Two Reasons Employees Do Not File Work Comp Claims

There are times that an employee might not pursue a claim or might not have a claim for a work related injury.  While this is uncommon for employees, it does happen.

 

 

Reason 1 – Excluded People (no coverage)

 

State Requirements

 

If an employer does not meet a state’s requirements for workers comp insurance, the employee might not have a claim. For example, where states require employers with three or more employees to carry workers comp insurance, and the employer only has two employees, the injured employee would not be able to file for workers’ comp.

 

In addition, some states exclude farm laborers, seasonal workers, domestic servants, real estate agents and direct sellers from coverage in their workers comp statutes.  If one of these employees is injured on the job, they have an option to sue their employer if they believe the employer’s actions caused their injuries.

 

Sole Proprietors and Partners

 

Injured employees that are sole proprietors or a partner in a business are not covered for a workers’ comp injury unless they purchased a workers’ comp insurance policy. Most sole proprietors do not carry this insurance.

 

 

Reason 2-Pursuing a Tort Claim (looking for the deepest pocket)

 

Choosing Own Medical Provider and Pursuing Bigger Settlements

 

In states where a workers’ comp insurer has full rights to subrogation recovery, employees will sometimes not pursue the injury claim against the employer because they want to choose their own medical provider.  For example, if the employee is a traveling salesperson injured in an automobile accident where a third party was at fault, the employee may not file a claim where the accident occurred in a state where the employer controls selection of medical providers and the employer/insurer has full subrogation rights. Instead of the employee being treated by the medical provider selected by the employer or the employer’s insurance company, the employee is treated by a medical provider selected by the employee’s attorney. The attorney may recommend a liberal medical provider who will keep the employee coming back for additional treatment for as long as possible. .

 

 

The longer the employee is off work and the higher the medical bills are, the greater the settlement the employee’s attorney can demand from the insurer of the vehicle at fault in the auto accident.  Attorneys representing injured employees often tell their clients that they can get a much bigger settlement through the tort system than they can through workers comp.

 

 

Injury on a Construction Site

 

An injured employee might opt out of filing a workers’ compensation claim where the injury occurred on a construction site. On a large construction project there are often various subcontractors working at the same time. The employee might have been injured due to the negligence of a third party. The employee again will have the choice between pursuing the claim for personal injury against the responsible party or filing a workers’ compensation injury claim. In states where workers comp insurers right of subrogation has been diminished or taken away, the employee’s attorney will often pursue both types of claims simultaneously.

 

 

Delivery People

 

A delivery person who trips and falls on a defective sidewalk belonging to a business where the employee is making a delivery might choose to pursue a tort claim.   While a delivery person has the right to pursue a workers’ comp claim against the employer, the property owner likely has liability insurance. The award that can be collected on the tort claim may surpass what can be collected on a workers’ comp claim.

 

 

Summary

While an employee usually will not opt out of coverage for a workers’ comp claim, it does happen. There are also times when insurance coverage does not apply to the work related injury. It is important for an employer to know when this occurs and to keep in close contact with the employee in case circumstances change.

 

 

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.

6 Steps to Identify and Address Mental Health Challenges Early

The days of focusing solely on an injured worker’s physical injuries are over. Savvy employers and payers are finding that ignoring behavioral issues can end up costing a boatload of money in delayed recoveries. Early intervention, good communication and worker advocacy are among the best practices to use.

 

Injured workers who have, or develop undiagnosed and untreated behavioral health issues are more likely to fall into the ‘creeping catastrophic’ claim pool; a simple meniscus tear that degenerates into a months- or years-long claim with multiple treatments and medications — and exorbitant costs.

 

Identifying and treating these issues is tricky. The stigma attached to mental health issues prevents many people from seeking treatment; providers and claims handlers are often unfamiliar with signs and symptoms; and payers may be reluctant to pay for something they believe is unrelated to the actual injury. However, it behooves employers and other payers to at least consider ways to target behavioral health issues among their injured workers.

 

 

Behavioral Health Issues

 

Behavioral health issues — also called mental health or psychosocial — include a variety of diagnoses. Anxiety and depression are the ones more commonly seen among injured workers.

 

In addition to an extended duration of the claim, some signs that may indicate a psychosocial issue is present include:

 

  • Pain develops due to non-medical issues.
  • Function does not improve.
  • Multiple providers are involved.
  • Visits to the emergency room with drug seeking behavior.
  • Overutilization of treatments.
  • Catastrophic thinking.
  • Perceived injustice, toward the employer or others.

 

There are myriad reasons why some injured workers develop psychosocial issues, related to such things as adverse childhood experiences, environmental stimuli or genetics. The important thing is to identify them and intervene as early as possible.

 

Identification

 

Training and education are key to uncovering psychosocial issues. Most claims handlers as well as medical providers and others don’t have the backgrounds to detect psychosocial issues.

The injured worker, supervisors, and all others involved in the claim should also be trained to understand the realities of mental health issues. Soft skills, such as communication, conflict resolution, and identifying potential issues should be included.

 

Contact with all injured workers soon after the injury and on an ongoing basis is a best practice. During the conversations, certain screening questions can be asked that might trigger a red flag for potential issues:

 

  • When do you think you will be going back to work?
  • How are you doing?
  • Have you talked with your employer?
  • What does your treating physician say about your recovery and return to work?

 

Such questions can reveal the injured worker’s overall feelings toward his workplace. The answers might signal contention between the injured worker and his supervisor and/or colleagues.

 

The person’s sense of control, or lack thereof over his work can also be an indicator of stress and, potentially, psychosocial issues. People who feel they have little or no control tend to experience more stress. The lack of a sense of belonging at the company, and concerns about job security may also lead to psychosocial issues. The injured worker needs to know his job is safe and that you want him back on the job as soon as possible, even if that means doing light duty.

 

 

Interventions

 

There are formal programs to address injured workers with psychosocial issues. Companies looking to develop their own programs should consider the following:

 

 

Special Attention

 

Once an injured worker has been deemed a potential risk for psychosocial issues, the claim should be handled by those who have been trained and have an understanding of the challenges. Specialized claims adjusters, for example should be assigned the claim. The injured worker should be given a detailed outline of the workers’ compensation process and understand what to expect and what is expected of him. He should be made to realize he does have control over his own recovery.

 

 

Team approach

 

The Claims adjuster, nurse case manager, treating physician, injured worker and anyone else should work together on the claim. The treating physician, for example, needs to be a part of the effort to avoid him undercutting the team’s efforts.

 

 

Clinical interventions with a work focus

 

The injured worker should have access to a mental health provider as soon as possible. If your company or insurer does not already have a psychologist in the network, working with a local provider should be considered. Community resources can be checked to see what is available.

 

 

Goal setting  

 

Working together the team should establish timeframes for various aspects of the recovery, with the injured worker’s buy-in. The focus should be on the injured worker’s abilities, rather than his disability. The employer must be open to allowing the injured worker to return in a light- or modified-duty capacity.

 

 

Conclusion

 

Some state workers’ compensation laws allow coverage for mental injuries while others do not. Regardless of the regulations in a particular jurisdiction, taking a proactive stance and, perhaps spending some money at the beginning of a claim will generally be much more cost effective than ignoring psychosocial issues.

 

 

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.

Claims Investigations 101: What Every Claim Handler Needs to Know

Investigating a workers’ compensation claim is an important step in claims management, however it can easily be overlooked or poorly done.  Now is the time to review how you investigate claims regardless of experience.  Doing so can save you time and ensure your program is effective and efficient.

 

 

First Things First: Determine Coverage

 

A workers’ compensation insurance carrier is responsible for a claim if they are contracted to provide coverage for an employer/insured.  This is something that should be verified from the onset of claim in order to avoid confusion later on in the process.

 

Verifying coverage is especially important in workers’ compensation cases that involve industrial exposure issues such as asbestos or repetitive trauma occurring over a period of time.  In other instances, insured falling into high-risk categories have multiple insurance carriers.  Conducting a diligent investigation on this matter may result in allowing a carrier to deny liability or identify other parties who may be responsible.

 

Important data points to consider as part of this review include:

 

  • Listed dates of injury on a claim petition;
  • Policy exclusions based on an employee’s different locations of employment; and
  • Dates when a policy was in force along with the requisite policy number(s).

 

 

Witness Identification 

 

All successful claim handlers need to be great sleuths.  They are given a limited set of facts found on the initial claim forms.  It is then their duty to ask questions and locate answers.  Part of this includes locating people who have information concerning the employee and the work injury.  Important people to consider include:

 

  • Employer: This includes not only the employee’s supervisor, but also other people who have contact with the injured party and understand their work activities.  It is especially important in claims subject to dispute such as unexplained injuries or those that take place over the course of time.

 

  • Other Fact Witnesses: These include a broad category of people.  It can include people who witnessed the accident in question, work directly with or have regular contact with the employee.  It is important to determine what information these persons have and also evaluate their credibility.

 

  • Employee: Contact with the employee is also important.  Not only will you be in contact with the employee as part of the injury report, but also following the injury as the claim handler manages the case.  Part of this contact may include a recorded statement.  When engaging in this activity, be sure to understand applicable rules and how to preserve it for use in litigation.

 

  • Expert Witnesses: The increasing sophistication and due process safeguards in workers’ compensation cases is leading to the growing us of experts.  This obviously includes medical doctors to address issues such as causation, the mechanism of injury and reasonableness/necessity of care.  Other experts include vocational rehabilitation counselors and others who can comment on design and safety matters.

 

 

Other Important Components of the Investigation

 

Members of the claims management team are responsible for investigating the claim at its onset.  This includes a number of other important considerations:

 

  • Determining issues of compensability. This goes beyond a determination of coverage and includes the threshold issue of all workers’ compensation claims—whether the injury “arose out of” and was “in the course of” employment;

 

  • Handling the injury triage and making sure the employee receives the medical care and treatment they are entitled to receive;

 

  • Obtain appropriate authorizations. This includes a number of different documents such as medical, insurance, workers’ compensation records and Social Security verification to name a few.

 

 

Organization is Key

 

A well-organized claim file can provide efficiency to internal processes, demonstrate competence to claim managers and assist legal counsel should the matter be referred for defense.

 

 

Conclusions

 

Members of the claims management team play an important role in investigating workers’ compensation claims.  It is important to be organized and work newly received file materials in an effective and efficient manner.  It can also result in a cost savings to your program, which pays dividends to all involved.

 

 

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.

9 Steps to Integrate Your Absence Management Policies

Navigating the minefield of workers’ compensation and other absences can be a nightmare for employers. The patchwork of policies and procedures overseen by multiple departments or vendors can result in compliance problems as well as decreased morale for workers, plus a waste of money and resources.

 

By integrating leave programs, employers can see significant cost savings, fewer days away from work and improved productivity. But going from a mixture of rules and regulations to a single, streamlined system can be daunting, especially for smaller organizations.

 

 

The Challenges

 

There are a variety of federal, state and municipal programs. The Family Medical Leave Act, Americans with Disabilities Act, short- and long-term disability, and workers’ compensation are just some of them, along with state, county and municipal leave laws and employer-specific leaves. Some may overlap. Some involve payments, while others do not. And they change frequently — through amendments or the implementation of new leave laws. Keeping up to date with them all and ensuring you administer them properly is a challenge for even the largest employers.

 

There are likely multiple contact points, depending on the type of leave involved. Each leave involves forms that must be filled out and, sometimes, require payments. If outside vendors are used, inaccurate information sharing may result in payments being too little or too much. Employees may receive information from multiple vendors, causing confusion and frustration. Finally, it’s nearly impossible for an organization to analyze the data and understand the impact of absences — unless the systems are integrated.

 

Getting a streamlined, integrated system involves collaboration, more than anything. Where there are silos within a company, those within them must be willing to work with one another and share information. At the least, HR, legal, benefits and risk departments must cooperate.

 

 

 

Leave Integration Programs

 

Integrating occupational and non-occupational leave programs can take a variety of forms, from the simple to the highly sophisticated. The more advanced models include wellness, disease management and even employee assistance programs.

 

Whatever type of program is implemented, integrating leaves generally results in overall lower costs and possibly better outcomes. You can start the process by taking stock of what’s already in place at your company.

 

  • Look at your data. Starting an integrated leave program should begin with an assessment of the amount and cost of absences taken annually by employees. Employers who do so typically find their employees are taking off more time than they realized, pointing to the need to take action.
  • Talk to your partners. Third party administrators and insurers, along with any vendors you use should be willing to provide data and other information that sheds light on the management of your leave programs; as well as what they do for other employers..
  • Read the handbook. Take a close look at the policies and procedures already in place for various leaves. You may find some that duplicate or contradict one another.
  • Bring in the troops. Departments that have any responsibility for absence programs should be included in discussions right from the start of the integration process. You might find ways to automate some of the existing processes.

 

 

Building the Program

 

Once you’ve seen a picture of your company’s leave programs and looked at the data, there are several key factors that can help make for an effective IDM program.

 

 

1) Single Claim Intake Source.

 

This will reduce administrative costs and make it an easier, more pleasant experience for employees. Having one phone number is a great way to ensure all leave requests are captured in a single source. This could also allow for a single provider to contact the worker if their leaves constitute more than one, such as short-term disability and FMLA.

 

 

2) Communication 

 

Any and all changes to leave policies should be shared with managers, supervisors and employees. It’s imperative that everyone has the most up to date information.

 

 

3) Collaboration

 

As explained above, integrating your absence management programs should involve personnel from several different departments who must work together. Workers’ compensation, group heath, disability insurers, legal counsel, and any other organizations that manage employee health should discuss how they can combine their data and resources. During such meetings, goals should be set and roles and responsibilities should be discussed and agreed upon.

 

 

4) Data Sharing / Tracking.

 

Employers can look at trends for such things as frequency, duration, cause, occupation and business unit to determine if and where changes could be made to reduce costs and improve productivity.

 

 

 5) Updates

 

Changes in laws that affect any of your leave programs should be brought to the attention of all involved. The team can assess the changes and determine how to proceed. There should be a process established to update leave programs depending on changing needs of your company. In addition to tracking legal and internal changes are technological advancements that should be considered. For example, having an app for employees to report absences might be useful.

 

 

6) Uniformity.

 

It is crucial that leave policies be administrated consistently and clearly.

 

 

7) Evaluating The Program.

 

Depending on how the program is handled, you want to be able to see the effectiveness. It may involve a software system or outsourced organization. Ideally, you should be able to identify lost time, costs and return-to-work rates, and see what if any changes should be made.

 

 

8) Keep Good Records.

 

Proper documentation will ensure your company is not on the losing end of a complaint.

 

 

9) Consider Outsourcing

 

Many employers have taken this option due to the complexity of coordinating leave programs. It may not be appropriate for your company, but you might at least want to shop around.

 

 

 

Conclusion

 

Integrating your leave policies can reduce costs, improve outcomes, and streamline efficiencies. It is not a quick process; but companies that have done so report improved compliance, increased control and higher employee engagement.

 

 

 

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.

20 Common Adjuster Mistakes And What To Do About It

One thing seldom heard from the either the insurance company or from the third party claims administrator (TPA) is “we / I made a mistake”. Mistakes happen. The difference between the excellent adjuster and the so-so adjuster is the number of mistakes made. Claims management , supervisors ,and managers also make errors in judgment, or unwittingly commit an oversight. There will not be a list of common claims handling mistakes on the insurance company’s website or TPA’s website. Therefore, we present what are common claims handling errors seen when the claims are audited by an independent claims auditor.

 

20 Common Adjuster Mistakes

 

  1. The failure to thoroughly investigate the claims including the establishment of the nature and extent of the injuries.

 

  1. The failureto properly document the average weekly wage and to properly establish the TTD rate.

 

  1. The failure to maintain the files on a diary (a regular scheduled file review by the adjuster to ensure all needed activity has been completed).

 

  1. The failureto recognize and document subrogation.

 

  1. The failureto have Action Plans.

 

  1. The failureto read medical reports.

 

  1. The failureto monitor and control medical treatment.

 

  1. The failureto conclude claims in a timely fashion when the opportunities were presented.

 

  1. The failureto know the workers compensation laws in their jurisdiction.

 

  1. The failureto file the appropriate state forms with the Industrial Commissions and Workers Compensation Boards.

 

  1. The failureto maintain contact and rapport with the claimants.

 

  1. The failureto record in the file notes the documentation received on the file.

 

  1. The failure to utilize Independent Medical Examinations when appropriate.

 

  1. The failureto utilize nurse case managers when appropriate.

 

  1. The failureto deny unrelated medical treatment or unrelated body parts when introduced into the claim.

 

  1. The failureto attempt to return injured employees to light duty work when the medical providers approved same.

 

  1. The failureto respond to important developments on the claims.

 

  1. The failure to provide proper litigation management on the litigated claims.

 

  1. The failureof management to provide supervision or guidance to the adjusters handling the claims.

 

  1. The failureof management to maintain continuity on the claims by changing the assigned adjuster on the claim during the course of the claim. (Occasionally it is necessary on a few files but not on a majority of the claim files).

 

What To Do About It

 

When mistakes occur in claims handling, the cost of the claim goes up. The insurance premium paid by employers is impacted by both the frequency and the severity of claims. While frequency of claims carries greater weight in calculating the insurance premium, the severity of the claims – what the claims cost – also impacts the insurance premium.

 

 

There are several things employers can do to limit the mistakes made on workers compensation claims, including:

 

  • Having a published set of Best Practices and insisting the claims office abide by them.’
  • Having a designated adjuster or dedicated adjuster(s) to handle all your claims.
  • Verifying the adjuster has reviewed the Employer’s First Report of Injury and has filed all appropriate forms on every claim.
  • Verifying the adjuster has obtained the proper wage/salary information for the calculation of indemnity benefits (calculate the indemnity benefit yourself and compare with what the adjuster is paying weekly or biweekly).
  • Providing to the adjuster any information you have or receive about the claim, whether it is medical documentation, the employee’s personnel file or even scuttlebutt heard around the office.
  • Establish a regular file review. (What get’s reviewed gets done).  If you do not have the time to review the adjuster(s) work yourself, hire an independent claim file auditor to review the files and identify the strong and weak points of the claims handling on your claims.

 

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.

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.

 

13 Indicators You Might Get Burned By Workers’ Comp Fraud

On November 18, 2015 the US Department of Justice in Eastern PA published a partial sentencing of Barbara Stanley who fraudulently obtained approximately $199,000 between July 2006 and December 2010.  After committing a crime for over 4 years, why did it take 5 more years until she would be tried for her crime and then another 3 months for sentencing?  Would the $199,000 ever be recovered?

 

Another case in California involving former San Quentin prison worker Hosea Morgan came to a head in September 2015 when he was convicted of making 2 fraudulent workers comp claims back in 2009.  The trial lasted almost a month and sentencing took place about a month after in November.  Adding the 2-month gap between conviction and sentencing to the 6-year gap between commission and trial is worrisome.  Morgan was sentenced to six months’ jail time, 500 hours community service, and 5 years’ felony probation.  Collecting the over $160,000 in restitution may never occur.

 

 

Exposure:

 

While these two cases made headlines and give a very clear picture of how much workers comp insurance fraud costs, there are countless other cases that do not make headlines nor are even reported or prosecuted.  In some cases, prosecuting costs more than the fraudulent claim itself, so those cases fall to the wayside and are dismissed with no retribution.  With the time it takes for fraud cases to come to conclusion, statutes of limitation may apply anyway making restitution collection impossible.

 

Unfortunately, even with reporting requirements in place, Special Investigative Units have no measure of keeping records for the results on how much workers comp fraud costs across the board.  The examples above give the illusion that authorities are tough on workers comp fraud, however they fall short of keeping within laws that provide incarceration, fines, penalties, and restitution.  Fraud cases are often handled poorly, and leniency tends to prevail in favor of the perpetrators who are either excused, plea bargained, or given light punishments.

 

There are, however, many reports online for restitution recoveries which reveal a very sad picture.  Per the California Department of Insurance statement on Workers’ Compensation Fraud:

“In fiscal year 2014-15, the district attorneys reported a total of 740 arrests, which also included the majority of Fraud Division arrests. During the same time frame, district attorneys prosecuted 1,409 cases with 1,654 suspects, resulting in 650 convictions. Restitution of $32,065,830 was ordered in connection with these convictions and $8,647,532 was collected during fiscal year 2014-15. The total chargeable fraud was $646,186,555 representing only a small portion of actual fraud since so many fraudulent activities remain to be identified or investigated.”

With 1409 prosecutions, only 650 convictions were made.  Over $32 million in restitution was ordered, but less than $7 million collected.  In relation to the amount stolen (over $646 million) the amount collected is just over 1% of the total.  That means $639 million could go uncollected.

 

 

 Properly Investigate Every Claim

 

Every claim should pass through a “bulletproof investigation procedure”.  This is designed to give you the proper information to make an accurate decision on the claim.  Further subrosa investigation should be used as an information gathering tool.  It is better to investigate EVERY claim, than to investigate no claims.

 

Here are 13 claimant behaviors that raise red flags:

 

  1. Injury takes longer to heal than medical guidelines specify.
  2. Injury is reported late, reported to a lawyer or the state commission before reported to the employer.
  3. Fails to attend weekly meetings.
  4. Is uncooperative; will not try a transitional duty job.
  5. Is not home during the workday when you phone.
  6. Only has a postal box, not a home address.
  7. Misses doctor appointments.
  8. Performs seasonal activities, hobbies, or work.
  9. Has moved out of town or out of state.
  10. Disputes average weekly wage due to additional income.
  11. Files for benefits in state other than principle location.
  12. Disputes information supplied by the employer.
  13. Submits repetitive medical reports indicating continuing, constant pain with conservative medical treatment.

 

 

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.

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