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.

 

3 Simple Tasks To Apply To Every Work Comp Claim

 

Members of the claims management team are always looking for cost saving measures on their workers’ compensation claims.  This is due to the fiduciary duty to the insurance carrier they work for and requirements under the workers’ compensation act to provide injured parties with the benefits they are entitled to receive.  While there are techniques developed over time, simple tasks on every file can lead to responsible cost savings on every file.

 

 

Step 1:  Know Your Files

 

The average workers’ compensation claim handler can be responsible for handling up to 200 claim files from potentially a variety of jurisdictions.  This creates countless headaches for everyone involved on the claim management team.  While each person may have their own style or file organization, there are certain steps that one can take to master the process and be effective and efficient.  These steps include:

 

  • Analyzing workers’ compensation claim trends and identify the various drivers that increase risk and impact loss experience. Various important trends include the demographics of the injured workers, the nature and extent of their claimed injuries and economic trends in the community in which the injury took place.

 

  • Understanding the barriers to settlement and ability to resolve cases in a timely manner. In the business of claims management, “the only good file is a close file.”  While some claims take longer than others to close, an initial analysis on what pitfalls might lay ahead will help the claims handler develop a strategy for getting the file closed in a timely manner.

 

 

Step 2:  Move Your Claims toward Settlement

 

The inability to move claims toward settlement causes stress on the individual claim handler and the rest of the team.  In some instances, more experienced claim handlers will need to pick up files from a team member if the claims are not handled in a proper manner.  Tips for closing files in a timely manner, but at the same time ensuring the injured party receives the care they are entitled to receive include:

 

  • Setting proper reserves on claims. Claims that are reserved too high need to be adjusted downward.  This places financial stress on an individual carrier and limits their ability to use capital in an appropriate manner.  In the same regard, claims that are reserved too low also have a negative financial impact and place limitations on settling other cases.  Common issues that arise when setting proper reserves include a realistic evaluation on future disability and medical care an injured employee may need.

 

  • Failure to review files on at least a quarterly basis. Dust collecting on a claims file is a sure sign of ineffective claims management.  By making the effort to review files on a consistent basis, proper evaluation will be given to matters that hopefully can close.

 

 

Step 3: Leverage The Insurer Relationship

 

An effective workers’ compensation claims management team should communicate with their insurer about risk.  This includes helping to understand simple items like how their workers’ compensation insurance premium is calculated and how to legally and ethically reduce costs.  This includes a number of different cost-saving mechanisms:

 

  • Ongoing discussions regarding the impact injury and disability have on the experience modifier;

 

  • How to legally report payroll amounts as required by state law. This is often an issue with part-time employees, or persons working for an employer as an independent contractor; and

 

  • How to improve the overall safety of work sites and facilities.

 

 

Conclusions

 

There are many simple ways to reduce workers’ compensation costs through effective claims management.  This includes the work of the individual claim handler to better organize their files and assist the interested stakeholders in the process.

 

 

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.

 

Give Your Work Comp Adjuster A Hand To Achieve Better Outcomes

Adjuster Objectives:

 

Some objectives of every workers compensation claim adjuster should be to:

  • Promptly investigate.

 

  • Monitor medical care.

 

  • Process the workers compensation claim to a timely full disposition.

 

  • Maintain constant dialogue with employee, employer, and all other entities directly connected to the loss.

 

  • Secure any potential recoveries.

 

  • Develop the loss for the best outcome possible.

 

  • Be adequately educated, trained and continually self-educated for continued professional growth.

 

Additional adjuster objectives:

 

  • Clearly compensable claims should be paid promptly at the proper benefit rate, medical care should be the best available, and prompt return to work should be a priority.

 

  • The adjuster should be available to assist the injured employee as needed.

 

  • Good claim work results in minimal disability, good employee relations, and lower claim cost.

 

  • Conversely, claims that are questionable, malingered, fraudulent, or suspect for any reason, require the claim adjuster to be extra determined so that a good investigation and claim preparation can sustain declination and litigation.

 

  • Workers Compensation Claims are always under time guideline and handling pressure. Decisions and actions must be made or done quickly.

 

 

Employer Injury Coordinator & Assisting The Adjuster

 

The adjuster has primary responsibility for successful claim disposition.  However, the adjuster can only be as effective as the information gathered during investigation.  Therefore, every employer should strive to get the full facts, and supporting documentation to the adjuster as soon as possible after the loss occurs.

 

Every employer should have at least one person assigned to establish policy and procedures to implement when an injury occurs.  The person should know and understand all requirements of the workers compensation management program, including the employer and employee responsibilities.

 

One of the biggest responsibilities of the employer injury coordinator is communication with the claim adjuster.  This should be done as necessary, and during acute stages of a claim it may be daily.   As time passes on this claim this should continue on a regular weekly schedule.

 

 

Conclusion:

 

Worker’s Compensation Adjusters need to have good education, training, and the highest objective standards in order to reach proper handling and resolution of claims.  However, they cannot achieve this without proper employer support and interface.

 

Employers who designate an employee to be the workers’ comp injury coordinator to assist the claim adjuster will reap the benefits of better claim handling and cost.

 

 

 

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.

 

What Is The Claim Handling Score At Your TPA?

claim-handling-scoreEmployers often wonder if they are getting quality claim handling on their workers’ compensation claims.  At the same time, the third party administrators (TPA) providing claim services to employers often struggle with producing a quality product due to the facts and circumstances of each claim being different.

 

 

 

Top-Tier TPAs Evaluate Every File for Claim Quality

 

Each TPA will have a set of Best Practices stating what is expected on every claim.  A top-tier TPA will not only have the written set of Best Practices, they will evaluate the adjuster’s claim quality using both performance measurements and diagnostic indicators to evaluate the adjuster’s performance.

 

As every activity of the adjuster on the claim file is recorded in the electronic notes of the computer file, it is simply a matter of data mining to determine if the adjuster is complying with the established Best Practices.  When the workers’ compensation adjuster enters a new file note, the date and time is automatically recorded.  Each file note has two drop-down selection codes, one for type of activity being completed and one for the type of person contacted – employee, employer, medical provider, employee’s attorney, defense attorney, etc.  After the note is coded, the actual details of what was accomplished are entered.  For example: “Requested Dr. Smith’s office to email us the office visit notes.”

 

With all this data, the grading and evaluating of the adjuster’s performance becomes highly measurable.  To prevent ‘gaming’ of the system, the TPA will have internal auditors reviewing select files, or with some top-tier TPAs all files, to insure accuracy of what is recorded in the system.  For example, if the adjuster coded the file note ‘contact – employee’, but the details of the file note reflect only left a voice mail, the proper coding should have been ‘attempted contact – employee’, and the file note coding can be corrected.

 

 

 

Areas of Evaluation

 

The areas of quality evaluated and graded through performance measurement include:

 

  • Initial employee contact within 24 hours

 

  • Initial employer contact within 24 hours

 

  • Initial medical provider contact within 24 hours

 

  • Initial reserve within 72 hours

 

  • Reserve review with 30 days

 

  • Initial report to client within 14 days

 

  • Status reports to client every 30 days, or as previously indicated in a prior report

 

 

The areas of quality evaluated and graded through diagnostic indicators include:

 

  • File on diary

 

  • Proper completion of claim progress notes

 

  • Reserve worksheet to support reserve changes

 

  • Timely ISO filing

 

  • Timely supplemental ISO filings

 

  • Payments made on closed files

 

With all the data generated, the computer program calculates the adjuster’s performance.  The computer program can be set to select only indemnity claims or it can include all claims.  The computer identifies all claims reported within the reporting month (normally a calendar month, but data can also be compiled on any 30 day period).  For example:  The computer identifies all indemnity claims assigned to Adjuster Jones during July, it reviews all data for the claims that had initial employee contact within 24 hour, and calculates the percentage of claims where the employee was contacted within 24 hours of the initial report of the claim.

 

The computer program completes the calculation for each of the performance measurements and diagnostic indicators and assigns a numerical percentage score to each category.  The computer combines all the categories into a numerical score for each adjuster to provide the TPA management a quality score for each adjuster.

 

 

Claim Quality Scores are Invaluable Tool for TPA

 

The quality scores compiled by the TPA are an invaluable tool that can be used for several different purposes. The score results can be used as:

 

  • A component of the adjuster’s semi-annual or annual performance review

 

  • A promotional tool to sell the TPA services

 

  • A motivational tool to encourage the adjusters to perform at their maximum

 

  • A way to encourage friendly, internal competition in each office to see which adjuster can provide the highest level of service

 

In addition to building adjuster’s pride by scoring well, some TPAs offer bonuses for top scores or a bonus to everyone who exceeds a predetermined mark.  For example – $100 monthly bonus for a score of 95% or higher, or a $500 annual bonus for averaging 97% or higher for the entire year.  Other prizes can be offered for the most improvement, the highest overall performance, etc.

 

 

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.

 

Pay Without Prejudice – Solution To Big Work Comp Problem

Imagine this scenario … you started working for your company about six years ago. One day you’re walking into work in the parking lot … you slip and fall and you hurt your back. There’s a question of whether or not that injury is work-related. You go in to get medical treatment. You’ve get a great health insurance plan but they won’t cover your medical expenses, because you have a work comp claim that’s in dispute. Also, because your work comp claim hasn’t been accepted you can’t get medical expenses covered under that plan either, so, now you’re left to have your injury continue to get worse.

 

 

Delayed Or Denied Medical Treatment Is Big Problem

 

This scenario that I’ve described is a problem in our industry. I’ll say it again. This scenario that I’ve just described is a problem in our industry. I’m Michael Stack, with Amaxx, and, today I’m going to be talking about a solution to that problem. It’s called, Pay without Prejudice, and, in Maine, it’s Statute Number 222, called Provisional Payments of Certain Disability Benefits.

 

I want to graph this out for you and show you what this looks like. It’s very common and a big problem, as I said, in our industry. Let’s talk about this. You have your back injury … here’s the time of injury. I’m going to graph this out in blue and in red. In blue’s going to be the cost of the injury, and in red is going to be the severity.

 

You have what might be a very simple injury. It might be something that just needs a little bit of treatment and you can get back to work right away, but because you can’t get your medical expenses covered, there’s a delay in treatment. Your injury gets worse and worse and worse. The cost is going to follow, of course, in a very similar timeline when it becomes more and more expensive.

 

The longer the delay in treatment the worse your injury becomes, the more expensive the injury becomes, the more of an impact it has on that individual’s life, the less likely they’re going to be coming back to work. The more likely they’re going to be out on a lifetime disability claim, the longer that injury goes untreated. This is a problem in our industry.

 

 

Pay Without Prejudice & Maine Statute 222

 

Here’s the solution. It’s called, Pay without Prejudice.” In Maine, again, it’s Statute number 222, Provisional Payment of Certain Disability Benefits. This is a concept we talked about in The National Work Comp Conversation, and, this Maine Statute really came into the conversation during those discussions. Basically, what it says is that there’s no delay in benefits. Even though a work comp claim is in dispute, you cannot delay or deny the benefits to get that medical treatment. It’s written right into the statute in Maine.

 

If you’re not in the State of Maine, you can write this right into your account handling instructions … your account service instructions. If you’re a self-insured employer, or, if you have a high-deductible plan this is a concept that should be in your policy, because this back injury can get addressed right away. This person can get right back to work and these costs remain contained. It creates a better outcome for the injured worker and significantly controls your work comp costs.

 

If it’s determined that your claim either was or was not compensable the appropriate carrier … either the health insurance carrier or the work comp carrier, can be reimbursed for those expenses appropriately. Pay without Prejudice, and, in Maine … Statute Number 222 … Provisional Payment of Certain Disability Benefits. If this is not in your state talk to your legislators. If this is not in your account handling instructions this is a concept that should be. Remember your success in worker’s compensation’s defined by your integrity … so, be great.

 

 

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.

 

Low Back Pain: Dealing with the Proverbial Pain in the Butt!

back-painInjuries to the lower back and the symptomology associated with such claims make up a significant portion or all workers’ compensation claims.  This requires members of the claims management team to be proactive when it comes to injuries involving the lower back.  It also serves as an opportunity to understand the origin of such incidents and take steps to prevent them.

 

 

The Anatomy of the Spine

 

The spinal cord is the core of a person’s central nervous and skeletal system.  It is an important part of the body’s infrastructure.  It is made up of many important parts that holds a person together.

 

With respect to the spinal cord, several key segments claim handlers need to understand.  This includes:

 

  • Cervical spine: This is the region of the spine that connects to a person’s brain stem.  It is comprised of seven (7) vertebrae.  In layman’s terms, this region of the spine is called the neck.

 

  • Thoracic spine: This is the midsection of the spine and is comprised of 12 vertebrae.  This portion of the spine does not bend back and forth as often, which allows vertebrae fractures to heal with some certainty.

 

  • Lumbar spine: This is the lower part of the spinal cord and is comprised of five vertebrae.  Like the cervical spine, this part is subject to many stresses of everyday activities.  Functions such as bending, twisting and sitting place extreme stress and are subject to a part percentage of everyday and work-related injuries.

 

There are also other important components to a spine.  They include:

 

  • Sacrum and Coccyx: The sacrum typically includes five vertebrae structures, which are attached to the lumbar spine.  In turn, the sacrum is connected to the coccyx, which is commonly referred to as the “tailbone.”  These bones are also involved in countless work injuries.

 

  • Discs: These are the spinal cords “shock absorbers” and are similar to a jelly donut.  Injuries to discs result in herniations, which causes them to lose their absorbency.

 

 

Dealing with Secondary Gain in Low Back Pain

 

Degenerative changes in the spinal cord, especially the lower back, are common for any person to experience over their lifetime.  This is based on activities of daily living that places stress on the vertebrae.  Studies indicate that the average American over the age of 40 has some degenerative changes in their back, which may include herniation without symptomogy.  The result of this is for members of the claims management team to be proactive when handling a claim involving a spinal cord injury.  Factors that delay recovery often include:

 

  • Common themes for this characteristic include the age of the employee;

 

  • Tenure in a position (both long and short term);

 

  • Language or other cultural barriers;

 

  • Lack of interest in returning to work;

 

  • The presence of return-to-work opportunities; and

 

  • Seriousness of the injury.

 

 

Identifying Secondary Gain and the Low Back

 

One common test used to identify malingering is the Waddell’s Test.  Gordon Waddell developed this test in 1980 to indicated symptom magnification in low back injuries.  This test can be a part of an independent medical examination, as well as a review by the treating physician.  Proper use of this test includes the following:

 

  • Superficial tenderness or overreaction exhibited by the patient;

 

  • Testing that does not cause stress on the spin, but results in pain;

 

  • Examination techniques that include distraction and re-verification when the patient is properly oriented; and

 

  • Disturbances that do not have a known etiology.

 

Claimants who exhibit a “positive” test should be scrutinized and possibly treated for other underlying conditions, which can include depression, or other psychological/psychiatric conditions.

 

 

Conclusions

 

Dealing with low back pain claims can be challenging for members of the claims management team.  Through properly training and understanding of the spinal cord, members can develop tactics to identify symptom magnification and resolve troublesome claims.

 

 

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.

 

You’re Fired! Work Comp and Retaliation Claims

The filing of a workers’ compensation claim often creates an adversarial relationship between the employer and employee.  This is based on a number of self-apparent reasons, which are compounded in some instances by the primary denial of benefits.  In other cases, the escalation of ill will between the employer and employees frays out of control and results in the employee being terminated from their employment during the claims dispute process.

 

 

Statutory Safeguards for Injured Employees

 

A variety of state and federal laws and rules protect employees when they claim a disability or injury in the workplace.  One common protection is frequently found in individual workers’ compensation laws that allow an injured worker to bring a civil lawsuit if the employer retaliates against them for alleging a work-related injury.  Under these anti-retaliation statutes, employees can receive the workers’ compensation benefits they otherwise would be entitled to, plus additional compensation.  This monetary amount is usually set forth in statute and enforced by civil courts, and not under an administrative process.

 

 

Understanding Work Injury Retaliation

 

The requisite elements for bringing a work-injury retaliation vary in each jurisdiction.  Always consult with an attorney if you have questions.  The general rule for an employee to bring such claims and make the prima facie case for a retaliatory discharge include the following elements:

 

  • The person in question must be considered an “employee” for purposes of the workers’ compensation act;

 

  • The employer must make an adverse employment decision or termination against the employee; and

 

  • There must be a “casual connection” between the employee and the adverse decision.

 

If these elements are properly demonstrated, the employer will typically have the ability to rebut the presumption of retaliation to provide a legitimate reason for the discharge, or other evidence demonstrating a non-discriminatory reason for their action.  Some information used by employers include:

 

  • Documented unexcused absence by the employee that is consistent with how other employees are treated;

 

  • Information concerning acts of misconduct or prohibited actions by the employee; or

 

  • Failure to accept work within restrictions as outlined by the treating medical doctor.

 

It is important to document the rationale for termination and treat all employees equally.

 

 

Avoiding Work Comp Retaliation Claims

 

Avoiding claims and allegations starts with proactive leadership at the employer and includes a role for the claims management team.  Effective strategies for reducing your exposure and the cost of claims starts with you:

 

  • Develop an effective response to all work injuries. Every person injured within a workplace is a human being and should be treated as you would like to be treated.

 

  • Assist injured workers and respond to their questions. Effective claims management teams and interested stakeholders at employers can build good will and confidence with an injured party by responding to their concerns.  They can also do the little things to make them feel important by sending a “get better soon” note or card.

 

  • Provide a non-legalistic to answer when communicating with injured workers. Remember, you deal with workers’ compensation on a daily basis.  Explaining benefit eligibility and the rationale for medical decisions can only be communicated effectivity if the person receiving the information understands it.

 

  • Sometimes an employee may need to be terminated while out of disability due to a work injury. When this takes place, it is important to be aware of applicable state and federal laws concerning employment practices, document all actions and reactions fairly and accurately, and be consistent when dealing with all employees—regardless of an injury or disability.

 

 

Conclusions

 

Retaliation claims in workers’ compensation claims are not common.  They can be costly if employment practices are inconsistent and not compatible with applicable laws regarding these matters.

 

 

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.

 

Guidelines To Determine Right Case Load For Your Work Comp Adjuster

When Workers Compensation Claim Adjusters have caseloads that exceed their capacity, experience, or training, the technical handling of the claim file can suffer greatly.  The resulting claim cost can be minimal to astronomical.

 

Problem:

 

An adjuster with a case load that exceeds their capacity, experience, or training can fail at the following:

 

  • Missing diary dates and following through on plans of action.
  • Allowing over payments of both benefits and medical bills.
  • Missing excessive treatments and prolonged disability.
  • Performing cursory investigations that allow the claim to be improperly processed to disposition.
  • Missing subrogation potentials.
  • Poorly documenting the file.
  • Poor reserving practices.
  • Allow subsequent involvement of underlying medical pathologies.
  • Fail to prepare properly for disposition.
  • Miss proper filings with the state that will incur fines and penalty.
  • Missing exaggerated or fraudulent situations.
  • Failing to establish professional rapport with the injured employee.

 

The list goes on…

 

 

Case Handling Guidelines:

 

Adjuster case load studies and independent claim audits generally reached similar conclusions as to what constitutes criteria for proper case work-loads.

 

They have found work should be distributed by level of claim needs, so the answer is not a one size fits all conclusion.  Jurisdictional requirements, adjuster experience, and ancillary support play a large part in determining claim personnel needs.

 

Here are some general guidelines by claim type:

 

Medical Only

 

Most claims only require medical care for short periods of time.  This ranges from 80% to 90% of the injuries sustained, and cases normally close within six months.  With current medical fees, the total cost should not exceed a $25,000 value.

 

There cannot be any lost time from work past waiting periods.  No permanent disability should be paid as a medical only.

 

In most jurisdictions, a medical adjuster can carry a monthly caseload as high as 250 to 300 claims.  (New cases should be assigned against closures.  Closures should be equal to or greater than new assignments.  Monitoring of open files must be a regular task to avoid cases remaining open that should be closed.)

 

A few jurisdictions require state approval before payment is made.   This may limit case count activity.

 

 

Active Lost Time Claims

 

Active lost time claims (indemnity cases) vary from a few days up to multiple years.  The adjuster’s active handling tends to slow within three to nine months, and most settle with minimal or no permanent disabilities.  The indemnity claims usually average between 5% and 8% of reported losses.

 

Depending on the jurisdiction, an experienced adjuster can handle a case load as high as 125 to 200 claims a month, and new cases should be assigned on the closure record. (Monitor that closures are current)

 

 

Fatalities, PTD, Catastrophic, Occupational Disease

 

The last category covers fatalities, permanent total disabilities (PTD), other catastrophic cases, and long term occupational disease that often require reinsurance intervention.  This level of adjuster typically has 10-15 years experience and handles multiple jurisdictions.  This adjuster will have a much lower case load because the claims are more complex.  Once the claim has settled into routine maintenance it can be assigned to a lighter experienced adjuster.

 

 

Summary:

 

The question of how many claims is too many claims for an adjuster does not have a one-size fits all answer.

 

To evaluate whether or not your TPA has assigned too many claims to the adjusters is often a difficult task as the TPA will be reluctant to admit the adjusters have too many files.  You can obtain a general idea as to whether the caseload is too high by reviewing the nature and type of claims, as well as the requirements of your states work comp act.  To know more precisely what the caseload should be, hire an outside, independent claims auditor to complete a Best Practices Audit of the TPA files.  The outside expert can assist you in identifying the issues impacting the claims quality and identifying the appropriate caseload for each adjuster handling your claims.

 

 

 

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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