers’ compensation costs is to change insurance companies or TPAs.

 

REALITY: Wrong! The best way to reduce workers compensation costs is to build a better relationship with your current claims administrator. The major cause of discontent between carriers and the insureds is lack of communication which causes a perception that something is being done improperly.

 

For example, in several situations a company believed nurse case management was too expensive; however, upon audit by our medical advisor, the nurse case management service should be used MORE, HOWEVER should be brought in earlier.

 

It wasn’t effective when it was used (thus seemed expensive and wasteful) because it was used too late in the process.

 

 

3 Ideas to Build a Better TPA Relationship

 

  • Start to build a better relationship by becoming more informed about the services your claims administrator offers. Hold a Vendor Day, and invite your TPA in with every one of their services – leave none out. Ask for samples of reports and deliverables so you can understand the product and will know when to request services. Have them bring brochures prior to Vendor Day, and read the brochures so you can ask knowledgeable questions during about the services.

 

  • Visit one or two claims offices, sit chair-side and observe the process. Learn the categories of desks at your carrier, for example, are there 4 levels of adjusters or 5? Do adjusters have backup and clerical support to get medical files or close files? Sit at the intake desk, then join the lost time and medical adjusters for a few minutes at their desks. Ask to see what happens to medical bills when they enter the system until the time they are paid and filed. This will give you a better understanding of how you can interact more effectively, what information adjusters need from you and what information you can provide about your workplace and employees.

 

  • Invite your adjusters to visit your workplace, so they know what your company does, the types of jobs and skills required of the employees. They can then visualize exactly how an injury occurred easier than if they’d never been to your work place. They can see the possible transitional duty tasks, and perhaps suggest a few more. They can even have coffee in the lunch room and be introduced to a few employees who come in. Make them feel like part of the team.

 

There are times when switching TPAs is the right decision.  However, try working out the problems FIRST, or you may end up with the same grass in a different pasture.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Maximize Your Third Party Administrator (TPA) Relationship With A Vendor Day

Maximize Your Third Party Administrator (TPA) Relationship With A Vendor DayIf your company is a large organization with many locations and numerous open claims at each location, you may need to consider having several return-to-work (RTW) coordinators. Have one RTW coordinator for each region. For example, one large company has East, Mid-West and Western Region coordinators. The number of coordinators depends on your claims volume, making sure each coordinator has enough claims to justify a full-time position while ensuring they are not overloaded and unable to follow-up on each claim.

 

Coordinators do not do the work of adjusters, but facilitate transitional duty and guide location management.

 

 

Understand What Your Third-party Administrator (TPA) Provides

 

Start your program with a Vendor Day.  Look at the capabilities and services provided by your claims administrator; regardless of whether it is an insurance company or a TPA, you need to know all of their capabilities in detail.

 

Have the claims administrator describe each of their services – a formal presentation; have your TPA come to your office to introduce’ and explain each service. Ask them to bring examples of each report. For instance, ask to see a sample nurse case management report, or an investigators report. Make sure you clearly state your expectations. You want the practice leader or a person who can explain everything about the services to attend.

 

Include all services: medical cost containment, medical management, investigative, recovery, and risk management information systems.

 

  • To prepare for Vendor Day, gather all literature from the claims administrator — have all sales brochures sent to you advance — and review the response to request for proposal (RFP) if the claims administrator was selected through the RFP Process.

 

  • Familiarize yourself with each available service, learn its name and find out how much it costs. For example, is a nurse case manager a telephonic nurse case manager or a field-based case manager who will attend medical visits with the injured employees?

 

  • Ask lots of questions.Is the case manager’ an RN, an LPN, or a non-licensed person with internal medical training? Before you can determine how effectively a service is delivered, learn the specifics of each service.

 

Companies often start the workers’ compensation correction process by selecting a new TPA without even knowing they are not using all of the services of their current TPA. For example, a major carrier has nurses who will go to each unit to help identify transitional duty jobs, yet their client was unaware of this service and its benefits. They didn’t know what they didn’t know.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

11 Ways to Manage Employer, Provider, and Employee Fraud in Workers’ Compensation

11 Ways to Manage Employer, Provider, and Employee Fraud in Workers’ Compensation Workers’ compensation fraud by workers gets the most publicity. But additional fraud is committed by staffing companies, professional employer organizations, medical and ancillary service providers, and brokers.

 

Sometimes multiple parties are involved, as in the case in California involving an alleged $40 million medical billing and kickback operation that involved more than two dozen physicians, pharmacists, and business owners.

 

Here are also some simple preventive measures that could potentially save companies mega dollars.

 

 

11 Ways to Manage Employer, Provider, and Employee Fraud

 

  1. Educate the workforce. Explain to employees that workers’ compensation fraud hurts the whole company and the loss of revenue may threaten upcoming pay raises or even their jobs. They also need to be informed that fraud is a serious crime with penalties. They should have a way to report suspected fraud anonymously.
  2. Teach the higher-ups. Managers and supervisors should understand that every reported injury should be treated as legitimate; however, they should also be taught to recognize some of the red flags that may indicate a fraudulent claim and have a procedure for reporting them. They also need to know how to take statements about an injury — from the worker and any witnesses.
  3. Work with the insurer. Report all suspicious claims immediately.
  4. Investigate ASAP. Make sure all reported injuries and illnesses are immediately and thoroughly investigated.
  5. Pay careful attention throughout the claims process to see if any information changes or doesn’t make sense about the injury. Also, note whether the injured employee was disgruntled prior to the injury.
  6. Drug tests. Require drug testing as a condition of employment. Drug users are statistically more likely to file fraudulent workers’ compensation claims than non-users.
  7. Implement a zero tolerance policy for fraud and take every action possible to expose and prosecute it.
  8. Make examples of cheaters. Whether it is a worker, provider or someone else involved in the process, all participants should see that you will take all steps necessary to fight fraud.
  9. Evidence Based Medicine (EBM). Make sure all treatment follows evidence based treatment guidelines and do not allow claims handlers to authorize treatment unless they have been trained in EBM
  10. Clean the provider network. Vet providers before allowing them into the medical network. Verify their physical location and try to determine if they own the clinic. Where possible, remove from your network any provider who has been accused of fraud.
  11. Involve workers. Regularly send out notices to injured workers with the dates and types of treatment that has been billed and ask them to report discrepancies.

 

 

Conclusion

 

Fraud costs companies billions of dollars. The money lost is passed on — in the form of higher premiums, increased prices for services, or lower money available to pay employees or expand the business.

 

Instead of turning a blind eye to the situation, organizations should adopt a zero-tolerance policy for fraud, educate all involved and enforce rules and regulations to expose the guilty parties and deter it from happening again.

 

See also: Be Aware of Employer, Provider, and Employee Fraud in Workers’ Compensation

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Be Aware of Employer, Provider, and Employee Fraud in Workers’ Compensation

Be aware of Provider, Employer, and Employee Fraud in Workers' CompensationWorkers’ compensation fraud costs the insurance industry an estimated $7 billion per year. Not only is it employee fraud, but employer and provider fraud can be just as, or even more expensive. Recent stories out of California, for example, revealed an alleged $40 million medical billing and kickback operation that involved more than two dozen physicians, pharmacists, and business owners.

 

Often the expense and time involved makes organizations reluctant to pursue fraud charges against offending parties. But being aware of the many ways fraud is perpetuated is key to preventing it. There are also some simple preventive measures that could potentially save companies mega dollars.

 

 

Types of Fraud

 

Employer Fraud 

 

Companies may misrepresent the nature of the business, or misclassify the types of jobs, number of employees or payroll to get lower premiums. They may hide premium scams behind dummy corporations. Or they may not even have workers’ compensation insurance, creating an unfair playing field for their market.

 

Here are some red flags that may indicate fraud by an employer:

 

  • The address. If a post office box is used or the company is located in an area different from its mailing address.
  • Workers are paid in cash with no payroll stub. Or, paid with in-kind services, such as free rent.
  • Too many admins. The number of clerical employees is significantly higher than the number of non-clerical staff for the type of business.
  • The company has not been audited.
  • Multi-businesses. The company has several businesses operating from the same address.
  • The name. The company’s name is inconsistent with the type of work done.
  • Too many independents. There is an excessive number of independent contractor classifications. The employer may require new employees to fill out a 1099 instead of a W-2.
  • Low bids. Estimated prices for projects are substantially lower than the industry standard.

 

 

Provider Fraud

 

Bills for unnecessary or nonexistent medical services have garnered media attention in recent years. In some cases, physicians team up with attorneys to commit workers’ compensation fraud. They may exaggerate the severity of injuries that do occur and bill payers for what would be the ‘appropriate’ type and number of treatments for the conditions.

 

In some scams, clinics and attorneys hire people to lure workers who may or may not even be aware something untoward is happening. In other cases, a ‘clinic’ may exist only on paper, or is just an office with little equipment. Then there are medical providers who game both the workers’ compensation and group health systems by billing both for the same treatment.

 

There are some red flags that may indicate provider fraud is taking place.

 

  • Questionable bills. The payer is billed for a treatment the injured worker does not recall.
  • Weekend bills. Invoices are received for services performed on weekends or holidays.
  • Bad timing. Provider sends bills for treatments after the injured worker has gone to a different provider.
  • Reports too alike. Medical reports appear nearly identical for different patients and conditions.
  • Questionable treatment. The type and length of treatment is not in sync with the type and seriousness of the reported injury.
  • Reporting delays. There are unexplained lags in receiving requested records.
  • Attorney closeness. The provider works with the same lawyer repeatedly on questionable claims.

 

 

Worker Fraud

 

Reporting an injury on a Monday morning or after a holiday are two of the biggest red flags that indicate something may be amiss with a claim. Other indications that an injury may be fraudulent include the following:

  • The worker is new, seasonal or contractual and/or has a history of short-term employment.
  • Early attorney involvement. The worker has a lawyer as soon as the injury is reported.
  • Changing situation. The employee is faced with possible termination or layoff.
  • Funny facts. The description of the accident does not make sense with the reported injury.
  • No witnesses. The worker was alone when the injury occurred.
  • The worker is resentful.

 

 

Conclusion

 

Fraud costs companies billions of dollars. The money lost is passed on — in the form of higher premiums, increased prices for services, or lower money available to pay employees or expand the business.

 

See Also11 Ways to Manage Employer, Provider, and Employee Fraud in Workers’ Compensation

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

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

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

 

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

 

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

 

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

 

 

Ask the following:

 

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

 

 

Make use of a Nurse Case Manager:

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

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

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

 

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

 

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

 

 

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

 

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

 

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

Vigilant attention to the employee will ease this process.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Two Very Important Steps When Managing A Catastrophic Injury Claim

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

 

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

 

 

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

 

 

Step #1: Immediate Attention

 

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

 

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

 

 

Attorney Alert!

 

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

 

 

Step 2: Medical Management

 

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

 

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

 

 

Summary:

 

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

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Is Your TPA Recovering Every Subrogation Dollar It Should?

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

 

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

 

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

 

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

 

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

 

 

1 – Claim File Quality Audits

 

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

 

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

 

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

 

 

2- Reserve Audits

 

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

 

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

 

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

 

 

3- Subrogation Audits

 

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

 

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

 

 

4- Fraud Audits

 

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

 

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

 

 

Summary

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

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