Understanding Rights of Recovery: Dealing with Liens in Work Comp

Members of the workers’ compensation claims management team are faced with many challenges.  One of these tests includes the resolution of liens, intervention claims and other interests as part of settling a claim.  Failure to consider and resolve these interests can be detrimental to effective claims settlement and negatively impact a program’s bottom line.

 

 

What is a Lien? Why is it Important?

 

According to Black’s, a lien is “The principle under which an insurer (or another party) has paid the loss under an indemnity policy is entitled to take on all the rights and remedies belonging to the insured against a third party concerning any injuries or breaches covered by the policy.”  Under this legal principle, members of the claims management team need to proactively identify, provide notice to and resolve interested third-parties for medical care and treatment (or other benefits) related to a workers’ compensation claim.  Failure to take these important steps can result in the insurance carrier or insured being subjected to fine, penalty or future repayment.

 

 

Medical Providers and Health Insurance Liens

 

Some of the most common liens in a workers’ compensation claim include those asserted by medical providers or health insurance carriers.  These liens typically arise in the following situations:

 

  • Denial of primary liability;

 

  • Assertion of an affirmative defense after liability is accepted. Common situations include defenses related to the reasonableness or necessity of medical care, or treatment parameters issues; and

 

  • Payments mistakenly made by a health insurance carrier for treatment not properly submitted to the workers’ compensation carrier for payment.

 

 

Providing Notice to Interested Third Parties

 

In many jurisdictions, the parties to a workers’ compensation claim are responsible for including these interested parties in the claim, including taking the following steps:

 

  • Putting the medical provider or health insurance carrier on notice of their rights under the state workers’ compensation law;

 

  • Including the interested party on all pleadings served and filed during litigation; and

 

  • Making good faith efforts to resolve the intervention claims if the matter resolves before a hearing on the merits.

 

State laws that require notice of intervention rights typically include provisions where a party can extinguish recovery rights of non-responsive third party.

 

 

Adopting Best Practices to Lien Resolution

 

Members of the claims management team need to be proactive and scrutinize claims made by medical providers and health insurance carriers.  Part of the process includes affirmative defenses one can assert related to these claims.  It is important to be mindful of such issues as notice, statute of limitations, prohibited acts defense and employee intoxication to name a few.  Additional areas to consider include:

 

  • Recovery by the interested third party only in instances where the employee receives a settlement, judgment or award;

 

  • Requiring the third party to prove the medical bills are related to the workers’ compensation claim. This proof must include a close review of all bills and claims to ensure it is related to the work injury; and

 

  • Requesting a copy of an applicable health insurance policy. In some instances, the policies ability to recover may be limited by Plan language.  In some instances, a group health plan may be self-funded by the employer.  In these cases, the Plan may be willing to waive its entire claim.

 

In cases where there is a settlement, members of the claims management team should seek a settlement with the third party based on a reduced amount.  Arguments need to be made that include the strengths of defenses available to the employer/insurer and weaknesses of the employee’s claim.

 

 

Conclusions

 

Members of the workers’ compensation claims management team need to be proactive when it comes to the settlement of liens and intervention claims.  It is important to remain proactive on these matters and understand the recovery rights of all parties.  It is also important to treat all parties fairly and with respect.  Taking these steps can effectuate settlement and reduce program costs.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Key Steps to Avoid, Manage, and Win Workers’ Comp Litigation

Key Steps to Avoid and Manage Workers’ Comp Litigation You’re missing a great opportunity if you view your defense attorney as a necessary expense rather than an asset to your workers’ compensation program. Employers who partner with their lawyers throughout the entire claims process can see fewer litigated claims and more wins when they do go to court.

 

While some workers’ compensation payers say defense counsel are not their friends, those who do find they have better outcomes and lower overall program costs. It involves getting the right attorney and treating each other as a fiduciary.

 

 

Attorney’s Role

 

The main function of your attorney is to represent your organization’s interests in legal battles. However, many employers are expanding the role of lawyers; making them part of a team focused first and foremost on reducing your losses. Rather than trying to control costs by keeping attorneys at bay unless and until a suit is filed, they have realized better results by working closely with them throughout the process.

 

The idea is to get the perspectives of several professionals before making decisions, such as whether to accept or deny a claim and how to proceed. The team approach creates a synergy, yielding better outcomes. Your defense attorney should play a prominent role in the group.

 

Ideally, the attorney should be involved from the very beginning — sometimes, even before a claim has been filed. Employers and payers should be able to contact their defense attorneys by phone or email and:

 

  • Ask questions based on the information you have.
  • Get advice on whether to accept or deny the claim.
  • Find out their thoughts on how best to limit exposure.
  • Get recommendations for particular experts, such as independent medical examiners.
  • Hear suggestions for investigative techniques.

 

It’s also incumbent upon payers to provide their attorneys with as much information as possible about the injury and the affected worker. For example, letting the lawyer know about an injured worker’s preexisting condition or the fact that he has been in therapy for three months could change his opinion and advice on how to move forward.

 

 

Getting the Right Attorney

 

If you wouldn’t feel comfortable contacting your attorney early in the claim process, you might want to find another attorney. If the lawyer starts billing you as soon as she picks up your phone call, she is not a ‘team member’ invested in your program.

 

To ensure you have the best attorney, look at his bills. He should not nitpick or overcharge you for simple questions or advice, and should be willing to explain all his charges.

 

Avoiding contact with your attorney at the beginning of a claim as a way to control costs should not be an issue. Your attorney should treat you as a friend and be willing to provide his thoughts without increasing his fee.

 

 

Winning in Court

 

Despite the best efforts of all involved, some claims will be contested. Having your defense attorney involved from the beginning gives you a leg up in court Additionally, you’ll have a competitive advantage if you investigate every case early and thoroughly, and be ready to try every single case.

 

While the employer technically does not have the burden of proof, in reality, that is how they should proceed. Payers should prepare based on the premise that they, not the injured worker, have to prove their case.

 

Among the most effective tools to gather early in the claims process are:

 

  1. Written statements. The injured worker, supervisor, and any witnesses should be questioned and asked to sign statements attesting to their recollection of the incident. These can be a great tool later in court if these same individuals have different memories of the incident.

 

  1. Videos. A recording of the actual event as it happens is ideal, but not always available. However, several types of videos can help with a case:

 

  1. Video of the area. The judge and others will have a clearer understanding of how the incident occurred if they can see the actual conditions.

 

  1. While an actual recording of the incident may not be available, you can try to recreate it. This might show that the incident could not possibly have occurred in the way it was described.

 

  1. Short video of the job. This will help educate the judge, as well as the treating physician, IME, and the attorney. For example, it might show a different version of the worker’s tasks than what he has described, leading a physician to clear him to return to work.

 

  1. Outside angles. Cameras outside the area or the building may provide valuable insight, such as if the injured worker suddenly loses his limp when he steps out of the building.

 

  1. Social media. Payers should peruse a variety of social media sites. Younger workers, especially, are prone to post themselves in many environments and activities, some of which may be in direct contrast to their alleged injuries.

 

An effective defense attorney goes above and beyond the norm. That means presenting the evidence in the most persuasive manner possible.

 

Rather than just going to court with written statements, the attorney should bring people to testify, including the supervisor, the physician — in person or via phone — and witnesses who have signed statements. Live testimony from the injured worker or witnesses who recall the incident differently than they had originally can be asked to read aloud their written statements. The attorney can also ask the supervisor and witnesses to dress the way they were on the day of the incident as it lends more credibility.

 

 

Conclusion

 

Working closely with your defense attorney can help you identify the cases you should accept and those you should fight. Getting the attorney involved early in the process and doing a comprehensive investigation can avoid litigation in many cases, and help you win cases that do go to court.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Work Comp Compensability – Understanding Jurisdictional Questions

Work Comp Compensability – Understanding Jurisdictional QuestionsProactive members of the claims management team need to be fully engaged on important issues.  This includes handling various questions of compensability that need to be answered on every claim.  Common questions include applying the law to the facts of the claim and often making decisions with little to no legal guidance.  Questions of jurisdiction are something all proactive team members must understand to run an effective program.

 

 

Questions of Jurisdiction

 

Issues of workers’ compensation jurisdiction vary from state to state.  It is important for members of the claims management team to understand the special rules that apply and seek legal counsel if they have any questions.

 

As a general rule, an employee is covered under a state workers’ compensation act in the state where they are hired or regularly employed.  When examining questionable claims from a jurisdictional standpoint, the following questions need to be asked:

 

  • In what state did the injury occur?

 

  • What state did the “last necessary act” of the hiring process take place? This is mainly a question in cases where the employee is hired via a telephone interview or travels to a different location during the hiring process.

 

  • Where does the employee spend a majority of their time or work activities? This is something that needs to be examined in instances where the employee travels or works remotely.

 

 

Issues Concerning Concurrent Jurisdiction

 

In some instances, more than one state can have jurisdiction over a workers’ compensation claim.  Members of the claims management team should pay close attention to these cases and engage legal counsel as necessary.

 

Concurrent jurisdiction in workers’ compensation claims typically arises in instances where the employee was injured in one state but performs a majority of their primary work activities in another.  Depending on the text of a workers’ compensation law, or case law interpretation, it can also occur based on the nature of an employment contract or collective bargaining agreement through a labor union.

 

 

Investigating Claims with Jurisdictional Issues

 

Claims that involve jurisdictional issues require immediate action by members of the claims management team.  Failure to do so can have a negative impact on the insured and possibly result in penalties.

 

  • It all starts with a quick investigation. Find out the specific location of the injury and determine what state it is in.

 

  • Review the applicable state law regarding jurisdictional issues. There may also be an issue of “concurrent jurisdiction.”  This is the result of conflicting state workers’ compensation laws and may allow the employee to choose the more favorable location to venue their claim.

 

  • Review applicable union and employment contracts. This includes a determination on how the employee was hired and where each actor (employee and employer representative) was at the time the hiring process was made official.

 

  • Obtain the assistance of legal counsel as necessary. This may include a legal opinion on what exposures are present in various jurisdictions.  Using the insurance “roundtable” to discuss these matters is another option.

 

  • Communicate findings to your claims management team and insured. It is important to do this promptly so thoughtful decisions can be made.

 

 

Conclusions

 

Although questions or jurisdiction are often clear-cut, it is important for members of the claims management team to understand the nuances of this confusing issue.  It all starts with a prudent and effective investigation, understanding of the law and use of legal counsel when necessary.  By taking the time now, all claims handlers can reduce workers’ compensation costs and confusion by adding jurisdictional matters to their initial survey of all incoming claims.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

3 Steps to Reduce Your Workers’ Comp Litigation Rate

workers comp litigation rateIs your litigation rate higher than you’d like? Do you know why?

 

There are myriad reasons injured workers hire attorneys to defend them, but there is often one overarching theme: fear.  By taking simple but highly effective steps, you can reduce the anxiety and significantly lower your litigation rate.

 

 

Why Hire Attorneys

 

Put yourself in the shoes of an injured worker, and you can begin to understand what they fear and how that drives them to hire attorneys. Say you’ve been in a particular job for several years, are doing well and suddenly you’re involved in an incident that renders you unable to work. And let’s supposed you like most people are unfamiliar with the specifics of the workers’ compensation system.

 

Now suppose you’ve been at home nursing your injury for a week. You’re in pain, the bills are piling up, your spouse is asking questions, and you haven’t yet heard from anyone connected with your employer or the workers’ compensation system. What would you do?

 

That scenario, in a nutshell, describes what far too many injured workers go through. Increasingly, they have fear:

 

  • Fear they won’t have money to pay their bills.
  • Fear they won’t have access to or money for proper medical care.
  • Fear they will lose their jobs.

 

While sitting at home seeing TV commercials for plaintiffs’ attorneys, many injured do what might be considered normal – they call a lawyer.  This situation is typical, and yet avoidable in the workers’ compensation system.

 

Showing empathy, communicating, and providing information are the primary tools to prevent a worker in the above scenario from hiring a lawyer. Creating an atmosphere of trust before injuries will help lower your litigation rate even more.

 

 

Eliminate the Fear

 

Knowing the fears mentioned above can help you avoid them. Here are some simple steps:

 

  1. Communicate. Getting in touch with the injured worker as soon as possible after the injury is crucial. The message should convey that you value the employee and want him back on the job as soon as he is ready. You can do this in a variety of ways:

 

  • Call. Just as you might call a worker who was out due to a non-work related injury, a brief phone call to inquire as to how the worker is doing shows you care about the person. You can also reassure the employee that his claim is going through the workers’ compensation process and let him know he will hear from those who are handling his claim.
  • Send a card. If another worker sustains a severe injury while boating over the weekend and is out of work, you might send a get-well card, right? It should be the same for an injured worker. They also want to know their employer and coworkers are concerned and thinking about them, and – especially in the case of injured workers – that their jobs will be waiting for him upon their return. A simple, inexpensive card with good wishes can make a world of difference to someone in pain and afraid.
  • Text. If it is a younger worker and someone who prefers texting to phone calls, send one. It can be short, ‘how are you doing today’ message.
  • Email. A quick email sends the message that you are thinking about the worker. You might also include something about the company – some news or a funny incident that happened with the employee’s coworkers.

 

  1. Explain the System. Those of us in the industry know the complexity of workers’ compensation. Imagine you are an injured worker, thrust into the middle of this process you don’t understand – or trust. You’d need someone or something to explain it to you. There are a couple of ways to do this:

 

  • Employee Brochure. A short, simple brochure should be given to all injured workers. It should tell them:
    • What to expect. It should say, for example, that the visit to the emergency room and follow-up medical bills will be paid. It should also include information about the workers’ compensation system and when and how determinations are made as to whether a claim will be accepted. It should also include a brief section explaining the consequences of fraud. You want the injured worker to know you care about them, but that you won’t tolerate abuse.
    • Who is in charge? Unless the company is self-insured, it should explain that the X company is the employer’s workers’ compensation insurer and that someone from that organization will contact the injured worker.
    • When/how. It should explain how and when the worker will receive benefits.
    • Perhaps most importantly, it should convey that you want the injured worker to return to the company as soon as possible, and provide information about light-duty work and other aspects of the employer’s return-to-work program.

 

  1. Create an Environment of Trust. Some organizations have a culture that discourages employees from reporting on-the-job injuries. There’s a message that doing so can hinder chances of a promotion or transfer, or may even result in firing. Ultimately, some injured worker in such a company will hire an attorney. Instead, you want to create an environment of transparency and trust. If your employees trust you, they are much less likely to engage attorneys when injured.

 

Talking openly about the workers’ compensation system is one way to do that; whether during safety meetings or through internal newsletters or emails. A brochure should be given to all employees to explain the workers’ compensation process and what to expect if injured, as well as provide information on how to report workplace injuries and illnesses.

 

 

Conclusion

 

Injured workers, like all of us, want to be treated with dignity and respect. Being injured and thrust into a system, they don’t understand people more vulnerable and insecure. By reaching out to them, showing empathy and explaining next steps, you create a trusting environment and can significantly reduce your litigation rate.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

4 Essential Elements of Work Comp Claims Investigation

workers' comp InvestigationIt is important for even the most experienced claims handlers to brush up on their claims investigation skills.  Doing so adds a layer of diligence to one’s claims investigation and improves client satisfaction.  It also provides an opportunity to look at things from a different angle and reduce workers’ compensation program costs in the long run.

 

 

Interviewing the Injured Worker

 

An effective claims management and investigative tool is the interview with the injured worker.  Not only are they a witness to the incident, but it can also help the claims handler and the team evaluate the case.  This includes the character and believability of the employee.

 

Important information to obtain from the injured employee includes:

 

  • How did the injury occur?

 

  • What type of work were they performing just prior to the incident?

 

  • How did they report the injury?

 

  • What was the extent of their injury?

 

  • Where did they receive medical care and treatment before and after the incident?

 

It is important to be friendly and remember the injured worker is a human being who deserves to be treated with respect and dignity.  One can empathize with the employee and still be an advocate for the insured.  Be sure to remain calm and establish rapport.

 

 

Determine Other Witnesses

 

This requires a member of the claims management team to act like a detective and ask the right questions.  Witnesses not only includes people who saw the incident occur, but others who know the employee’s habits and conduct.  It can also include people involved in the recovery of the employee.

 

Important information to obtain can include:

 

  • Activities or interests of the employee beyond work. Do they go to a certain restaurant?  Whom have they received medical care and treatment from in the past?  What organizations do they belong to?

 

  • A determination as to the employee’s educational and vocational background. It is also important to know if they have been involved in prior workers’ compensation claims or personal injury litigation.

 

 

Injury Site Reconstruction

 

Many denied or disputed claims rest of the proposition that an injury could not of occurred based on the described mechanism.  This is often relevant in repetitive injury cases where the employee is claiming the injury occurred over a period of time.  In these incidents, it is important for a medical or vocational expert to provide expert opinion testimony as to the physiological aspects of a claim.

 

Members of the claims management team may also need to work with a client who is not cooperative.  In order to capture this evidence, it is important to develop professional relationships and educate the insured on injury site reconstruction and evidence preservation prior to the occurrence of an injury.

 

 

Understanding the Law

 

Lawyers are a great source of accurate information concerning the law in workers’ compensation matters.  However, members of the claims management team need to understand the law.  The goal is to reduce program costs by limiting attorney referrals to those instances where it is necessary.

 

In the meantime, members of the claims management team can be proactive in this area without getting a law school education.  This can include:

 

  • Hosting defense attorneys for “lunch and learn” opportunities;

 

  • Attend continuing education programs with an emphasis on state specific rules and case law trends; and

 

  • Use in-house roundtable sessions to better determine what cases should be referred to legal counsel.

 

 

Conclusions

 

It is important for members of the claims management team to master the basics when handling workers’ compensation files.  This includes frequent refresher courses on handling claims with an emphasis in reducing workers’ compensation program costs.  This includes simple things that include interviewing witnesses, including the employee, and understanding this law.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

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

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

 

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

 

 

There are five common areas of employee workers comp fraud:

 

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

 

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

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

 

 

Steps to Prevent Workers’ Comp Fraud

 

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

 

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

 

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

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

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

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

 

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

 

 

Coverage

 

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

 

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

 

 

Description of Accident

 

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

 

 

Insured

 

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

 

 

Employee

 

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

 

 

Jurisdiction

 

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

 

 

Compensability

 

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

 

 

Reserves

 

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

 

 

Indemnity Benefits

 

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

 

 

Injury

 

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

 

 

Rehabilitation

 

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

 

 

Second Injury Fund (in states where it still exists)

 

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

 

 

Subrogation

 

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

 

 

Litigation/Legal Expense

 

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

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

 

 

Action Plan

 

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

 

 

Diary for Future Reports

 

  1. Date an updated status report will be provided

 

 

Attachments

 

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

 

 

Summary

 

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

 

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

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Reduce Work Comp Costs Through Advocacy Based Claims Management

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

 

 

What is “Advocacy Based” Claims Management?

 

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

 

 

It Starts with Words

 

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

 

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

 

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

 

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

 

 

Finding Common Ground

 

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

 

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

 

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

 

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

 

 

Conclusions

 

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

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Inside Tips & Tricks for Effective Social Media Investigation

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

 

 

Social Media: Going Beyond the Basics

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

 

Vehicle Tracking and Sightings

 

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

 

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

 

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

 

  • Establish a pattern of locations visited by an employee;

 

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

 

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

 

 

Keyword Search Technology

 

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

 

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

 

 

Conclusions

 

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

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

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

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

 

 

Start with Injury Prevention and Investigation

 

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

 

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

 

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

 

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

 

 

Promotion of Settlement Practices

 

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

 

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

 

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

 

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

 

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

 

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

 

 

Conclusions

 

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

 

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

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Professional Development Resource

Learn How to Reduce Workers Comp Costs 20% to 50%"Workers Compensation Management Program: Reduce Costs 20% to 50%"
Lower your workers compensation expense by using the
guidebook from Advisen and the Workers Comp Resource Center.
Perfect for promotional distribution by brokers and agents!
Learn More

Please don't print this Website

Unnecessary printing not only means unnecessary cost of paper and inks, but also avoidable environmental impact on producing and shipping these supplies. Reducing printing can make a small but a significant impact.

Instead use the PDF download option, provided on the page you tried to print.

Powered by "Unprintable Blog" for Wordpress - www.greencp.de