6 Elements To Review In Your Adjuster’s Action Plan

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

 

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

 

 

Pre-Accident Training

 

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

 

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

 

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

 

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

 

 

Prompt Reporting

 

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

 

 

Claim Service Standards

 

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

 

 

Employee Follow-up

 

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

 

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

 

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

 

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

 

 

Medical Follow-Up

 

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

 

 

Return to Work Program

 

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

 

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

 

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

 

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

 

 

Summary

 

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

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Avoid Ethical and Legal Pitfalls In Workers’ Comp Surveillance

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

 

 

Use of Surveillance in the Right Case

 

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

 

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

 

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

 

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

 

 

Avoiding Ethical and Legal Pitfalls

 

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

 

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

 

 

Practice Pointers and Effective Techniques

 

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

 

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

 

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

 

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

 

 

Selecting the Right Private Eye

 

Other tips for effective surveillance include:

 

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

 

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

 

 

Conclusions

 

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

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

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

 

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

 

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

8 Categories To Define Winning Workers’ Comp Litigation Strategy

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

 

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

 

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

 

 

Defense Counsel Selection:

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

 

The Answer:

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

 

Initial Legal File Handling:

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

 

Defense Counsel Acceptance:

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

 

Defense Counsel Staffing:

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

 

Budget:

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

 

Claim Handling:

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

 

Actions of Defense Counsel:

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

 

Hearings / Trials:

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

 

Legal Bills:

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

 

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

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

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

 

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

 

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

3 Prongs To Crystal Clear Workers’ Comp Investigation

Incident Injury Report Form Document Concept

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

 

 

Crystal Clear Employee Report of Incident

 

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

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

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

 

 

Witness Report of Incident

 

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

 

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

 

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

 

 

Adjuster Recorded Statement

 

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

 

 

Properly Investigate All Accidents

 

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

 

 

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

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

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

 

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

 

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

 

 

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

[photo courtesy https://michaeljfox.org]

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

 

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

 

 

Fox’s Journey

 

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

 

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

 

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

 

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

 

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

 

 

Attitude

 

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

 

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

 

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

 

 

Reframing the Focus

 

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

 

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

 

 

Conclusion

 

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

 

 

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

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

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

 

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

 

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

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

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

 

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

 

 

Information Reported to Central Database On Every Claim

 

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

 

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

 

 

Protect Yourself From Paying For Prior Injuries

 

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

 

 

Example: Employee Sustains Injury Every Deer Hunting Season

 

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

 

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

 

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

 

 

Fraudulent Employees Often Switch Doctors

 

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

 

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

 

 

Central Index Bureau Submission as Standard Best Practice

 

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

 

 

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

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

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

 

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

 

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

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.

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