Worldwide Business Network Chronic Pain Management & Other News Tidbits

Worldwide Business Network w/ Kathy Ireland: Chronic Pain Management

For many injured workers chronic pain can give way to the overuse of pain medications, prolonging the functional restoration and well-being of the individual.  Watch Broadspire Executive VP of Medical Management on a Fox Business segment discuss pain management and early intervention services which put the right processes in place to successfully return injured workers to work.

 

 

 

Tower MSA Partners Selects Patricia Smith as EVP, Clinical Operations

Patricia Smith, RN, BSN, MSCC, CDMS, CLCP has joined Tower MSA Partners as executive vice president of Clinical Operations. In this role, Smith reviews and monitors clinical trends related to Medicare coverage criteria within the confines of Medicare Secondary Payer compliance, develops clinical strategies to support company’s pre- and post-Medicare Set-Aside intervention workflow and manages all clinical and pharmaceutical oversight teams.

 

 

Chicago Area Settlement Planning Consultant joins Ringler

Ringler, the nation’s largest settlement planning company in the nation, is pleased to announce that Derek J. Perkins, CSSC, of Rockford, Illinois, is joining Ringler as a Settlement Planning Consultant.  Mr. Perkins joined the Structured Settlement industry after an extensive career in Finance as a former CPA and having held a management position at Protiviti’s Credit Risk Management practice. His success in settlement services is directly attributed to his financial background that helps to bring credibility to the table.

 

 

4 recent updates to the drug pipeline

Over the past month, Express Scripts’ Emerging Therapeutics team focused on four new drug approvals. n February 6, the U.S. Food and Drug Administration (FDA) approved Gammaplex® 10% (immune globulin intravenous [human], 10% liquid). It is indicated to treat adults who have primary immunodeficiency (PI) or chronic immune thrombocytopenic purpura (ITP). The manufacturer, Bio Products Laboratory, also markets Gammaplex® 5% (immune globulin intravenous [human], 5% liquid in the U.S. Intravenous immunoglobulins (IVIGs), are used as replacement for patients who have immunoglobulin deficiencies. They are dosed by weight. For treating PI, one Gammaplex 10% infusion is recommended every three to four weeks.

 

 

Do What You Love, Where You Love Doing It

Work and play is what life is all about. Wouldn’t it be great to take care of people who work in all types of industries and not worry about billing them?  While doing what you love, where you love to be?

 

 

 

 

 

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

 

Author Michael Stack, Principal, COMPClub, 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 of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

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.

 

5 Ways to Get to the Bottom of Work Injury Causation

Some things were a lot simpler back in the day, like determining whether an employee’s injury or illness should be compensated through workers’ comp. Workers tended to stay with the same employer throughout their careers, creating a solid trust level on both sides. Employees also were more inclined to retire earlier, before the onset of age-related and comorbid conditions.

 

But things are more complicated now and proving causation can be a tricky business. You want to ensure that injured workers who sustain work-related injuries at your company are duly compensated, but you certainly don’t want to pay for injuries that did not result from your employ. While determining causation is not an exact science, there are some tools you can use to assure you pay only for those injuries truly related to your workplace.

 

  1. Investigate

The best place to start is at the beginning, as soon as you get word of an injury or illness. Work with your team to find out what happened. In addition to speaking with the injured worker, talk to any witnesses. Drill down to the details. Ask lots of questions – of witnesses and others who may have been aware of potential problems in the area in question. Take pictures of the area, since that may shed some light on what was happening at the time. If nothing else, you may at least uncover a festering problem in your workplace that can be corrected to prevent another injury.

 

 

  1. Look at the mechanism of injury

The MOI can reveal valuable details to medical professionals about injuries to the bones, skin, muscles and organs. Did the person fall from a height? How high? Or, was it a ground level fall? If it involved a motor vehicle accident, what speeds were involved? Get as many details as possible as soon as possible after the injury is reported.

 

 

  1. Understand chronic vs. acute

While the medical nuances are best left to those in the biz, you can at least have a general idea so you can speak the lingo with medical providers, adjusters and others. The problem with chronic conditions is that they affect just about everyone on the planet in some way, at some time, and often we don’t even know it’s happening to us. Degenerative changes may build up somewhere in the body yet the person has no awareness of it until an awkward movement at work renders him wracked with pain. Of course, he assumes it is work related. But maybe it’s not.

 

For example, arthritis is not typically aggravated by soft tissues trauma, so check that out before you agree to pay for a knee replacement in such cases. Researchers have found that low back pain — one of the most common ailments among injured workers — often has a genetic basis rather than a link to an occupational activity. A rotator cuff injury may be chronic, especially if it is associated with muscle atrophy; however, such a tear may become larger after acute trauma.  And, contrary to what many believe, carpal tunnel syndrome does not necessarily result from keyboarding. It behooves you to request and get medical evidence to help identify what is your responsibility under workers’ comp and what is not.

 

 

  1. Use quality providers

Seek medical providers who use evidence based medicine, especially in jurisdictions where you have a say in the physician the injured worker sees; look at their credentials — board certification, etc., and check out their educational backgrounds. Same with other providers and medical facilities — you want to make sure the MRI that’s the basis of your decision on a claim is of high quality and read by a top notch radiologist.

 

If you use a medical expert in a challenge to a claim denial, find one that is believable. Ask questions such as how the provider arrived at a certain diagnosis, whether the MOI was accurately described and applied, and how EBM pertains to the case.

 

 

  1. Know the law

 

Causation standards have changed in a number of states in recent years, with many requiring work to be the major contributing cause of injury. However, some injured workers and their attorneys have become more adept at challenging those standards.

 

There are also legislative proposals in several states that would ensure first responders are compensated for instances of post-traumatic stress following an incident on the job. Still other statutes or proposals would guarantee benefits to firefighters who contract certain cancers. It would be a mistake to assume all states have the same types of allowances for workers’ comp benefits.

 

 

Conclusion

Weeding out the legitimate claims can be tough, as there is often no black and white answer. By being proactive when a claim is first reported and using the right experts, you can save yourself headaches, time and money.

 

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

 

Author Michael Stack, Principal, COMPClub, 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 of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

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 Strategies to Eliminate Chronic Pain Claims

Chronic pain is the most prevalent health condition in the U.S. workforce with cost estimates of more than $100 billion annually in lost productivity, healthcare, and workers’ comp/disability payments.

 

The good news is medical science and research has evolved to enable the workers’ comp community to effectively address this prevalent and costly issue. The bad news is many employers and payers believe the steps needed to move injured workers from chronic pain status to productive individual are too complicated and too expensive. They are wrong.

 

 

Typical case

 

A 45-year old male sustains a ‘minor’ twisting injury while lifting something at work. He’s anxious to get back on the job and optimistic about his recovery, based on what his physician tells him. Seven years later — after umpteen surgeries and a smorgasbord of additional medical procedures — his chronic back pain is such that he cannot stand longer than 2 minutes, uses a walker and is afraid to move off the coach for fear he might cause more damage and more pain. He takes a long list of medications, especially opioids and other drugs to counter their side effects, and his wife is threatening to take the kids and leave. One can only imagine how much is being spent on this injured worker.

 

What could have helped this injured worker soon after his injury — and even years later, is a combination of coordinated care, more accurate diagnoses, and attention to issues beyond just his physical ailment.

 

 

Approaches to Pain

 

In the scenario above as in many other cases, the physician took a biomedical approach, which assumes all pain symptoms have a specific cause and once alleviated, the pain will disappear and the patient will be fully recovered. But for many people, this method just doesn’t work.

 

Research shows that chronic pain is a complex and dynamic interaction of psychological and social factors as well as biological conditions. A biopsychosocial approach is what is needed; a multidisciplinary effort that includes physical therapy, occupational therapy, psychology, neuromuscular massage and other experts. There are several things that could have been done in the above situation..

 

  1. Identify at-risk injured workers

A variety of potential red flags could have alerted the injured worker’s case manager and others involved in his claim to issues that might exacerbate the patient’s pain. Among them are:

 

  • Getting medications dispensed from his physician.
  • Recommendations for implanted devices.
  • Getting medical treatment outside the network.
  • High medication costs and increased use of medications.
  • No functional improvement by anticipated dates, despite various treatments.
  • Adverse childhood experiences — such as verbal, physical or sexual abuse; neglect; family dysfunction.

 

Chronic pain cases require interventions early on to prevent them from digressing to the point of the patient described above. The claims management team should have had weekly conversations with the medical providers to get updates on his progress. A thorough medical history should have been done to find out of the initial medical diagnosis was correct. A look at the injured worker’s family situation and other psychological challenges should have been investigated and addressed.

 

 

  1. Set Realistic Goals

 

All human beings are not alike and treating people for chronic pain should not be a one-size-fits-all method. However, the goals of treatment for anyone with chronic pain should be the same. These should include:

 

  • Ensure the patient has realistic expectations. An injured worker may not be able to be completely pain free, but he can still be a functioning member of society. Patients in pain need to understand that, and be given tools to help them manage their pain.
  • Provide education to help the person gain a locus of control, instead of feeling he is at the mercy of others. The injured worker should be just as involved in medical decision-making as anyone else involved in the claim.
  • Quality medical care that is evidence based. Treatment should be based on scientific studies to guide clinical decision making; ensure consistent, proven medical practices are used; and reduce unproven, ineffective care. The effect is better medical outcomes at lower costs.

 

 

  1. Use elements of Biopsychosocial Approach

 

There are a variety of treatments available that have been shown to help at-risk injured workers in chronic pain return to work. Whatever is used should be a process that helps the person gain the skills, knowledge and behavioral change necessary to avoid medical complications and take charge of his physical and emotional well-being after the injury. Treatments may include:

 

  • Pharmacological interventions to wean the person off opioids.
  • Psychological aspects to assist with psychosocial issues.
  • Cognitive behavioral sessions that focus on function and coping with pain. They may include relaxation training, guided imagery, desensitization, and addressing anger and entitlement issues.
  • Physical and occupational therapy. This may involve aquatics therapy, Tai Chi or Yoga, spine stabilization and stretching, and aerobic conditioning.
  • Follow-up care. Since at-risk workers may be vulnerable to reinjury or lapsing into disability mindset, there should be consistent communication with various referral sources, either face-to-face or by phone.
  • Include family and friends. The home and social lives of injured worker are key factors in recovery, so enlisting family members and friends to support the patient and reinforce positive outcomes should be strongly considered.

 

All treatments should be undertaken within a coordinated, goal oriented, functional restoration approach

 

 

Conclusion

 

Employers and payers that fail to recognize and deal with injured workers with psychosocial issues are doing their companies a disservice. Instead, they should be proactive and identify those with the potential for delayed recoveries, support and encourage early intervention, ensure quality medical providers using evidence-based medicine are employed, and provide whatever elements are needed to help workers in chronic pain regain their functionality.

 

 

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

 

Author Michael Stack, Principal, COMPClub, 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 of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

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.

 

11 Red Flags Of Escalated Work Comp Claim Costs

One of the biggest threats to an employer’s workers compensation cost is often not one bad claim, but an escalated cost an multiple claims.

 

With that in mind, there are several ways whereby an employer can reduce the chances for leakage and continuously higher claim costs.

 

 

11 Red Flags Of Escalated Claim Cost

 

At the time a workers compensation adjuster gets their hands on different forms of indemnity claims, they will first place an indemnity reserve on the claim.

 

In instances where workers comp adjusters discover challenges in coming up with the correct reserves deals with the potential problems claims that are dealt with at the on-set of the claim as just another typical claim.

 

Various versions of workers’ comp claims that can potentially lead to much higher financial outcomes than first thought are:

 

  1. Employees with a prior history detailing neck or back injuries;
  2. Claims that deal with back surgery (fusion, laminectomy, etc.) on a person who is involved in manual labor;
  3.  Employees who begin things with a hostile attitude toward the employer or the insurer;
  4.  Each and any claim with a long time period between the date of the injury and the date the claim is first noted to the business owner;
  5.  An employee who is not satisfied with the medical treatment being received and switches doctors more than once. (This is oftentimes done by the worker who is seeking a physician that won’t question the employee’s subjective complaints).
  6.  Changing doctors, this after obtaining an attorney, and going with a doctor known in the local insurance field and medical community to be “pro-surgery” or “pro-claimant” by many people;
  7.  Any claim where the employee becomes tied to pills;
  8.  The employee is closing in on retirement age;
  9.  The employer announces an impending work-force reduction, or the employee has just suffered a layoff from work (work comp indemnity checks are typically found to be much higher than unemployment checks);
  10.  The employee applies for social security disability (in some cases, this happens prior to the adjuster receiving the medical reports from the treating doctor);
  11.  The workers comp check is higher per week than the employee’s prior take home pay (this ties to when home compensation is reduced by union dues, 401K contributions, state income taxes, etc).

 

  

Responsibilities of the Adjuster

 

It is the adjuster’s responsibility to look for and handle oversight on these issues when they become known to him or her.

 

If the adjuster does not respond to these types of matters when they first come to the forefront, the claims will fall apart, and it will cost a whole lot more than it should. The risk manager for the employer should step up and take action when the inexperienced adjuster does not see or confront the impending problem.

 

Any time the adjuster, the adjuster’s supervisor or the risk manager witness a potential problem coming to the forefront, they should act immediately. It is much easier to halt a new problem claim from developing into a bad claim than it is stop a bad claim that is well-established.

 

 

Always Remember Value of Investigating

 

Always keep in mind that many major problems can and could have been lessened or even prevented by initiating an investigation.

 

If something seems suspicious, there is always the chance that it is for a reason. Just like in other circumstances, one who thinks or knows for sure they are being investigated is less likely to move forward with illegal behavior. And if they do continue, your investigation could very well trip them up into making a mistake.

 

 

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

 

Author Michael Stack, Principal, COMPClub, 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 of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

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

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

 

7 Steps To Implement Advocacy Based Claims Model

tammbr4okv4-ian-schneiderThe ‘advocacy-based claims model’ is the new buzz term in the workers’ compensation system. It relies on the old adage that you can catch more flies with honey than with vinegar. We’re increasingly seeing it in the movement to focus attention more on the injured worker than on the complicated processes that typically encompass workers’ compensation claims handling.

 

Proactively communicating and focusing attention on the injured worker is a best practice that has worked extremely well for the past 30 years (read one of this blog’s earliest posts here), and it will continue to work well for the next 30 years. What is encouraging is the growing adoption that improving outcomes for the injured worker leads to lower costs for the payer.

 

 

Benefits of Advocacy Based Claims Model

 

Companies that have adopted an ‘advocacy-based claims model’ are finding a multitude of wins:

 

  • lower litigation rates
  • expedited return-to-work
  • and happier, more productive workers

 

…all of which can translate to major cost savings. Simply put, it’s the idea that by making the injured worker part of the claims equation rather than an outside observer, he will have more buy-in for his own recovery and work with, rather than against those involved in the claim.

 

Injured workers who feel their employers actually care about them and are willing to work with them are more likely to feel empowered and valued and, thus, less likely to thwart return-to-work efforts. They have a better understanding and appreciation of the process, which can eliminate much of the confusion and frustration injured workers often experience.

 

Implementing changes doesn’t need to be formal, complicated — or expensive. Much of it involves treating the injured worker with respect and as an integral part of the workforce.

 

 

Steps To Implement Advocacy Based Claims Model

 

There are several steps that any organization — regardless of size or type — can take to reduce the adversarial nature of the claims process and avoid letting injured workers with seemingly minor challenges slip through the cracks and into the 5 percent of claims that drive the majority of workers’ compensation costs.

 

Steps to implementation includes:

 

  • Immediately address medical needs. When a worker is injured, the first order of business should be to address his medical needs — not filing a claim. This can be easily accomplished by leveraging a best-in-class injury triage provider. In fact, by getting treatment immediately, a claim can often be avoided.

 

  • Communicate early, often and clearly — and maintain the dialogue throughout the claims process. Designate someone – in Human Resources, Risk Management or a supervisor to contact the worker on a regular basis to see how he is doing and how the process is going.

 

  • Educate and inform. If possible, have a medical person, such as a triage nurse explain the medical processes involved. The workers’ compensation system is fraught with complexities. Let him know how the process works, what to expect, and how he can help the process along. Also, let him know who will be involved along the way and whom to contact with questions

 

  • Show compassion. Sending a get well cards for example, is easy, inexpensive and effective and lets the workers know he is a valued member of the team.

 

  • Watch your language. The word “claimant” should be replaced by “injured worker.” Instead of “investigator” or “adjuster,” use the term “advocate,” as it implies the person is working with, rather than against the employee.

 

  • Consider the worker a whole person — with personal issues outside of work that may affect his recovery, rather than just a body with an injury.

 

  • Simplify the process wherever and whenever possible. For example, a company’s website or mobile app can be used for employees to report an injury immediately and easily, rather than having to figure out whom to approach and what information is needed.

 

Taking simple steps toward an advocacy based claims model focused on can lower your litigation rates, reduce claim durations, cut down on the number of lost time claims vs. medical only claims, improve RTW rates and improve workers’ satisfaction.

 

 

Trust Biggest Factor in Claim Outcomes

 

The amount of trust between the injured worker and the company is the biggest factor in the claim outcome. When injured workers trust that you are care about them and are doing all you can to facilitate their recoveries, they are more likely engage in the process and do whatever is necessary to return to work.

 

 

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

 

Author Michael Stack, Principal, COMPClub, 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 of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

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

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

 

©2016 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.

 

Understand The Work Comp Heart Attack Presumption

fire-fire-fighter-brand-delete-feuerloeschuebungThe grand bargain of the workers’ compensation system requires employees who allege work injuries or conditions to prove compensability of their claim.  This includes the initial threshold question that it “arose out of” and occurred within the “course of” their employment activities.  While this threshold question applies to all employees equally, there are various presumptions that allow firefighters, police officers and other emergency personal to obtain compensation for heart attacks or other exposures with a lesser degree of evidence.  This is known as the “heart attack presumption,” and is something all members of the claims management team should understand.  They should also be aware as to how to deal with these cases and rebut the presumption when appropriate.

 

 

Origins of the Heart Attack Presumption

 

Employees that work in emergency situations deal with a constant flow of stressful situations during the course of every workday.  This includes rushing to various emergencies, working prolonged and abnormal hours and being subject to constant peril.  The result was a recognition in multiple jurisdictions that these professionals should receive additional protections that while rebuttable, allow them to peruse legitimate claims without having to prove issues of causation to the extent that other employees are required.

 

 

Application of the Presumption

 

It is important to note that the occurrence of a heart attack by a firefighter, police officer or other emergency responders does not automatically trigger compensability.  In order for the presumption to be successful, there is typically a requirement of “an absence of contrary or conflicting evidence on the point and the circumstances which form the basis of the presumption must be of sufficient strength from which the only rational inference to be drawn….”[1]  In other words:

 

  • The employee must fall into the “protected class” given their employment;

 

  • There must be some medical evidence that demonstrates a connection between the heart attack and the employee’s work activity; and

 

  • The connection must be rational or reasonable.

 

In all jurisdictions that have such statutory presumptions, the employer/insurer are able to rebut it with evidence to the contrary.  Other jurisdictions have imposed pre-employment physical requirements and limited the applicable qualifying conditions.

 

 

Rebutting the Heart Attack Presumption

 

When reviewing any workers’ compensation claims, members of the claims management team have a duty to their insured to investigate fully the allegations made before rendering an opinion on compensability.  This includes instances where a qualifying employee suffers a heart attack.  In those instances, the ability to rebut the presumption is defined in statute or interpreting case law.  Examples of the presumption rebuttal include:

 

  • Proof of causation that a non-work related event took place at the same time as the heart attack and was manifested itself in the alleged condition;

 

  • Contemporaneous medical evidence that demonstrates the existing of a condition, which was not related to the employment and resulted in the heart attack; or

 

  • Evidence that the employee died from a condition other than a heart attack, and the death was not related to one’s employment.

 

 

Practice Tips and Pointers

 

Any workers’ compensation investigation should be ethical and diligent.  In instances of a heart attack, the following additional steps should be taken:

 

  • Obtain a complete medical history and set of medical records for the claimant;

 

  • Obtain complete pharmacy records for the claimant. The use of medications for high blood pressure, cholesterol or other conditions are important to the claims investigation; and

 

  • Schedule an independent medical examination with a board certified cardiologist to determine issues of causation. In instances of death, an autopsy may be necessary.

 

 

Conclusions

 

The existence of a heart attack presumption is part of the grand bargain to ensure fairness in compensation for emergency workers.  While this may result in the payment of a claim under a lesser standard of scrutiny, it is important for members of the claim management team to understand how it works and rebut the presumption when evidence suggests non-work related factors were the real result of the condition or death from a heart condition.

[1] Hopson v. Hungerford Coal Co., 187 Va. 299, 305, 46 S.E.2d 392, 395 (1948).

 

 

 

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

 

Author Michael Stack, Principal, COMPClub, 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 of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

 

©2016 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.

Combatting Compound Trends in Workers’ Compensation

esi-1According to the (ODG), compounded medications are not considered first line for treating work-related injuries.

 

As we’ve discussed before, compounded medications pose safety concerns because they do not have standardized dosages and duration for use, and do not undergo the same rigorous drug review process as commercially available drugs, which are approved by the U.S. Food and Drug Administration (FDA).

 

In addition to the safety concerns posed by these products not undergoing FDA review, the cost of some compounds can be tens or even hundreds of times more expensive than similar prescriptions or over-the-counter products that are readily available to injured workers.
Analyzing the Costs Associated with Prescriptions Dispensed at Compounding Pharmacies

 

Express Scripts researchers examined the difference in cost-per-prescription for compounded medications to non-compounded medications used by injured workers and dispensed in compounding pharmacies in the U.S. between 2012 and 2014. We found significant cost increases year-over-year.

 

esi-2

 

These trends require action.

 

 

A Solution to Change the Trend

 

Express Scripts combats this rising trend through our compound management solution. The negative trend reported in our 2015 Workers Compensation Drug Trend Report reflects our effective compound strategies. Last year, Express Scripts Workers’ Compensation compound management solutions helped lower spending on these products by 33.7%

 

Approval is required prior to filling compounded medications at the pharmacy. This approval process allows the payer to make a decision at the time the prescription is filled. Additional physician and injured worker outreach communications are available on compounded medications to bring awareness of the associated risks and ensure that they are clinically necessary.

 

Of course, there are certain instances when a compounded product is the only clinically appropriate option – such as for patients who can’t swallow pills or who have an allergy to on of the ingredients in a commerically available alternative. But these instances are very rare, and our compound management solution ensures that these patients are still able to access these medically necessary compounds.

 

 

reethi-iyengarAuthor: Dr. Reethi Iyengar, who joined Express Scripts Health Services Research team in September 2011 as a Senior Research Manager, is responsible for providing timely and scholarly research related to use of and associated spend on prescription medications. She has previously interned in the department of chronic disease prevention and health promotion at the World Health Organization (WHO) in Geneva, Switzerland. Dr. Iyengar received her doctoral training in Health Services Research from Virginia Commonwealth University. She also holds an MBA from Radford University and an MHA from India.

15 Point Checklist For Your Account Service Instructions

Article PDF: 15 Point Checklist For Your Account Service Instructions

 

Often one of the first reactions when workers’ compensation costs spike is to look at changing the insurance carrier.  Sometimes this is appropriate, but before you pull the trigger, consider the following: The insurer may not be meeting expectations because neither the client nor the broker clearly communicated expectations.

 

The answer can often lie in improved Account Servicing Instructions (ASI). Every insurer and third-party administrator distributes its standard account servicing instructions to its field offices and adjusters.  The ASI governs settlement authority, selection of attorneys, reporting, reserves, subrogation, investigation and virtually all aspects of claim handling.

 

15 Point Checklist for Your Account Service Instructions

 

  1. Settlement Authority
    1. Who has settlement authority? The company or the insurer?
  2. Selection of Counsel
    1. Do you select your own legal counsel?
    2. What type of legal counsel does your company utilize?
  3. Reporting
    1. How often do you receive status reports for open claims from your insurer? Over 30, 60 or 90 days?
  4. Reserves
    1. Does the insurer provide a written explanation each time reserves are raised over $10,000 or more?
    2. Do reserves set take into consideration the company’s aggressive return-to­ work program, probably resulting in lower wage loss?
  5. Dedicated Adjuster
    1. How many adjusters are dedicated to processing company files in each office?
  6. Payment/Review of Legal Bills
    1. Do you receive bills for legal services?
  7. Investigations
    1. How do you request investigations?
  8. Structured Settlements
    1. Do you consider structured settlements for all cases over $20,000?
  9. Subrogation
    1. Are all cases reviewed for subrogation potential?
    2. Who closes a file and waives subrogation recovery?
    3. Do you want to be consulted before a lien is waived or compromised?
  1. Workers’ Compensation
    1. Do you receive copies of payments being made on each open file?
    2. Do you review checks or a list all payments made for accuracy?
  2. Referral to Physician Consultant
    1. How are outside vendor services activated and coordinated?
    2. Are all medical records sent to the physician consultant before an independent medical examination is conducted?
  3. Medical Bill Review
    1. Who audits medical bills for your open claims?
    2. How and when are medical bills audited
    3. Who will audit the hospital bills? What level of hospital bills are audited?
    4. Do you decide if medical case management is warranted?
    5. ls there immediate and automatic referral of complex lost-time cases to medical case management
  4. Utilization Review
    1. How do you decide which bills and services will be reviewed?
    2. Who have you retained to provide this service?
  5. Referral to Vocational Rehabilitation
    1. Who decides if vocational rehabilitation is warranted?
    2. Do you automatically refer complex lost-time cases to vocational rehabilitation?
    3. Will reports be sent to your company?
  6. Alternative Dispute Resolution/Mediation
    1. Is alternative dispute resolution considered on all claims for all lines?

 

 

Author Michael Stack, Principal, COMPClub, 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 of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 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.

 

Pick The Right Adjuster For The Right Workers Comp Claim

The experience and expertise of your adjuster will have a significant impact on the cost and life of a workers’ compensation claim.  Every employer must be absolutely certain the adjuster handling claims knows what, how, and when to do everything from the first report of injury to the final disposition.

 

Claim supervisors and managers need to be the most experienced, as well as have sufficient time to monitor staff and claim handling.  They also must teach, critique, and discipline all claim handling.

 

An adjuster needs to be part detective, part doctor, part lawyer, part father confessor, part director, and part politician.  Investigating facts and activities requires an inquisitive mind with questioning capacity.

 

Additional Adjuster Tasks & Responsibilities:

 

  • Adjusters must know medical facets of traumatic injury, healing periods and usual complications.
  • Proper medical care must be achieved.
  • Adjusters must direct and control the claim.
  • Complying with the law’s requirements and duties requires legal knowledge.
  • Listening, being empathetic, and addressing injured worker needs, is paramount to successful resolution.
  • Adjusters must be good communicators in spoken and written format.
  • Adjusters must have convincing gravitas to have people accept their proposals.
  • Adjusters deal with all walks of life. They must be comfortable in public dealings.
  • A college degree might be preferred, but it is not always necessary.

 

There are two schools of thought for selecting adjusters.  First, hire only experienced people.  Second, train your own.  Both have pros and cons. Each has had successes and failures.  Selection is a matter of choice.

 

 

Various Adjusters:

 

Medical Only Technician:

 

Medical-only adjusters, an entry level position, are trainees with little to no experience. They handle minor medical claims involving simple lacerations and minor strains/sprains not involving any lost wages or complicated medical injuries/conditions. When an employee has a few clinic visits the employer sends the claim in with the bills and the adjuster sets up the claim, processes the bills, and closes the claim.

 

Some issues a medical technician faces are:

  1. The history of the injury occurrence may only be addressed in the first reporting and billing.
  2. Aggravations for underlying pathologies may be casually addressed or not commented on.
  3. Often a treatment number is the only clue that the employee is being treated for more than the original injury.
  4. Treatment time and expense exceeds normalcy or claim unit authorities.
  5. Treatment may be going on that was not authorized.
  6. Missing permanent partial disabilities. Or paying permanent partial disabilities as a med case instead of an indemnity case.

 

Lost time/indemnity adjuster

 

Lost-time/indemnity adjusters are more experienced, with knowledge of local legal statutes and a high degree of medical training in handling occupational claims. Their expertise is with claims running past 90 days involving more severe injuries such as a complicated lacerations, level 2/3 sprain/strains, surgical repairs, or pending surgeries. When employers question claim compensability, the claim is immediately assigned to the lost time/indemnity adjuster.

 

Some issues that could hamper performance are:

  1. Assigned case overload impeding ability do a proper job
  2. Performing tasks that are better served clerically
  3. Failure to be analytical and innovative
  4. Have attitude issues that can cause cases to explode
  5. Failure to explore the worst case scenario
  6. Lack of empathy for the injured employee
  7. Lack of effort to resolve cases promptly and expeditiously

 

 

Litigation Technician:

 

Litigation adjusters handle claims involving lawsuits. These adjusters share the same level of experience as the lost-time adjuster. However, they have advanced training in legal issues and in investigating the compensability of occupational claims.

 

 

When a compensable claim is disputed, and the claimant retains counsel and files a Notice for a Hearing, the claim goes from the lost-time adjuster to the litigation adjuster. The litigation adjuster works with in-house or outside counsel gathering details on the injury, and appears for hearings and mediations to quickly resolve the claim at minimum legal expense.

 

 

Catastrophic adjuster

 

This level of adjuster is the most complex, handling very difficult claims, usually ones where the claimant has a severe injury requiring multiple surgeries, amputations, loss of sight, hearing loss, or internal medical issues such as asbestosis or chronic joint degeneration due to occupational exposure, etc.

 

General/catastrophic adjusters have many years of experience in the Insurance industry, combined with advanced medical and litigation training and experience. They also have advanced claim investigation training, and may possess a law degree or are licensed attorneys.

 

 

Summary:

 

It is vitally important for adjusters to have the proper intelligence, personality, and training to obtain maximum resolution of their claims.  Cases should be assigned  at proper levels of adjuster competence.  Supervisors, managers, and employers need to monitor adjuster activities to maintain maximum benefit for the claim.

 

 

Author Michael Stack, Principal, COMPClub, 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 of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 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.

 

 

 

5 Steps When Favorite Employee’s Workers Comp Claim Is Denied

The foundation of workers’ compensation is the employer-employee relationship.  Depending on the injury and the relationship, this can mean an awkward scenario if your favorite employee’s workers compensation claim is being denied. Your employee is coming to you for help, but you are essentially powerless. Or, you are the agent and your client is upset that the carrier you recommended will not cover this particular comp claim.

 

 

  1. Get both sides of the story.

If you are only listening to what your employee is saying, you are only getting one side of the story. This will show how involved you are with your claims. If you do not talk to your adjuster a lot, or if you do not know who your adjuster is, chances are you will be confused as well. But you cannot take the side of your employee without also hearing the facts from your adjuster — especially if this is a questionable, subjective claim to begin with. You may want to protect your employees, but both of you cannot team up against your carrier, who, by the way, is working hard to investigate all claims and make the proper decisions, which affect your overall premium.

 

 

Take the time and call the adjuster and get their side of the story. If there is something you do not understand, ask them to explain it. Make sure you really understand what the issue is and why it is there. This way you will understand what is going on, and you can explain it to your disgruntled employee. Carriers do not create the laws, they only abide by them. Each adjuster has different styles as well, so if a worker had a similar claim six years ago and it was accepted, and now the same thing happened and it is denied — find out why. Make sure the adjuster has legal evidence to back up the denial.

 

 

It is possible the claim has not been denied; it could be suspended pending results of investigation or upon receipt of medical records. Whatever the case, call your adjuster and talk to them about it before you start choosing sides on who is right and who is wrong.

 

 

  1. Meet and discuss in person with all parties and counsel.

The best way to decide who is right and who is wrong is to meet up. The employee can come as well, but it is probably best they do not — at least not at this point. But you, as the employer, should go discuss the case in person and roundtable it with all of the involved players.

 

If the case has potential for litigation, get local counsel or the house counsel the carrier uses involved. This way you can all discuss the file in a global aspect, and also plan for the ramifications should certain decisions be made. Going over pros/cons, future exposures, and the costs involved with all of those decisions helps not only you as the employer, but the adjuster as well. This forces him to get deep into the file, discuss monetary values, develop plans of action, etc.

 

 

  1. Find a middle ground for plans of action, if possible.

Just talking about the file and meeting up in person does not mean you will all agree on what to do.  If you are not satisfied with what you are hearing, see if there is a middle ground, or a non-aggressive approach to everyone agrees.  Considers options such as an independent medical examinations (IMEs), nurse case management, or a vocational assessment.

 

After you have compiled all the options, go over the pros, cons and monetary values of each one, then work to choose a strategy. Explore your options, and come out of the meeting with an agreed-upon plan. Not just agreeing to disagree.

 

 

  1. The adjuster knows best.

The adjuster has had medical and legal training, negotiation training, and is up to date with the current law changes and trends. Adjusters also have experience to know which doctors’ opinions are questionable or strong.

 

When push comes to shove, the adjuster and legal counsel likely know best about what option you should be taking. Thorough discussion should bring you to this point, but be sure to understand why they are taking a certain course of action.

 

 

  1. Leave your personal feelings behind.

The hardest part from the employer perspective is not to drag personal feelings into a decision. Whether the injured worker is your favorite employee or your worst hire, you cannot bring personal feelings into your overall decision on the file. You can alert the adjuster to these feelings, but you cannot let it influence your decision.

 

 

In the end, the decision must be fair, and backed by legal precedence. The carrier requires good reason to deny or accept a particular claim.  They understand that the worker may be your friend and you want to do what is best for them, but you cannot force the issue.

 

 

No matter who is injured, when they are injured, or what they were doing when they were injured, personal feelings often develop about why a claim should be accepted or denied. The best way to feel comfortable with the final decision is to understand all of the information through effective communication.

 

 

 

Author Michael Stack, Principal, COMPClub, 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 of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 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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