What Is A Workers’ Comp Vocational Consultant?

Vocational consultants are not needed on most of your worker’s compensation claims; just the severe claims. When an employee has a level of permanent partial disability, to the point that the impairment from the injury will prevent the employee from returning to work, a vocational consultant is required.

 

 

Vocational Consultant Evaluates Ability of Injured Employee to Work

 

A vocational consultant evaluates the ability of the injured employee to work and then assist the employee in finding employment within the physical limitations of the employee. The typical course of the vocational process is for the vocational consultant to perform a vocational assessment including vocational testing, perform a labor market analysis, a transferable skills analysis and assistance with job placement.

 

To access the injured employee’s ability to perform a different occupation, vocational testing is used. Testing to measure the employee’s educational achievement, aptitude, interests, and level of intelligence may be used to gauge what the employee’s skills are. These tests are the first steps in a vocational assessment for the employee.

 

The vocational assessment for each employee is done on an individualized basis. To make a complete evaluation of the injured employee’s abilities, the vocational consultant will:

 

  • Complete a detailed interview to obtain the employee’s background information on formal education, trade schools, prior work experiences, interests and hobbies

 

  • Based on the results of the detailed interview of the employee, a transferable skills analysis will be completed

 

  • Vocational testing to verify the level of the transferable skills the employee has will be completed

 

  • Vocational testing to identify other skill sets the employee has but did not express or disclose

 

 

Based on the results of the employee interview and the battery of tests administered to the employee, the vocational consultant assesses the employee’s educational level, skills, interests and abilities. This assessment will include:

 

  • Educational achievement

 

  • Vocational interest

 

  • Vocational function level

 

  • Aptitude/talent level

 

  • Intelligence level

 

  • Personality traits

 

 

Vocational Consultant Identifies Potential Jobs

 

The vocational consultant will analyze all the interview and testing information obtained about the employee and will complete what is known as a transferable skills analysis. Subsequently, the vocational consultant will identify occupations or jobs the employee will be able to perform at the level of permanent impairment the employee has using the transferable skills the employee has.

 

Before the use of computers, the vocational consultant had to manually review numerous (often hundreds) types of jobs to try to find one or more jobs the employee could perform. With the advent of computer programming, the injured employee’s physical limitations, prior training, and vocational testing results are compared to the requirements of thousands of job descriptions. The vocational consultant will obtain a listing of all the jobs the employee can perform with his physical limitations and existing abilities.

 

Utilizing the list of jobs the employee can perform with his impairment, the vocational consultant will complete a labor market survey to locate actual jobs the employee is capable of handling.

 

 

Vocation Consultant Continues Until New Work Is Found

 

While the identification of occupations/jobs the employee can perform is a big step forward, if there are no jobs available, the injured employee will continue to receive workers’ compensation indemnity benefits as he remains off work. The vocational consultant then becomes a career coach assisting the employee in locating jobs to apply for, providing guidance on how to interview for the jobs, and providing support and direction to the employee in the job search. The vocational consultant will continue to work with the employee until the employee is hired by a new employer.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Five Factors to Review in Your Workers’ Comp Claim Files

While every workers’ compensation claim is unique, every claim contains certain key events and documents. The best practices established either by the insurer or the third party administrator creates a certain amount of uniformity in the claims.

 

When you review the workers’ comp claims of your employees, you will see established criteria in the handling of the claims. Each claim will contain information on:

 

  • Coverage
  • Contacts
  • Investigation
  • File Documents
  • Evaluation and Settlement

 

 

Coverage: 

 

The very first step the adjuster takes when handling a claim is the verification that there is coverage. This includes checking the policy number to be sure it is accurate; the policy dates to be sure the injury occurred during the time frame covered by the policy; the state(s) covered by the policy; and, any endorsements to the policy or any exclusions of coverage. If any aspect of the coverage verification is missing, the wise adjuster stops any further activity on the file until there is proof insurance covers the claim.

 

 

Contacts: 

 

Once the workers’ comp adjuster verifies there is insurance coverage in effect for the named insured, on the date of the injury, and in a location covered by the policy, the adjuster contacts all involved parties. Whether the adjuster contacts the injured employee first or the employer first depends on the nature and extent of the injury and the time frame of known events. The adjuster also contacts the medical provider’s office to obtain the initial medical treatment information, to provide information to the medical provider on billing for their services, and to provide the medical provider with information on the return to work policy of the employer. Any other parties who may impact the claim are also contacted; for example — witnesses on questionable or severe claims.

 

 

Investigation: 

 

Contact with all parties involved is the start of the claim investigation, but a proper investigation contains many other actions impacting the future outcome of the claim. Some of the investigation steps include:

 

  • A comparison of the details of the accident as provided by the employer, the employee, the medical provider, and any witnesses. Any deviation in the information obtained from the various parties needs to be analyzed by the adjuster.
  • The filing of the Insurance Service Office inquiry to determine if the employee has made prior insurance claims, and if so, do they impact the present workers comp claim. For instance, the employee, who suffered a lower back strained in your claim, also had a lower back injury workers comp claim with a previous employer.
  • A determination if there is a third party responsible for the employee’s injury, and if so, the documentation needed to pursue a subrogation claim.
  • An analysis of the nature and extent of the employee’s injury, the medical treatment plan, and the prognosis for the employee’s recovery.
  • An analysis of the employee’s job duties, equipment used, the return to work restrictions from the medical provider and the modified duty information obtained from the employer to determine if a modified duty job is an option.
  • A determination as to the future course of action needed on the file, also known as an Action Plan.

 

 

File Documents: 

 

Every claim file has basic claim documents to support the claim and the activity taken on the claim. Depending on the extent of the injury, the file may have additional documentation that might not be found in a simple injury claim. The documents you may see in the claim file include:

 

  • The Employer’s First Report of Injury (FROI).

 

  • The recorded statement summary of the employee and possibly the recorded statement summary of the employee’s supervisor and/or witnesses.

 

  • The required state forms filed with the governmental office enforcing the workers’ compensation statutes of the state.

 

  • The wage statement is showing the employee’s earnings during the required calculation period.

 

  • The Insurance Service Office report.

 

  • The medical records.

 

  • Vocational and/or rehabilitation reports.

 

  • Subrogation documentation.

 

  • Correspondence to and from defense counsel, correspondence to and from the employee’s attorney, and correspondence between defense counsel and the employee’s attorney.

 

  • Reserve worksheets used to calculate the cost of the claim.

 

  • File notes (a log of activities undertaken) making a record of every telephone call, piece of mail, e-mail, fax or other communication on the claim.

 

 

Evaluation and Settlement:

 

When the claim file has progressed to the point where the adjuster can start the evaluation process (usually when the employee has reached maximum medical improvement); there will either be a reserve worksheet or an evaluation worksheet establishing the financial exposure of the claim. The evaluation of the claim includes the compensability, the disability rating, the jurisdictional law, and any legal questions that need to be resolved. The file notes should describe the adjuster’s settlement discussions when they have taken place.

 

An essential part of risk management is to know as much as possible about the exposures your company faces. We recommend obtaining electronic access (on a read-only basis) to the insurer’s or third party administrator’s claim file. By knowing what is in your claim file, you can contribute any additional information benefiting the adjuster in bringing your employee’s workers’ comp claim to a satisfactory conclusion.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

4 Strategies to Dispute a Workers’ Compensation Claim

For the most part, workers compensation claims are generally compensable. The general public thinks the opposite — that all insurance companies want to deny injury coverage.

 

In actuality, it’s estimated that 80 to 90 percent of claims are initially accepted. However, claims can be denied later down the road for various reasons. How does an employer properly dispute a claim when there is a compensability question?

 

 

4 Strategies to Dispute a Workers’ Compensation Claim

 

 

  1. If a reported claim is questionable, the adjuster needs to know right away so a proper dispute for investigational purposes can be filed.

 

At the time a claim is reported to the carrier, employers will know more than the adjuster. Once the adjuster receives the file, he or she sets up the claim, contacts the employee and employer, reviews medical records, and only then makes an initial decision.

 

But if the employer calls the claim questionable, it should be marked as questionable right away so the adjuster can file a dispute that the claim’s compensability is under investigation. Most jurisdictions have a time limit on how long the claim investigation can be. If the adjuster fails to file for the extension within the time limit, the claim could be conceded as compensable — at least in the beginning.

 

 

This leads to leakage because claims dollars are being spent on a claim that may not be compensable. It takes time to take statements, get medical records, get past records, do background checks, etc. If an adjuster can file an initially extension they can take time to investigate the claim and make the proper decision on compensability.

 

 

Generally, questionable claims receive more of the adjuster’s investigative attention. This is especially true when the employer notes on the first report of Injury that the claim is questionable; this automatically raises a red flag for the adjuster. The adjuster will review the claim’s initial parts and form questions to ask the employee when taking their statement.

 

 

An adjuster’s first call will be to you, the employer, asking why the claim is questionable. Employers can talk to witnesses, and follow up on leads made by other employees that a claim may not be 100 percent compensable and pass that information on to the adjuster in the beginning of their investigation.

 

 

All of these issues greatly help the adjuster, and after the investigation is completed, a proper decision can be made on the claim as to overall compensability.

 

 

  1. What if a claim starts off as compensable then needs to be disputed later on?

 

A claim can start off as compensable and then change. For example, an employee strains his back while working. There was a witness, and it was reported promptly. The worker was sent for treatment the same day. Usually, benefits will be conceded, and the claim will be accepted into initial stages.

 

 

But, a month later the claimant tells the doctor he hurt his back the weekend before the work injury doing yard work, then he made it worse while working. This should lead to a dispute in all cases. The adjuster has no way of knowing how bad the claimant had injured themselves while outside of work, and most often the injured worker will not be able to go back and say the injury/ongoing disability is 100 percent work-related.

 

 

Unfortunately, these cases are rare. Claimants are often intelligent, and even if this did occur most do not go to an occupational clinic and tell the doctor about how they injured themselves outside of work. But it does happen, and the adjuster should catch this every time. This can be seen in emergency department records, too.

 

 

  1. What if a worker is injured doing a simple task, and the diagnosis is worse than it should be in relation to what the worker was doing at the time of injury?

 

For examples like this, adjusters rely on the medical records and the mechanism of injury. For example, a claimant states she sustained a lumbar strain while at work lifting a 20-pound tote of parts. Then the doctor finds all sorts of objective evidence on exam of severe, disabling back pain. Something is not right. Lifting 20 pounds should not have such excessive force that it herniates multiple lumbar discs. The adjuster should seek an opinion of a peer-review physician or medical advisor to comment on the severity of symptoms in relation to the stated work injury.

 

 

This type of scenario is a lot more common than one would think. The general public probably has never had a diagnostic workup on their spine or an MRI test. If a claimant sustains a simple injury and the resulting MRI shows all sorts of issues, it does not mean they all are related to the work injury.

 

 

An employer also has to beware of false positives. Just because someone has multiple levels of disc bulges, does not mean all of those are related to work. Research shows workers of all ages and occupations can have a varying level of degree of spinal issues. It is the adjuster’s job to determine what, if anything, is related to the work injury, treat those issues, and deny ongoing treatment for the rest of the worker’s spinal problems.

 

 

  1. If you know the injury is not legitimate, should you file the claim anyway?

 

The answer is in all cases is YES. It is the adjuster’s job to determine if an injury occurred out of the course and scope of employment. A human resources professional is not an adjuster, and if a worker comes to you and alleges a work injury, no matter what the circumstances, it should be reported to your carrier/TPA. The adjuster has training and certification, and he or she is qualified to deny claims. Some jurisdictions can carry heavy penalties for failure to report a work injury to the carrier. You do not want to be hit with one of those penalties. The company pays a carrier’s premium to be protected in insurance matters. The employer should gather all the pertinent details and report the claim promptly. Indicate on the first report of injury that the claim is questionable, and go from there. Follow up with the adjuster, and chances are it will be denied as you suspect.

 

 

Summary

 

There are several ways to dispute a questionable claim. But the most important thing an employer can do is gather all the information on the claim before reporting it promptly to the carrier. Then, follow it up with a phone call to the adjuster. The more you work together with your carrier, the better chance the questionable claims will be denied.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Your Adjuster Has a Critical Role in Legal Defense Management

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

 

 

Once Attorney Hired, No Further Contact with Employee

 

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

 

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

 

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

 

 

Adjuster to Maintain Positive Contact with Employee Before Attorney Representation

 

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

 

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

 

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

 

 

First Notice of Claim Could Be Request for Hearing

 

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

 

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

 

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

 

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

 

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

 

Adjuster Critical in Management of Attorney Costs

 

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

 

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

 

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

 

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

 

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

 

 

 

Multiple Defense Relationships Should be Engaged

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

6 Strategies to Determine Workers’ Comp Causation

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

 

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

 

 

The Problem

 

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

 

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

 

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

 

 

Scenarios

 

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

 

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

 

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

 

 

Solutions

 

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

 

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

 

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

 

 

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

 

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

 

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

 

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

 

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

 

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

 

 

Conclusion

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

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

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

 

 

1- Claim Investigation:

 

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

 

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

 

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

 

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

 

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

 

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

 

 

2- Medical Documentation:

 

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

 

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

 

 

3- Indemnity Documentation:

 

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

 

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

 

 

4- State Forms:

 

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

 

 

5- Hearings & Legal:

 

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

 

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

 

 

6- Medical Management:

 

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

 

 

7- Vocational Rehabilitation:

 

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

 

 

Summary:

 

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

 

 

 

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

Contact: RShafer@ReduceYourWorkersComp.com.

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

 

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

 

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

 

 

 

Avoid High Cost of Denied Claims With Solid Investigation Strategy

Avoid High Cost of Denied Claims With Solid Investigation Strategy

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

 

 

Program Efficiency and Denied Claims

 

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

 

 

Barriers to an Effective Claim Investigation

 

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

 

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

 

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

 

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

 

 

Improving the Claims Process — Making Better Decisions

 

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

 

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

 

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

 

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

 

 

Conclusion

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Advocacy and Engagement: 4 Reasons Why and 7 Ways to Do It

Advocacy and Engagement: 4 Reasons Why and 7 Ways to Do It‘Advocacy and engagement’ is much more than a buzz term in the workers’ compensation system. It’s a concept that can easily cut 5 – 10 percent of your workers’ compensation costs. Not only that, but companies that embrace the idea are more profitable than those that don’t – 16 percent more, according to some estimates.

 

With approximately 70 percent of workers feeling disengaged from their companies, the task of persuading injured workers to take a vested interest in the post-injury process may seem daunting. But there are simple things organizations can do to engage their workers and reap the benefits.

 

 

What it Is

 

Advocating for injured workers and getting them engaged in the claims process means focusing on them as human beings, rather than viewing them as ‘claimants’ and being interested only in the dollars and cents part of it.

 

Engaged injured workers are a vital part of the process, starting at the beginning of the claim. Rather than having conversations about the injured worker, claim discussions need to include the injured worker. The ‘us vs. them’ approach needs to be eliminated. The goal is to get them healed and back to function. The vast majority of injured workers share that objective.

 

 

Benefits

 

Selling the idea of advocacy and engagement to the C-Suite should not be hard, once the benefits are explained. In addition to overall happier employees, studies bear out many positive outcomes among injured workers in companies that have an advocacy-based model.

 

  • Faster return-to-work rates. Injured workers heal faster when they are truly engaged in their recoveries. Rather than being passive and having things done to them, they are actively involved in their own treatments, which gets them back to work sooner.

 

  • Less litigation. Part of the engagement process is educating the injured worker on what to expect, along with his rights and responsibilities. Understanding the process and having consistent and constant communication eliminates the majority of reasons an injured worker hires an attorney. Reduced litigation can be a tremendous cost saver, as studies show attorney involvement increases the cost of a claim by an average 4.5 times.

 

  • Better network penetration. Engaged workers are more likely to go to a physician of your choosing, even in states without employer-directed care. There is a level of trust they feel and will listen to your suggestions.

 

  • Improved morale. Injured workers who feel they have been well taken care of during their absence have a positive attitude upon returning to the workplace, which typically spreads to coworkers.

 

 

Tactics

 

The idea of treating injured workers nicely and with respect should be a no-brainer. But the reality is many companies and/or key members of an organization view injured workers negatively, even with disdain.

 

Dealing with the logistics and paperwork is often seen as a deterrent to meeting production deadlines. Many view the injured worker as someone just trying to game the system.

 

Research shows that a small percentage of injured workers fit this description, but nearly all have the same interests as top managers; to recover and get back on the job as quickly as possible.

 

Best practices for engaging injured workers include:

 

  1. Staying in touch with the injured worker starting from day one and then on a consistent basis is vital to show a worker the company truly cares about him. Ideally, the supervisor or manager with whom the worker is close should call the worker. That person and other colleagues should continue the dialogue with phone calls, get well cards, and the like.

 

  1. Along with communicating with the injured worker is active listening. The injured worker may ask questions, express concerns or air complaints. It’s important to hear what the injured worker is saying and reflect that, without engaging in combative dialogue.

 

  1. Education/information. Injured workers don’t know what to expect, are worried about their financial and job security and are in pain. They need to be made aware of the process for them to be engaged. The best way is through an employee brochure that is given to workers upon hiring, and then again if and when they become injured.

 

Here are some additional advocacy strategies organizations use to better engage their injured workers.

 

  1. Onsite care. While a fulltime onsite clinic is ideal, ergonomic evaluations, biomechanics and stretching programs for workers can help them improve their physical stamina and make them feel engaged.

 

  1. Telehealth services. Some companies have a private room with a computer available for workers to speak privately with a healthcare provider. Employees given this option feel their companies truly care about their wellbeing.

 

  1. Nurses and triage. A telephonic triage system for workers who sustain on-the-job injuries is invaluable. A nurse can determine what treatment is appropriate and, at the same time, make the injured worker feel someone is there to help.

 

  1. Partner with other departments. The benefits side of an organization may offer programs that help workers feel more engaged in the company and have a sense that the company cares about them. Examples include:

 

  • Back health, where employees call a number, explain their symptoms and are given specific exercises. This is especially helpful since back injuries are among the most costly in the workers’ compensation system.
  • Second opinions. Some wellness programs include a second opinion to workers free of charge. These can be extended to injured worker as well as those not hurt at work.
  • Family health assistant. Some companies with a whole health model provide a number for workers to call for advice on health-related problems of anyone in the family.
  • Employee assistance programs are available to all workers and can be a tremendous benefit for injured workers who want to talk with someone about financial, familial or other concerns.

 

 

Conclusion

 

The value of engaged employees – especially those who become injured – are clearly borne out in the research. Companies that rethink their attitudes and demonstrate caring and concern for their employees can benefit tremendously.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Use These 16 Tips To Plug Work Comp Claim Leakage

The failure by the self insured’s third party administrator (TPA) or in-house staff adjusters to comply with workers’ compensation claim handling Best Practices normally results in higher than necessary claim cost.  Just like in any other business, the failure to manage the cost of doing business – known as leakage – places the self-insured employer at a disadvantage in the market place.  To recover the excess cost of poor claims handling, the company must raise the amount they charge for their products or services to cover the additional cost.

 

Leakage in an insurance claim is any payment on the claim that is more than it should be.  Leakage is normally defined as the difference between what the claims adjuster spent and the amount he/she should have spent.   Leakage has also been defined as the lost opportunity to save money on the claim.  In essence, leakage is excess and unnecessary claim costs.

 

 

16 Tips To Plug Work Comp Claim Leakage

 

There are about as many different types of leakage in workers’ compensation claims handling as there are workers’ compensation subjects to be discussed.  Some common examples of the claims’ handling errors that cause leakage in workers’ compensation include:

 

  1. A failure to properly investigate compensability resulting in paying claims that should be denied.
  2. A failure to timely get a claimant to Maximum Medical Improvement (MMI) leads to leakage because at the point of MMI a claim should be settled.  The failure to do so leads to increased indemnity benefit payments to the claimant.
  3. A failure to adjust medical bills higher than the medical fee schedule down to the medical fee schedule amount.
  4. A failure to utilize the employer’s return to work program leads to excess indemnity benefit payments to the claimant.
  5. An improper denial of a claim leads to the claimant obtaining a lawyer which drives up the cost of a claim.
  6. A failure to properly investigate and tie down the scope of a claimant’s injuries leads to increased claim costs because the claimant can add non-compensable injuries which drive up the cost of the claim.
  7. A failure to run an ISO report or obtain medical records from prior injuries or pre-existing conditions can lead to excess claim costs being incurred for treating injuries which are not part of the claim.
  8. A failure to establish the proper average weekly wage results in miscalculation of the temporary total disability (TTD) indemnity benefits to be paid the claimant, often with a corresponding overpayment of TTD.
  9. A failure to determine that the injury claim was caused by a third-party which results in the cost of the claim not being recovery from the responsible party (loss of subrogation rights).
  10. A failure to select the most qualified defense counsel.
  11. A failure to timely pay medical bills or indemnity benefits results in fines and/or penalties.
  12. A failure to properly manage utilization review opportunities
  13. A failure to control the selection of the medical providers in those states where the employer selects the medical provider results in increased claim cost because the claimant and/or his/her attorney is free to choose a “claimant friendly” medical provider.
  14. A failure to provide a nurse case manager on complex injury claims leads to higher and/or unnecessary medical costs because there is no professional oversight of medical costs.
  15. A failure to read a claimant’s medical reports results in errors including payment for unrelated medical care, providing unnecessary medical care, unnecessary time off work, and various other claim handling mistakes.
  16. A failure to maintain adequate payment records results in duplicate payment of bills

 

 

Independent Claim Auditor Advantageous

 

When the self-insured employer sees the cost of their claims increasing greater than normal, the employer can do a detailed review and analysis of each claim.  However, most self-insured employers find it advantageous to hire an independent claim file auditor to review the work comp files for compliance with Best Practices.

 

The claim file auditor will analyzed the claim handling errors in regard to the financial impact each error had on the claim.  The claim file auditor will assist the TPA or the self-insured’s staff adjusters  to identify areas where leakage is occurring and will provide guidance on how to prevent future leakage.  Plus, when the independent auditor identifies leakage due to the failure to subrogate, or due to duplicate payments, the employer may be able to recover some of the money that has been lost.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

7 Reasons A Workers’ Comp Claim Should NOT Be Closed

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

 

 

Salary Bonus Program Based on Closed Claims

 

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

 

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

 

 

Adjusters Game The System

 

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

 

 

Only Close Claims When All Known Activity Is Completed

 

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

 

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

 

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

 

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

 

 

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

Contact: RShafer@ReduceYourWorkersComp.com.

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

 

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

 

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

 

 

 

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