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

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

 

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

 

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

 

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

 

 

Ask the following:

 

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

 

 

Make use of a Nurse Case Manager:

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

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

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

 

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

 

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

 

 

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

 

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

 

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

Vigilant attention to the employee will ease this process.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Two Very Important Steps When Managing A Catastrophic Injury Claim

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

 

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

 

 

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

 

 

Step #1: Immediate Attention

 

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

 

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

 

 

Attorney Alert!

 

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

 

 

Step 2: Medical Management

 

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

 

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

 

 

Summary:

 

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

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Is Your TPA Recovering Every Subrogation Dollar It Should?

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

 

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

 

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

 

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

 

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

 

 

1 – Claim File Quality Audits

 

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

 

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

 

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

 

 

2- Reserve Audits

 

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

 

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

 

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

 

 

3- Subrogation Audits

 

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

 

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

 

 

4- Fraud Audits

 

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

 

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

 

 

Summary

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

6 Elements To Review In Your Adjuster’s Action Plan

Workers' comp Plan of ActionThe old adage “Time is Money” definitely applies to the handling of workers’ compensation claims.   Experienced claim professionals know the longer a work comp claim remains open, the higher the overall cost to conclude the claim. Every delay along the path from the start of the work comp claim to its conclusion costs your self-insured program or your insurer money (eventually coming back to your company as higher work comp insurance premiums).

 

Here are some tips and suggestions on ways that you, the employer, can speed up the processing of your workers’ comp claims.

 

 

Pre-Accident Training

 

Every employee needs to know what to do in the case of a work comp injury. Your company needs to set the stage for your involvement in the work comp claim process from the very beginning.

 

Your new hire package must include instructions on the proper and timely reporting of the work comp injury. The accident reporting instructions must specify that the injury must be reported immediately, to whom the employee reports an injury, who are the approved medical treatment providers (in the jurisdictions where this is permitted) and information informing the employee of the return-to-work program your company uses.

 

Display, where all employees can see them, posters and/or billboards clearly showing these requirements, including the importance of immediately reporting the work comp injury. Be sure to post these materials in the employees’ prime languages in addition to English.

 

Remind supervisors and managers on a regular basis that all work comp injuries are to be immediately reported to your work comp claims coordinator. The supervisors and managers should be familiar with the information required to complete the First Report of Injury form required in their state.

 

 

Prompt Reporting

 

When the work comp claims coordinator receives the information about the new work comp injury, the claims coordinator immediately reports it to the claims handling office. If for any reason the claims coordinator does not have all the information necessary, the claim is still reported to the claims office with a note indicating the rest of the information will be forthcoming as soon as it is available. This allows the work comp claims adjuster to go ahead and get started on the claim.

 

 

Claim Service Standards

 

When your company starts an insurance program, the insurer or third party administrator (TPA) should provide you with information on their claim handling service standards. Those service standards usually specify within how many hours the adjuster will contact the employee once the claim is reported to the claims office. Great service standards specify the employee will be contacted within 2 (or 4) hours, while good service standards specify the employee will be contacted within 24 hours. If the service standards are silent on how fast the work comp adjuster will be in contact with the employee, ask them to make the 2-hour contact with the employee a claim-handling requirement on your files. If the insurer or TPA is reluctant to require prompt contact with the injured employee, it is time to get another insurer or TPA.

 

 

Employee Follow-up

 

When employees are injured, they are concerned about their future with your company, their future income and their ability to care for their families. When the employee’s supervisor or your company’s work comp claims coordinator contacts the employee shortly after the accident, the employee knows and feels s/he is valuable to the company.

 

When the employee initially reports the claim to the employer, the employee is instructed to keep the employer informed of medical treatment and medical progress. Emphasize the employee can expect to hear from the employer if the employee does not provide timely updates to your company.

 

Keeping in contact with injured employees lets the employees know the employer cares about them and their well-being. Employees who feel valued by their company are less likely to malinger off work when they could return to work, or hire an attorney.

 

For employees who are off work for an extended period of time, the claims coordinator should be contacting them on at least a monthly basis to inquire about their condition, their treatment and their expected return-to-work date.

 

 

Medical Follow-Up

 

In the majority of states the employer is allowed to contact medical providers in regards to when the employee is medically able to return to work. Regular follow up with medical providers reinforces the importance of the employee returning to work.

 

 

Return to Work Program

 

Employees should know the expectation is they will return to work as soon as medically able. Often an employee is willing to return to work, but the treating physician is concerned that the employee may be re-injure by attempting to return to work before full recovery from the accident.   Or, the employee is afraid to return to work because of concerns for his/her own safety. To protect themselves from malpractice claims, doctors often keep employees off work longer than is necessary.

 

The best way to alleviate both the fears of the employee and the fears of the doctor is to have a modified duty return-to-work program available to accommodate the employee. A modified program allows them to return to work before they are 100% recovered from their injury. The return-to-work program is structured to remove from the employee’s regular routine the activities the doctor feels could possibly cause the employee to be re-injures, whether it is a lifting restriction, standing restriction, bending restriction, etc.

 

The sooner the employee is back on the job, the sooner the employee fully recovers from the injury. A modified duty program provides the employee with physical reconditioning for the work they will be doing when the job restrictions are lifted by the treating physician.

 

The return-to-work program has a major impact on the amount of temporary total indemnity benefits are paid to the employee, reducing your overall work comp cost. Plus, when the treating physician states the employee has reached the maximum medical improvement, the employee who is back to work will normally receive a lower permanency rating then the employee who is still off work. The lower permanency rating also translates into lower work comp cost for your company.

 

 

Summary

 

Follow the proper steps throughout the work comp claim process from before the accident occurs, to when the employee returns to work. The time saved translates into savings for the employer through lower workers’ compensation cost and improved productivity by the employee being back on the job sooner.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Avoid Ethical and Legal Pitfalls In Workers’ Comp Surveillance

Surveillance can be an effective tool to reduce costs in a workers’ compensation program.  While many service providers can show “injured” employees doing some crazy activities, it comes with a price and often does not produce the desired results.  Before hiring a service provider to engage in surveillance activities, claims handlers and their managers should understand how to use it in an effective manner.

 

 

Use of Surveillance in the Right Case

 

The sheer volume of workers’ compensation claims coupled with the cost of surveillance limits the amount of cases that can use this discovery tool.  A proactive claims management team must set parameters on when it is to be used and for the length of time to conduct surveillance on a suspect employee following a work injury.  Cases that are prime for using surveillance often include:

 

  • Cases where the claimant is likely to or has made a claim for permanent total disability cases. It is understood that these are the cases with the most exposure.  This can also include catastrophic work injuries and their resulting complex claims;

 

  • Instances where you receive a report of possible fraud or other information the employee may be engaging in suspicious activity that exceeds their stated limitations or abilities. Tips should obviously be carefully vetted.  This is especially the case where the tip is anonymous.  Always consider the source; and

 

  • Instances where the information being reported by the employee does not coincide with verifiable information.

 

 

Avoiding Ethical and Legal Pitfalls

 

There are ethical and legal implications to surveillance that may impact your cases.  It is important to act within the confines of the law and other regulations governing a workers’ compensation act.  This also applies to the service providers you hire.

 

Before hiring a service provider, it is important to do your homework.  Before hire them, it is important to verify the company has the requisite licenses or permits to engage in surveillance activities, if applicable.  It is also important to verify the people conducting work on your behalf know the law and follow them.  Checking with state agencies or business bureaus regarding complaints or infractions is a necessary step.

 

 

Practice Pointers and Effective Techniques

 

Given the costs of most surveillance activities, it is important for claims handlers to do their homework in advance.  They should know when the claimant will be in public and report that information to the service provider.  Key events can include:

 

  • When the employee has a doctor appointments or will be seen by an independent medical examiner;

 

  • Civic groups or organizations they belong to and when certain events they may attend will take place; and

 

  • Other activities they like to do outdoors such as exercising or even if they get the mail, go to the grocery store or visit a local coffee shop.

 

 

Selecting the Right Private Eye

 

Other tips for effective surveillance include:

 

  • Selecting a service provider with a track record or proven results; and

 

  • Authorizing a service provider to conduct surveillance activities for at least two to three days in a row. It is also important to allow the investigator to work for at least eight to 10 hours per day to maximize the chance of better results.

 

 

Conclusions

 

Surveillance can be an effective tool to resolve workers’ compensation claims in a timely manner.  It is costly so it is important to use this tool wisely and within the bounds of the law.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

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

 

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

8 Categories To Define Winning Workers’ Comp Litigation Strategy

Legal fees in litigated workers compensation claims can quickly become a significant part of the overall claim cost.  Fortunately, there are some very good ways to control legal cost without having a negative impact on the overall claim settlement.  The best time to establish control over legal fees is when the defense attorney is first employed; however, the best time to control the overall strategy of the litigation is before counsel is even hired.

 

Prior to hiring counsel, a fast track defense strategy should be established to ensure that appropriate actions are taken immediately upon notification of a claim. [The individual components of a fast track strategy are beyond the scope of this article.] The establishment of some basic ground rules for the legal fee billing before the attorney goes to work on the workers compensation claim will result in a measure of cost control without sacrificing the best possible settlement of the claim.

 

Litigation cost control is much more than negotiating the hourly rate and whether or not you will be charged for postage.  There are Best Practices for Litigation Management that should be utilized as a major part of your legal cost control.  The Litigation Management Best Practices can be broken down into easy to measure performance goals.  The following questions will assist you in determining if your current litigation program is controlling cost fully.

 

 

Defense Counsel Selection:

  • Is the defense counsel on your company’s list of approved counsel?
  • Is the defense counsel selected a law firm, or a specific attorney (preferably), within the law firm? Many carriers have an “approved list” of attorneys they use; this doesn’t necessarily mean those are the best attorneys or the most knowledgeable for your purposes, so consider their qualifications carefully and if you have another attorney you wish to use, discuss adding him/her to the list of approved counsel.
  • If the defense attorney is new to representing your company, has the attorney been provided the terms and conditions of the assignment?
  • Have they visited your operations, seen your products and know the basic requirements of the jobs within your workplace?
  • Have the reporting requirements been clearly stated?
  • Was a litigation budget request incorporated into, or attached to, the assignment letter?

 

The Answer:

  • Did the workers compensation adjuster refer the matter to defense counsel timely when an answer must be filed?
  • Does the employer provide the complete facts of the injury immediately such as how the injury occurred, photographs of the accident, information about weight of objects lifted, the employee’s application for employment, information about any prior injuries, prior claims, or prior medical absences. Having the employment file is very helpful.
  • Does the defense attorney have everything needed to complete ALL blanks on the First Report of Injury. Does he have the OSHA Report?
  • Does the defense attorney offer arbitration or mediation as an alternative to protracted litigation?

 

Initial Legal File Handling:

  • Are all medical and/or indemnity issues covered by the workers compensation policy?
  • Is the potential exposure on the claim evaluated correctly?
  • Is there an economic justification for a quick disposition of the claim?
  • Are there any statute defenses that need to be addressed?
  • Are there any unique aspects of the claim that could alter the outcome favorably or unfavorably?
  • Are all potential third parties noted?

 

Defense Counsel Acceptance:

  • Does the defense counsel send an acknowledgment of the assignment to both the workers compensation adjuster and to your workers compensation coordinator?
  • Does the defense counsel provide an initial review and evaluation report within the first 30 day?
  • Does the initial review offer alternative courses of action and the probable outcomes?
  • Does the defense counsel provide a detailed budget plan within the first 30 days?

 

Defense Counsel Staffing:

  • With the acceptance of the assignment, did the defense counsel specify who will be working on the claim?  (Unless the claim is extremely complex, the defense attorney, possibly one junior associate and one paralegal are all of the law firm that should be involved.  Multiple associate attorneys and multiple paralegals will add time [cost] learning the claim before being able to proceed with an activity).
  • Is the hourly rate for each of the law firm members clearly stated?
  • Does the attorney do work that should be done by the paralegal?

 

Budget:

  • Is the budget completely itemized?
  • Is research time included only for extraordinary issues?
  • Does the budget include the cost of any experts that will be retained?

 

Claim Handling:

  • Does the defense counsel make recommendations for any additional adjuster work that should be done?  (Defense attorneys are notorious about having the paralegals do the adjuster’s job of obtaining medical records and other documentation).
  • Does the defense attorney have the adjuster hire other vendors (surveillance, nurse case managers, vocational rehabilitation, etc.) or does the defense attorney complete the adjuster’s work?

 

Actions of Defense Counsel:

  • Is defense counsel avoiding the expenses of depositions and other discovery if it is the intent to settle the claim? Often, some discovery prior to settlement can reduce the amount of the ultimate settlement.
  • Is the defense counsel requesting only necessary depositions?
  • Is the defense counsel reporting significant developments timely?
  • Is the defense counsel reporting the progress of the claim at least every 90 days if the case is moving slowly?
  • Do the reports from defense counsel cover all pertinent information without repeating prior reports?
  • Does each report include an action plan to move the claim forward?

 

Hearings / Trials:

  • Is the hearing / trial date reported as soon as it is known?
  • Does the defense attorney provide a pre-hearing / pre-trial report at least 30 days ahead of hearing / trial?
  • Does the defense attorney provide a strategy for the hearing / trial?
  • Does the defense attorney timely request additional settlement authority when needed?
  • Does the defense attorney provide a timely update or report on the hearing / trial?

 

Legal Bills:

  • Is the amount billed for each activity appropriate?
  • Are the bills properly itemized with each activity being billed separately?  (As opposed to block billing where several activities are lumped together and one charge is given for all work done).
  • Do the legal bills follow the defense attorney stated course of action?
  • Are the legal bills in compliance with the litigation budget?

 

If you are uncomfortable trying to control the litigation cost or feel you need an expert to review the litigated workers compensation claims, please contact us for assistance.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©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 Prongs To Crystal Clear Workers’ Comp Investigation

Incident Injury Report Form Document Concept

Many employers miss a golden opportunity to control the cost of their workers’ compensation claims by failing to take appropriate action to investigate a workers’ compensation claim when it is reported.

 

 

Crystal Clear Employee Report of Incident

 

The employee should be asked to provide a written description of what caused the accident and to offer his/her opinion on how the accident could be prevented in the future.  The employee’s recall immediately after the accident is more complete and will be the more accurate then months or years later.

By having the employee document the accident details and the nature and scope of the injury, the employee is prevented from embellishing the details of the event later if he/she decides to capitalize on the injury by pressing for a higher than justified settlement of the claim.  Also, by having the employee specify exactly what body parts were injured, it limits the employee’s ability to bring in additional body parts at a later time.  For example – the employee fell and hurt his elbow. By having the written description of the injury from the employee, the employee cannot claim months later he/she also hurt her knee in the accident.

If the employee is manufacturing a claim, or even has a legitimate injury, the employee will be reluctant to try to expand the claim when he/she knows she has committed the details of the accident and the extent of the injury to a document that the employer has.

 

 

Witness Report of Incident

 

The written accident report of the employee is made more beneficial when the employer also obtains a written statement from each witness to the event.  The independent witnesses are an excellent source of information about the accident, and the extent of the injury to the injured employee. Beware of the accident that has no witnesses, or only a witness who is a close friend of the employee.

 

The information collected from the employee and the witnesses should be reviewed by either the employee’s supervisor or someone knowledgeable about the work process to verify the information provided is accurate.  The employee’s accident statement and the witness statements should be provided to the workers’ compensation adjuster, along with the First Report of Injury form.

 

If the employer has knowledge of a previous workers’ compensation claim, that information should also be provided to the adjuster.  Any information about accidents or injuries the employee has had in the past should be shared as well.  If the employee is known to participate in strenuous physical activities, sports or hobbies, that should be disclosed to the adjuster as well.

 

 

Adjuster Recorded Statement

 

If the adjuster has any reason to question the claim, the adjuster will often take a recorded statement from the employee.  The adjuster will be particularly interested in deviation of the accident details, or the nature and scope of the injury, from what the employee provided to the employer.  The adjuster in addition to inquiring about the accident details will ask the employee about any prior injury claims, any other accidents (for example – personal automobile accidents) and any prior injuries to the same body part (for example – previous back injury).

 

 

Properly Investigate All Accidents

 

The majority of workers’ compensation claims are valid and the employee deserves the medical care and indemnity benefits specified in the workers’ compensation statutes.  The investigation of the claim identifies those claims that are questionable or fraudulent and should be resisted.  The investigation also limits the ability of the employee of questionable character in exploiting the legitimate workers’ compensation claim.  We strongly recommend you establish the protocol of investigating all accidents.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©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.

 

 

RIMS 2017: Leverage Michael J. Fox’s Lessons to Prevent Creeping Catastrophic Claims

[photo courtesy https://michaeljfox.org]

Most people wouldn’t think of Parkinson’s Disease as a gift. But for Michael J. Fox, that’s exactly what it is. “It teaches resilience and optimism,” the actor and ‘PD’ advocate said at RIMS 2017 in Philadelphia.

 

Speaking to a packed audience at the closing ceremonies, Fox regaled attendees with stories of his life growing up in Canada, his success in Hollywood, and how he’s used his celebratory status to advance awareness and research into the disease that threatened to end his career more than 25 years ago. His own resolve and the tools he’s developed have allowed him to continue leading a happy and productive life and can serve as lessons for the workers’ compensation industry.

 

 

Fox’s Journey

 

If you asked any of his 4 kids to list 10 factors about ‘Dad,’ Parkinson’s Disease would probably not be among them. “’Annoying’ might be on their lists, but not PD,” he said. Humor is one of the characteristics that help define Fox.

 

“I was playing golf in my 40s and someone asked, ‘what’s your handicap?’ he said. “I said, ‘isn’t it obvious?’”

 

But his self-deprecating, easy going manner about his condition took a while to materialize. Fox was 29 and making the movie ‘Doc Hollywood’ when he woke up one day with a twitching pinky. Attributing it to a hangover after a night out with fellow cast mate Woody Harrelson, Fox was shocked to later learn he had PD, and even more stunned when the neurologist “nonchalantly” told him “you have 10 years left to work.” The powerful impact of those words resonates even now, as Fox teared up on stage as he related the story. But Fox’s decision to live with acceptance instead of resignation led him on a different path.

 

Fox studied up on the disease and soon found a community of people with PD and their advocates. He went on to create the foundation that bears his name to focus on the most immediate need: research dollars. To date, the Michael J. Fox Foundation for Parkinson’s Research has raised more than $750 million.

 

Career-wise, the 55-year-old has acted well beyond the 10 year limit he was given. Describing himself as a ‘happy guy’ Fox has also written three books since his diagnosis, and he and his wife, actress Tracy Pollan are celebrating 29 years of marriage.

 

 

Attitude

 

Michael J. Fox had lots of support when he was diagnosed. He was already a beloved actor in a solid marriage and had lots of friends. But even he admitted that “you need support” to be resilient and optimistic in the face of a potentially devastating health determination.

 

Many injured workers whose claims turn into creeping catastrophics have little or no such support. Those who have been in the depths of despair and managed to regain function and return to work often speak of the encouragement they receive from people trying to help them as a deciding factor. A medical provider who exudes positivity rather than giving up on the patient, or a nurse case manager who is able to convince a patient that he will be able to go fishing again can change the course of recovery.

 

Injured workers generally believe what they are told. Those who are at risk of having their claims deteriorate may either develop a disability mindset or return to productivity and function. A supportive, positive attitude from the entire team — claims adjuster, medical providers, nurse case manager, and employer can help keep a claim on track for a positive outcome.

 

 

Reframing the Focus

 

Injured workers themselves say reframing a negative message makes a huge difference in their own attitudes and, ultimately, their recoveries. Focusing on what the injured worker can do, rather than what he can’t, changes his mindset.

 

Pain is more an experience than a sensation. Injured workers who can eliminate their fear of pain and refocus their attention on what they have rather than what they have lost find their pain levels reduced. It also helps address depression, which can exacerbate the disability mindset.

 

 

Conclusion

 

The vulnerability of an injured person cannot be overstated. Whether it is a high profile, much admired celebrity or a typical employee who has suffered a sudden injury, both need support, encouragement and advocacy to reach the best outcome.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

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

 

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

How To Use Central Index Bureau To Stop Workers’ Comp Fraud

One of the best fraud fighting tools is provided by the Central Index Bureau report, a division of the Insurance Services Office. It is known as a Central Index Bureau report, a CIB report, an ISO, or as a claim index. The terminology varies from insurance company to insurance company. Regardless of the name, the CIB is a basic record of the insurance claims filed by an individual. What makes it effective is it is one of the very few areas where insurance companies share information.

 

Over 90 percent of all insurance companies are members of the ISO Central Index Bureau. Be sure your insurer is a member too. If not, the insurance company may be paying fraudulent claims which will have an adverse impact on workers compensation insurance premiums.

 

 

Information Reported to Central Database On Every Claim

 

When one of the employees files a workers compensation claim, the basic information about the claim and the claimant (employee) is obtained. The CIB report will contain the claimant’s name, social security number, maiden names, aliases or former names if known as well as address, former addresses if known, occupation, and date of birth. The CIB report will include the accident location, the date of the accident and the alleged injuries. It will identify the type of injury whether it is automobile bodily injury, general liability bodily injury, automobile medical payments or PIP, workers compensation, homeowner’s liability, medical malpractice, or a non-occupational disability claim.

 

The report will identify the medical provider by name and address as well as the lawyer’s name and address if the claimant is represented. The report will also contain the adjuster’s name, the name of the insurance company (or third party administrator), the insurance company’s address, and even the adjuster’s phone number. It identifies who the insured is for the insurance company and the insured’s address.

 

 

Protect Yourself From Paying For Prior Injuries

 

Why is all this information reported to the insurance services office on every insurance claim, including property claims? The reason is to protect the insurance company from paying for a prior injury. The claimant’s attorney is not going to tell the insurance adjuster that he has previously represented Mr. Bad Luck on his five previous injuries, two auto accidents, one slip and fall, and two workers compensation claims against five prior insurance companies.

 

 

Example: Employee Sustains Injury Every Deer Hunting Season

 

Take the example of Mr. Bad Luck. When the workers compensation adjuster interviewed Mr. Luck, he stated he was in excellent health, had never had a real injury before, but now he severely injures his back. The adjuster is alert. She electronically files the Central Index Bureau report and receives an electronic report that lists all the information on Mr. Bad Luck, even though his social security number was changed 3 times and his address four times. Suddenly the claimant has selective memory about previous injuries.

 

In one claim file audit of governmental pool‘s workers compensation claims, the auditor notices the adjuster has received 18 hits (prior injury claims) on one unfortunate employee. The employee was employed 17 years with the same city government during each of the 18 workers compensation injuries. Of the 18 injuries, 14 of the injuries occurred in the first two weeks of November in fourteen different years. It turns out the claimant is a deer hunter, and deer season is the last two weeks of November.

 

Fortunately the claimant always made a fairly quick recovery from various strains and sprains and was able to return to work on the first Monday of each December. The claimant is committing fraud by taking a two to four week leave of absence each year paid for by workers compensation. The employer knew this, and the adjuster knew it too. Why they did not prosecute the claimant for fraud is unknown.

 

 

Fraudulent Employees Often Switch Doctors

 

Please note that most adjusters reviewing a case like this will be aggressive about the claim when the claimant is alleging a new injury to a body part that was part of a prior injury claim.

 

Injured employees like Mr. Bad Luck above will often change doctors so that they can tell the doctor they have no previous injuries. The smart adjuster will share the information with the medical providers on the claimant’s prior injury by obtaining and providing the relevant medical records from the prior medical providers. Also, there is something about the claimant knowing the adjuster is aware of prior injury claims causing many claimants, even those represented by an attorney, to make a speedy recovery.

 

 

Central Index Bureau Submission as Standard Best Practice

 

Make sure the use of Central Index Bureau submissions is a standard part of best practices and is included in your account handling instructions.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

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

 

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

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