Workers’ Compensation Costs Can Be Reduced by Implementing Operational Best Practices: Learn How With This New Guidebook.
A company that wants to implement a new workers compensation program or revamp an existing system will find this book helpful. Maybe your company has recently expanded and you realize the need to train a workers compensation manager or regional coordinators how to hold down compensation costs. Whatever your need, here is the answer:
Workers Compensation Management Program: Reduce Workers’ Comp Costs 20%-50%.
Used by more than 150 firms across the country, this is THE book to help every employer develop a more effective workers compensation program to reduce workers compensation costs. It is based on field research and decades of experience in workers compensation from all aspects of the business. Best practices are described in detail for each person in the injury process.
This easy-to-read manual has been updated for 2012. It now includes:
An index for quick topic look-up so you can view a term or a procedure and see all relevant references.
NEW – Workers Compensation Basics
Purpose of Workers Compensation
Who Pays for Workers Compensation?
Parties Involved in Workers Compensation
Benefits for the Employer
Independent Contractors
Benefits for the Employee
Injuries Covered
Types of Workers Compensation
How Losses are Categorized
How Losses are Reported
Calculating Your Premium
How Mod Effects Your Premium
Good/Bad Mod Example
Five Ways to Reduce Your Mod
NEW – Fundamentals of Cost Containment
Reasons Workers Compensation Costs are High
Who is in Charge?
Work Ability Form Properties
Who is Responsible for Managing Workers Compensation Claims?
Who is Responsible for Managing Workers Compensation Process?
Hidden (Indirect) Costs of Workers Compensation
Additional Costs
Calculating WC Costs
External Obstacles to Cost Control
Internal Obstacles to Cost Control
NEW – Working with Your Adjusters or TPA
Account Handling Instructions
MD Participation
NEW- Reporting a Claim
Critical Issues
Essential Intake Considerations
Nurse Triage
NEW- Directing Medical Care
Occupational Health Clinics
Remote Health Services
Directing Medical Care in California
NEW- Return to Work
What to Include in a Transitional Duty Policy
Non-Profit, Volunteer or Charitable Positions
Employees Who Never Return to Work
Coordinating WC with Federal and State Leave Statutes
NEW – Other Indemnity Cost Containment Services
Telephonic Disability Intervention
NEW – Medical Cost Containment
URAC Certification
Mental Health RNs
Chronic Pain Programs
An Aging Workforce
At Home Recovery Services
Medical Fee Schedules
Fee Schedule Coding
ICD-9 and CPT Codes
NEW- Physical Therapy and Physical Rehabilitation
Differences between Physical Rehabilitation Programs
Pharmacy Benefits Management Program
Authorized Drug Formulary
Toxicology Screening
NEW – Fighting Fraud and Abuse
Medical Terminology Used to Identify Malingering
Reviewing Investigation Reports and Videos
Avoid good Day/Bad Day Syndrome
NEW – Claims Resolution and Settlements
Conditional Payment and Final Demand
Pharmacy Component of MSA
California Settlement Process
A 183-page guide covering how to assess your workers compensation program, design program materials, roll out a program to the organization, and monitor and manage the program once implemented.
Written by a national expert on workers compensation cost containment with over 25 years experience helping companies reduce their losses 20% to 50%.
T. Ronca, a workers’ compensation defense attorney from Long Island, NY, said the
book is an invaluable desk reference. “It is one of the tools that should never be out of reach for a risk manager. Direct employer involvement with claims in the first weeks is the difference between success and failure. This manual will guide the conscientious employer through the pitfalls,” Ronca said.
What’s more, the book can be delivered with your company logo on the cover and a full-color ad for your company on the back cover.
Take it out to the field. Text tabs are available to put on each chapter and it is ready to go as your company training manual. All you will have to do is customize the Training Agenda that is in Part I of the book.
Included in the manual are topics such as: Return to work and transitional duty, claim reporting, employee communications, controlling fraud and abuse, directing medical care, medical cost containment solutions, post injury response procedures, reporting procedures, working with your carrier and third party administrator. There is information about physical therapy, pharmacy benefits management programs, training supervisors and gaining management commitment. It also contains concepts of claim settlement and resolution as well as safety and loss control. New areas are identified above.
There are 5 sample worksheets in the manual to help organize an efficient workers’ compensation program. These include: timetable for implementation, the injury coordinator job description, and several sample roll-out letters. We recently received a terrific phone call from a third-party administration firm saying how the manual provided an organized way to train clients at loss prevention and has helped their clients put "layers of better WC management" in place. Everyone benefited.
One large distribution firm wrote to us to say the chapter on safety and loss control led to a company-wide safety change that only cost a few hundred dollars but prevented a specific type of injury that had been draining its budget, says Rebecca Shafer, Esq., President of Amaxx Risk Solution, Inc. who authors the book. Shafer is a national expert on workers’ compensation cost containment with more than 25 years of industry experience helping many companies reduce their losses 20-50%.
When you order your copy of Manage your Workers’ Compensation Program from Advisen at
http://corner.advisen.com/wcbooks, the 183-page guidebook shows how to assess your program, design program materials, roll-out a program to the organization, and monitor and manage the program once implemented.
The workbook is also available with a customized front and back cover for bulk purchases. Discounted rates apply to bulk orders.
One company said, "After reading the manual, we took a look at past workers comp practices and saw that every department did things differently. Manage Your Workers’' Compensation Program 2012 gave us the guidance we needed to standardize our workers’ compensation programs across the country. It was like a pre-prepared lesson plan," according to the risk manager.
A regional hospital in North Dakota wrote that, "Our small company expanded rapidly and we actually didn’t have any official workers’ compensation program in place. This manual gave us step-by-step procedures from the first meetings with management to monitoring the final program. Buying and reading the book was almost like hiring another employee – one who was an expert in workers’ compensation."
Who Uses the Workers’ Compensation Book?
Risk Managers and Workers’ Comp Managers find it useful learning about the cost containment niche and use it for themselves and to bringing new team members up to speed very quickly. The book becomes a “lesson plan” tool.
Safety Directors use the book to train supervisors in workers’ compensation claims management. They learn more about their area of responsibility — post loss cost containment — adding to their overall knowledge. They also learn what to do after an injury and what steps are supposed to take place during the first 24 hours.
Brokers use it for prospects, as well as, to learn about specific aspects of cost containment, passing their knowledge on to their clients. For example, when discussing how to develop a return-to-work program and a client asks about, “off-site return-to-work programs,” the broker quickly finds the relevant section in the book, reviews it and passes the answer on to the client, along with a copy of the cost containment book with the broker’s logo.
Adjusters use the book to gain a better understanding of the employer’s perspective. Adjusters also want to learn more about cost containment to add to their overall workers’ compensation knowledge in order to grow their careers and stay abreast of new services.
Account Producers give the book to prospects during formal presentations to illustrate their company is on top of the workers’ compensation industry. The book makes an excellent client gift.
Vendors such as doctors, physical therapy networks, occupational clinics and medical management firms learn how their service might fit into the workers’ compensation marketplace, what is important to employers, and what they look for in medical services to enable the vendors to enter the workers’ compensation marketplace.
The manual is a cost-cutting tool to learn more about systematic and operational techniques for reducing workers compensation costs.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
Posted in
Claim Audits & File Review,
Communication with Employees,
Coordinating Medical Care,
Federal Workers Compensation,
Fraud and Abuse,
Insurance Issues, Rates, Premiums,
Lowering Premiums & Experience Mod,
Management Commitment,
Medical Cost Containment & Managed Care,
Medicare Set Asides (MSAs),
Professional Development Issues,
Return to Work and Transitional Duty,
Risk Management,
Safety and Loss Control,
Settling WC Claims,
TPA and Claims Administration,
WC 101,
WC in Other Countries (International) |
Morale hazard is loosely defined as the presence of an outside item or system that affects typical behavior. I like to use an example of SUV-type vehicles. Because of added safety features and the enormity of the vehicle, drivers report feeling safer and often take more risks then when driving smaller, less-safe vehicles. For example, an SUV driver may be more aggressive during dangerous snowy conditions, or drive more aggressively in general simply because she feels safer. WCxKit
To put this in a Workers Compensation context, the morale hazard is the comp system itself. The system’s rules and laws make people behave differently than if they were presented with the same injury and medical scenario outside of the work comp atmosphere. We further discuss these scenarios below:
1. Increased pain behavior
Within the WC world, adjusters often complain about claimants overreacting to pain and complaining about the presence of pain with even the most trivial injury. This is thought to happen due to the nature of the claimant feeling that they have to prove their injury to the doctor and to the carrier. Even though, as adjusters, we understand injuries occur and most times they do indeed hurt, the need presents itself for the claimant to feel as if they have to be sure to state how unbearable this particular injury is, in order to make the injury seem more believable.
If you take WC presence away, when a similar strain injury occurs, outside of the workplace, for example, the reaction may be wildly different. Claimants may shrug off the pain as “age-related” or due to overdoing it instead of feeling the need to play up the pain to their doctor, as is often the case in workers compensation claims. Adjusters will rely on physicians using the “Waddell’s signs” to evaluate pain behaviors in relation to the severity of injury. As you see, the mere presence of the work comp system can provide the means to making claimants overplay pain as much as possible to make their case more concrete or believable.
2. Increased drug-seeking behavior
Minor strain injuries generally resolve with modified activity and time. But when a work comp case is present, some claimants feel the need to seek out certain types of medications, typically opiate in nature, to cement the legitimacy of their injury. The thought process is, “If I did not have a bad injury, why would I need these stronger medications? Therefore, my claim must be legitimate.”
One factor muddling this is physicians who are quick to prescribe opiate medication even when the clinical need is not present. Strain type injuries can heal with assistance from anti-inflammatory medication, not necessarily stronger opiate classifications of prescriptions. Many resolve with hot/cold compresses, several special deep knee bend type exercises, rest and 1-2 chiropractic treatments. I speak from experience.
Removing the comp system again can show the normal behavior. If a person injures themselves mowing their lawn, if they do not like going to the doctor in general, they may take over the counter medications and feel just as good the next day as if they did indeed take a stronger medication prescribed to them by their physician. So you see, drug-seeking behavior is rampant in work comp cases due to the need for the claimant to seek approval from their comp carrier for that injury.
3. Poor work quality in light duty work classification
If you have the capability for light duty at your factory, when claimants get injured and have work restrictions, proactive employers place them in lighter duty jobs until they get released by their doctor to full duty. A common situation in comp is the worker complaining even the light duty work makes their pain worse. This can happen even when it seems impossible the light work could cause pain. This is due to the presence of workers compensation. Had the worker not been injured, and you placed them in this light-duty job, it is doubtful they would be making the same complaints.
4. Increased work absences due to pain
Similarly, employers may see an increase in work absences due to alleged pain complaints. Workers will say, no matter what job they do, they just cannot get out of bed and back to work due to injury pain. In the example of the lawn-mowing injury – when the comp system is removed, it is probable this worker will show up as scheduled and ready to work as if it were any other day. This again may be due to the claimant feeling the need to legitimize their claim to the carrier. True, sometimes it's not.
5. General avoidance with the employer
Sometimes outright avoidance becomes apparent. Missed phone calls, voicemails not returned, and an employee not bringing in medical slips to the HR department as instructed may start to happen. Remove the comp system and injury, and this wouldn’t happen. A responsible worker injured outside of work keeps the HR department up to date with medication restriction slips. Once you introduce the work comp system to this same scenario, avoidance behavior may come to fruition. WCxKit
To review, morale hazard is the presence of a particular system or entity that can affect a person’s behavior negatively. This is made clear within the presence of workers compensation. Adjusters see these behaviors day in and day out. What the employer calls a “great, dependable employee” could be to the adjuster a claimant who exaggerates pain, has drug-seeking behavior, and exhibits typical avoidance maneuvers in general. This all negatively impacts the claim, and actually makes it more difficult in the long run. From the workers point of view, these behaviors make their claim more legit — just the opposite occurs.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
Never heard of a "med-legal" conference? Neither had I. I learned when I did a chair side visit to a major third party administrator in Windsor, CT. I asked the adjuster who was hosting me, "What is the next step in the indemnity claim?" – my standard question when an adjuster walks me through a client's claims, when I seek to learn how the adjusters in that office approach claims. The adjuster said that the "med-legal" conference was coming up soon. Huh? The WHAT kind of conference? Ah, med legal… I had never heard of it and neither had the employer's risk management team. Tell me more.
Medical care for an injured employee can be complicated. When the injured employee is represented by an attorney, the plaintiff’s attorney often tries to make the injury appear more serious than it is. Defense attorneys who have handled many similar claims often have a fairly good understanding of the medical terminology and what is meant by various medical reports and are not fooled by the plaintiff attorney overstating the nature and extent of the injury.
However, there are situations where the injury to the employee is unique, and the seriousness and/or complexity of the injury is not fully understood by either the workers comp claims adjuster or by the defense attorney. It is in situations of this nature that a conference between the defense attorney and the doctor is needed. These medical-legal conferences are normally held during the discovery phase of a workers comp claim in litigation, but can be held at any time and are often held in person at the doctor's office attended by the claimant's doctor and the employer's attorney. (WCxKit)
Med-legal conferences can occur by telephone, but more often the defense attorney will reserve an appointment with the medical provider to review and discuss the medical treatment an injured employee is incurring. The med-legal conference allows the defense attorney to better understand the injured employee’s medical care. The defense attorney will have the opportunity to ask questions about the medical reports and will hence be able to decipher and understand the medical reports better.
The med-legal conference puts the nature of the injury, the extent of the injury and the future medical treatment needed into plain English that the defense attorney will be able to understand and convey, if necessary, at a Board hearing or in a full-blown trial. This makes the negotiation of any settlement on the workers comp claim more accurate and feasible.
The med-legal conference also will assist the defense attorney to understand the chronological sequence of the injury, the medical treatment and the recovery. The defense attorney will also better understand the reasonableness of the previously provided care and of the proposed future medical care.
To better understand the use of a med-legal conference, consider the following real claim.
The employee was removing a motor from a dump truck. The employee fastened a chain around it and lifted it with a fork of the forklift (no safety program at this employer!). When the forklift moved, the motor dangling on a chain, swung around and struck the employee in the top of the back, breaking the right clavicle with a compound fracture.
After four months of treatment, the medical provider placed the employee at MMI. The workers comp adjuster paid the PPD rating and thought the claim was done. Two months later the claimant calls the doctor and is in severe pain. The doctor does an x-ray and the clavicle, which had been healed in the prior x-ray before the employee was placed at MMI had developed a non-union along the fracture lines. The plaintiff attorney filed for a “worsening of condition” with a request for additional medical treatment, additional temporary total disability and was pursuing a higher PPD rating.
The defense attorney met with the doctor following the resumption of medical care to discuss the cause of the non-union and how it could have developed after the employee was released from care. The doctor explained that within a reasonable degree of medical certainty the failure of the previous union of the bones had to be caused by the employee suffering an aggravation at his new employer. The doctor explained there was diagnostic evidence of an aggravation. The aggravation breaks the chain of causation resulting in the employer at the time of the initial injury no longer being responsible for the claimant’s medical condition.
To prepare for the med-legal, the employer's medical director can have a conversation about the injury with the defense attorney (their defense attorney). The better understanding the defense attorney has, the more effective the discussion with the claimant's doctor will be. Get the Injury 101- version of the injury from your own doctor, then be prepared to gather advanced information from the claimant's doctor.
Attorney Theodore Ronca suggests for the employer's attorney ask the claimant's doctor, "What is your timeframe for return to work?"
The cost of a med-legal conference is the cost of the doctor’s time and the cost of the defense attorney’s time. The med-legal conference will often answer the questions the defense attorney has in regards to the medical treatment and the status of the injured employee, eliminating the need for a formal deposition and the associated cost.
It is often worthwhile to pay for the time the doctor and the defense lawyer spend reviewing the medical care, the causes of medical issues and the proper resolution of the medical issues. Med-legal conferences should be used any time the medical issues are complex and the understanding of the employee’s medical condition is not clear.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
As a Risk manager, claims coordinator, agent, human resources representative — whatever your title may be, the name of the claims game comes down to reserves. Reserves are the tangible part of what an injury costs you, either directly out of budget, or as potential future increased premium costs. A lot of speculation and estimation goes into reserving a file, but a good percentage of the time when you try and come up with a number for a file you find yourself way too low. Why are the numbers that your adjuster recommends so high? What exactly do we have to cover as future medical cost, even though this claimant may no longer work for you? How do adjusters learn how to reserve?
1. It is the cost of the claim for “life”
When you think about reserving a file for the long term, you have to think long term. Not long term as in 10 years. Long term as in for the rest of that person’s life. In most states, if an injured worker needs long-term reasonable and necessary medical treatment for their injury, and the doctor relates treatment specifically back to that injury, then your company is probably responsible. You can get an IME (Independent Medical Review), or record review to fight why the recommended treatment is not related but, typically, the burden of proof is just causal relationship. If the patient can show the need for treatment relates back to the injury of 20 years ago, they have met their burden of proof. This is when these injuries can come back to bite you. Instead of settling 10 years ago because you thought the number was “too high,” now you are going to have to scramble to come up with a defense and, if it is indeed related, not only will you have medical costs but you may have wage-loss costs as well. (WCxKit)
The future is your biggest enemy in surgical claims with long-term exposure. Once surgery is performed, nothing is ever the same. Scarring, nerve issues, accelerated arthritis symptoms, the need for ongoing medication and doctor evaluations, diagnostic testing, etc. These things all lie in wait for the future. Sure, right now in 2011 the claimant’s demand of $100,000 may seem like a lot. But you have to break the file apart, and this is what the adjuster does. If your injured worker is 30 years old, you potentially have 55 years of exposure. If back surgery was in 2011, and the claimant is 30 years old, you have a ton of problems sitting there waiting for you. The claimant may be fine now and the surgery was a success. But what about 5,10,15 years from now? Will be needed another surgery? Maybe that one will not go as well. So consider the long term: The life of the claim, the life of your claimant, and the need for future medical treatment.
2. The injury requires potential future surgical risk
Surgical cases are major red flags for future problems, especially when some sort of hardware is implanted. Most of the time these people return back to doctors due to pain, usually due to hardware or screws becoming loose. Then this person has to undergo a procedure to have it removed. Then, they have to rehab from that, and then they can return to work. But, again, the issue here is when will the person need that hardware out? Some can live with it forever and never come back. Some come back in a year or two. Some have constant problems with it and it creates problems preventing them from making a full recovery from surgery.
Back surgery is especially risky. In the world of workers comp you do not hear about many success stories with major back surgery. It may lessen the pain, but it can create a ton of future issues. When you evaluate these claims and costs of settling them, be sure to account for future surgical risk. It is very costly, and very risky, and maybe you better get rid of that risk now if you can versus adopting a “wait and see” attitude.
3. The costs ongoing medications
If you pick up any newspaper you will run across a story about the costs of medications and how they are dramatically increasing. Each drug manufacturer has their reasons to increase price but, whatever the reason, the bottom line is prices are always going up. And if you have a claim where a claimant has to take ongoing medication for pain or nerve issues, those meds are typically not the cheapest ones. Sometimes generics are available and worth looking in to, but its still an ongoing monthly cost that can drag on for years. You can find out from your IME doctor if it is necessary for your claimant to continue taking these meds, how often they should be taking them, etc. That way you can properly estimate the future cost. But keep in mind to add in a percentage for inflation over the years, since prices show no indication of decreasing.
4. An MSA may be needed
Perhaps the biggest roadblock to settling a claim is the need for a Medicare Set-Aside (MSA). The MSA breaks down future cost for those who require future treatment while also being on Medicare or of retirement age. If your veteran worker sustains a major shoulder injury a year before retiring that is not good. Not only do you have to cover surgery and rehab on a veteran worker in your shop, but also, the chances for a good recovery are guarded, which means ongoing treatment could last for years. An MSA is needed if you want to move this case to settlement. MSA numbers are not small. There are several vendors who specialize in MSA reports and submissions, and they will tell you they are very costly once approved by CMS (Center for Medicare/Medicaid Services).
MSA’s are costly, speculative treatment estimations. And the key word here is “estimates.” There is no guarantee the claimant will need another surgery. But they may estimate it for you, and make you pay for one just in case. So maybe that is a scenario where you should not settle. It is something to discuss with your adjuster. The point is, be aware if an MSA is needed it is going to financially cost you to settle and resolve your risk involvement in this case.
5. The age/general health of the claimant matters
Obviously if a 22-year-old worker falls and breaks his neck, you have about 63 years of medical exposure. If your 67-year-old, part-time janitor falls and breaks his ankle, you have maybe 16 years of exposure. Age matters. The younger the claimant, the more severe the injury, the more costly it is going to be. Reviewing employees personal health histories correlates to cost as well. The healthier the person, the speedier the recovery and the less it may cost to get them back to full duty work.
It is hard to control genetics. Everyone is different and heals differently, but you can get a good idea about if someone is “healthy” or not. If you have seen your claimant in the past eating fast food and chain smoking during daily breaks or lunchtime, you know quick healing is probably not in that person's future.
Summary
The art of reserving a file for life expectancy is part science, part estimation, and part experience. Adjusters see the same injuries day in and day out. Sometimes they deal with poor healers and sometimes they deal with those who make a speedier recovery than planned for. This is why reserving a file for probable outcome is an art form. All you can do is look at the evidence and what the future may hold. If in doubt, aim for a higher rather than lower reserve figure.(WCxKit)
For your long, large claims, utilize the help of a life care manager or an MSA company. Talk about future medical needs and costs with your adjuster. Roundtable the file with your peers and see if you are missing anything. Ask your adjuster during your weekly roundtable meeting. If you don't have a weekly roundtable, it might be time to ask for one. It is complicated to think about every cost an injured worker may need between now and 40 years from now, but if you use the tools at your disposal you should be able to get an accurate, effective reserve for the life of the file. If you want to outsource this – and many do - to a an expert, consider the Life Care Planner services of your TPA or MSA company. Also, ask your adjuster for the Reserving Worksheet – this can clear up any problems.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com.
Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
If you are a risk manager that has been with a company for a long time, you probably have developed a relationship with some of your employees. If you are an agent, and you have been in the business a long time, you probably know your book of business very well and would do anything to keep them happy and to keep them coming back to you for their insurance needs. Same thing for the risk manager: They do what it takes to resolve their employee claim problems.
But, when workers comp is brought in, this is the elephant in the room. As much as you — the employer, agent, etc. — want to help the employee, there is only so much you can do. Comp is a separate issue, with another party handling the actual claim and the compensability of the claim. It is not like glass damage where a risk manager’s agent says, “Do not worry about it; we can file a claim with the carrier and they will pay.” Sometimes they will not. It is the same with work comp. No matter how great a person your injured worker is, there is a chance their case will not get accepted for whatever the reason.
This puts you in an awkward scenario. 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. What do you do? Here is some advice for when you are caught in the middle:(WCxKit)
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 even 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 in the end affect your overall premium.
Take the time and call the adjuster. 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 these laws, they only abide by them, and they are different state to state. Each adjuster has different styles as well, so if a worker had a comp claim similar to one six years ago and it was accepted, and now the same thing happened and now it is denied — find out why. Make sure the adjuster has legal evidence to back it up.
It could also not even be denied; maybe it is just 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.
2. 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 this case has a 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. It can only produce a better outcome for all.
3. Find a middle ground for plans of action, if possible.
Just because you talk about the file and you meet up in person does not mean you will all agree on what to do. At the end of the day, the employer gets affected by these decisions through their premium. Or, if self-insured, it is your money heading out the door on this file. This is where the employer has to be involved in some of the decisions.
If you are not satisfied with what you are hearing, see if there is a middle ground, or a non-aggressive approach everyone agrees on. This is where independent medical examinations (IMEs) can be done. Nurse case managers can help, voc assessments can be performed, etc. Then after you have compiled all this info, and go over the pros, cons and monetary values of each one, then you may choose a strategy.
Maybe you do not want the carrier to take the ultra-aggressive approach because it could backfire. But you do not want them to roll over either, so find a common ground you all agree with. This way, not only are you involved in the process, but you are also involved in decision making. The adjuster wants to make the employer happy because she is also a client. But you have to abide by the statutes within your state of jurisdiction. Explore your options, and come out of that meeting with an agreed-upon plan. Not just agreeing to disagree.
4. The adjuster knows best.
Let us say you have been a risk mgr for a long time. This does not mean you are the adjuster. The adjuster has had medical and legal training, negotiation training, and she is up to date with the current law changes and trends. Adjusters know which doctors’ opinions are not worth the paper they are written on. They also know the doctors who will “slash for cash” — meaning they will perform surgery at the drop of a hat. Those doctors are out there, and hopefully your employee is not being treated by one of them.
When push comes to shove, the adjuster and counsel probably know best about what options you should be taking. Thorough discussion should bring you to this point. At the end of the day, the carrier is going to protect themselves from exposure just as much as they are trying to protect you. But be sure you understand why they are doing what they are doing. This effective communication will help you understand why the plan is what it is, and why it is best for you and your company.
5. 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 best pal or your worst hire, you cannot bring those feelings into your overall decision on what to do 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 it must be backed by legal precedence. The carrier is not going to deny a claim just because they feel like it. There is a reason. On the flip side you cannot force a carrier to accept a claim they are not going to accept. They understand that this worker may be your friend and you want to do what is best for them, but you cannot force the issue. All you can tell them is that this person is your buddy and you want what is fair. Again, it comes down to communication. Know why they are doing what they are doing, and you will walk away understanding why the decisions are what they are.
In conclusion, no matter who is injured, when they are injured, or what they were doing when they were injured, you will have a personal feeling about why a claim should be accepted or denied for whatever reason. But, at the same time, you have to educate yourself on why claims are accepted or denied. You can accomplish this through communication.(WCxKit)
We talk a lot about being involved with your claims, and the examples stated above point to why you need to be involved, and why you need to understand why claim decisions are made. You need to know your carrier or third party administrator (TPA) makes these decisions to protect your company and your interests, as well as their own. The decision should be fair, backed by legal statute, and ethical. Whether the claim is accepted or denied, it will be a fair decision.
Author Rebecca Shafer
, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com.
Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Catastrophic injury claims make up less than 1% of all workers compensation claims, but different studies show they entail approximately 20% of all workers comp costs. For the small employer, one catastrophic injury claim can distort the severity factor in the workers comp premium calculations and have a major impact on the workers compensation premiums for years into the future.
Catastrophic injuries are injuries that disable the employee to the extent the employee can never return to work and significantly alters the employee's life in general. Common examples of catastrophic injuries are: (WCxKit)
1. Brain/brain stem injuries.
2. Severe burns over 50 % or more of the body.
3. Spinal cord injuries.
4. Multiple amputations.
5. Multiple trauma.
6. Total vision loss.
7. Occupational lung diseases. (WCxKit)
The eventual cost of a catastrophic injury is very difficult to establish early in the life of the claim. Even the experienced adjuster does not have a crystal ball to determine if the overall cost of the claim is going to be $500,000 or $5 million when establishing the initial reserves on the claim. With catastrophic claims, as additional medical and rehabilitation information becomes available, the reserves are often adjusted by large amounts (6 figures or more) several years into the claim.
To establish the value of the catastrophic injury claim, there are various factors the adjuster considers. While it is the adjuster's responsibility to establish the reserve, the smart risk manager does not leave it all up to the adjuster. It behooves the employer to review the factors that go into reserving to be sure the adjuster is setting the proper reserve and not taking the easy way out by reserving a nice round number like $1 million.
The factors that go into establishing the value of the catastrophic injury claims can be divided into the three areas: indemnity, medical, and claim related expenses. Look for vendors specializing in
Life Care Planning.
Lifetime cost of the indemnity includes:
1. The employee's average weekly wage and weekly indemnity benefit.
2. The time span of the indemnity; does it last for a set number of weeks, (500 weeks), as it does in about half of the states, or does it last a lifetime, or to a set cut off point in the retirement years?
3. The employee's age and projected life span on the actuarial tables.
4. Does the indemnity rate remain the same for permanent total disability as for temporary total disability, or does the compensation rate change?
4. What is the amount of the offset for social security disability?
Medical factors in establishing the value of the claim:
1. The cost of immediate medical care following the injury.
2. The cost of surgical interventions in the first years following the injury.
3. The on-going cost of medical care on an annual basis after the medical status is stabilized.
4. The cost of modifications to the employee's home and current and future vehicles.
5. The cost of institutional medical care.
6. The cost of durable medical equipment (wheelchairs, artificial limbs, hospital beds, oxygen tents, etc.).
Claim handling expenses for catastrophic claims:
1. Nurse case managers.
2. Rehabilitation specialist.
3. Defense attorneys.
4. Actuarial experts. (WCxKit)
The above items impacting the value of the catastrophic claim are not the only factors to consider when establishing the future claim cost. If the insurance company decides to settle the catastrophic workers comp claim, they work with the Centers for Medicare and Medicaid Services (CMS) to obtain approval of the Medicare Set Aside Agreement (MSA). The value of the settlement has to be high enough that the claimant (in theory) never has any future medical cost paid by CMS.
Another factor impacting the value of the catastrophic injury claim is the availability, in some states, of a Subsequent Injury Trust Fund to cover part of the future cost of the claim. Also consider whether or not the insurance company can resolve the claim with a structured settlement and of the future cost of the claim being sold to another insurance company. (WCxKit)
While it is possible to calculate the value of the catastrophic injury claim, keep in mind a catastrophic injury is a major life altering event for the employee. The catastrophic injury impacts almost every area of the employee's life and family. It is a personal tragedy far beyond the financial cost of the claim.
Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. Shafer is the author of Workers Compensation Management Program: Reduce Costs 20% to 50%. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
When a work injury occurs most of the time there is no one to blame other than the worker. This could be from lifting too much at one time, trying to work too fast, or from simply doing too much at one time. These types of claims are typically straightforward and easy to investigate. If a person injures their back from repetitive lifting, the lifting of materials is the cause or mechanism of injury. Right? Maybe not.
But what if the injury happened due to some other outside force? Maybe an outside vendor an employer uses from another company is walking through the halls cleaning or waxing the floor and fails to place signs to not walk in that area. And a worker then falls and fractures an arm. So what to do then? (WCxKit)
There are a lot of varying factors and legal issues in the world of subrogation that vary from state to state. But, still it is worth exploring some sort of recovery that can help recoup medical expenses and wage loss paid. Subrogation should be ruled out in every claim, even if it seems the injury was due to simple “employee operation error.” We discuss some of these scenarios below.
First, what is "subrogation"? Subrogation is the right for an insurer to pursue a third party that caused an insurance loss to the insured. This is done as a means of recovering the amount of the claim paid to the insured for the loss.
1. Slips and Falls
When I receive a new claim from a slip or fall, the first question I ask is where the accident occurred. Let us say this happened in a parking lot of the employee’s work place. Why did the employee fall? Was it snowing? Was the lot plowed and salted properly if the fall was in the winter? Was it plowed previously then more snow accumulated? Did any other employees fall or notice slippery conditions?
This is most important when having an outside vendor that is hired to maintain the outside premises during winter months. If this is the case, then there may be a subrogation claim to pursue. If the outside vendor had a duty to maintain the premises, and failed to do so, then it can be argued depending on the jurisdiction.
Now say that an employee fell in a hallway or in a bathroom. Was an outside vendor onsite to wax or clean the floors and forgot to wipe up some water that the employee then fell in? Was the area roped properly with warning signs? Where were the signs located? Did anyone else see the signs? Again, if a maintenance contract exists with this company, there is a claim to pursue. Winning one of these subrogation claims can mean that the outside vendor pays the employer back expenses to get the worker back to full duty.
I know of employers that choose to use outside vendors for this specific reason — this way they can possibly shift the risk to an outside vendor. Any failure to properly mark areas as being worked on or being “wet” can result in the pursuit of a subrogation claim. The same goes for parking lots and sidewalks. Some vendors will allow employers to list demands for winter care when the need for salting, sanding, and snow arrives. The employer can be as rigid as preferred (with some vendors) and this way if an injury does occur, the expense shifts to the other carrier rather than incurring the total cost of the medical and wage expenses under the employer’s carrier. Every carrier usually has a subrogation unit to pursue injuries such as these.
2. Tripping over something
Did an employee fall over a mat that was not placed down properly? Did a worker stumble and fall due to a rug or placemat that had holes in it or it was not in proper working/functioning order? Again, using an outside vendor to maintain these areas and rugs can help if an injury occurs. These vendors have a duty to properly place the rugs or mats, and these floor coverings have to be in proper working order. Now it can be asked “How can a rug not be in proper working order?” If a rug is down on the floor, it is in working order. But, maybe these rugs are old and worn out in certain areas, and therefore they are not as productive as they should be. They are ineffective for the purpose. Employers use entry and exit rugs and carpets, relief mats in front of machines, anti-slip strips on steps, etc. If any of these are in disrepair or appear in poor shape, and an injury occurs, it could be a subrogation claim. This vendor may be responsible for failing to replace these worn items, again shifting the risk and expense from you the employer to them.
3. Machinery injuries and Mechanical failures
When I have a claim where a person gets injured while using a machine, the manager I talk to about the accident usually says that the employee was not paying attention when the injury occurred. This may be true, but also these machine manufacturers have a duty to design proper, safe equipment to sell to the employer. Sometimes these machines do have design flaws and can lead a person to injury. Maybe there should be a guard in a certain area where there is not one. Maybe a hand can reach an area it should not be able to reach. Maybe the machine does not turn off all the way, even though the switch is turned fully to the off setting. All of these issues can result in injury, and the company that makes the machine can be held responsible. This will involve the carrier bringing in some sort of machine expert, or engineer, but it can be worth the cost. Especially if the injury is a bad one. Typical machine injuries are laceration or crush injuries, and even worse amputations. So the exposure is there. Do not be so quick to point out operator error as the sole cause to an injury involving a machine. The operator may have made a mistake, but the problem may stem from deeper design issues.
4. Vehicle Accidents
In certain states the driver that causes an accident can be held liable. The worker may have been doing nothing wrong other than driving down the road, when another vehicle slammed into the vehicle from behind. Maybe the vehicle that hit the employee’s vehicle is from another company. Even though the van may not be marked as a commercial van, it still could be a business van used for company purposes. Who owns this vehicle that hit the employee? What was the driver doing? Where were they going, and why did the accident occur? Motor vehicle accidents can be nasty as well. If there is subrogation in a vehicle case, a thorough investigation into is definitely worthwhile.
5. Injuries from other vendors on your premises
If a vendor is on the premises conducting normal business, and an injury happens, there could be subrogation potential. Maybe the cart slid away and hit the employee. Maybe a vehicle or other mode of transportation on the jobsite was being used, lost control and hit another worker. Maybe the vendor was unloading supplies in the back area and while stacking boxes the boxes fell and landed on the employee. The subrogation unit will determine if this vendor is responsible for the injury, and they could have to reimburse you, the employer, for the cost to heal an injured worker. (WCxKit)
Summary
Subrogation investigations and claims can come from injuries where employers least expect. Do not be so quick to chalk the injury up to the employee’s error. There could be a lot of other circumstances that caused the injury. Talk with the carrier about subrogation and if the carrier has a unit dedicated to only subrogation investigations and the pursuit of subrogation claims. It can save a substantial amount of claims expense, especially on those severe injuries. Subrogation should be reviewing every injury to see if a claim can be pursued. And every claim pursued could yield the employer some sort of reimbursement from another carrier.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. Rebecca is the author of Workers Compensation Management Program: Reduce Costs 20% to 50%. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
1. Introduction
This is an outline of measures that can be taken by employers to reduce NY comp expenses. The measures outlined have been undertaken by employers in the past with success. The measures do not come at the expense of workers and worthy claims; they limit delay and arrive at correct payments without enlargement due to inefficiency and insufficient information.
2. The NY workers compensation system since 1947
The present compensation system was largely created by the 1947 changes, the most significant of which was enlarging the number of lump-sum settlements. Although only 1% of all claims resulted in a lump sum, these claims carrier 60% of all attorney fees awarded. (WCxKit)
The second significant change occurred in the 1960s when the Board declared that its medical guidelines were obsolete but failed to adopt new guidelines until the 1990s. In the intervening period, this led to decades of litigation with a “blank yardstick” resulting in the majority of settlements clustering at 50% disability on PPD claims.
3. Recent attempts at reform
In 1984, a compensation commission report called for creation of objective medical guidelines to limit the growing number of trials, appeals and prolonged adjudications of claims which resulted in frustration of workers and dubious accuracy in results. The then proposed changes threatened to radically alter the practice of comp law for both claimant and defense lawyers and were resisted, as have recent changes.
Currently, extensive guidelines have been enacted for medical treatment and evaluation of permanent disability, but there are still no published methods for measuring post-injury loss of wage earning capacity a claimant has returned to work or has received a valid offer of work within residual capacities. Such offers will be one of the methods for cost reduction described in this outline.
4. Reasons for prolonged litigation in New York
New York has had an anomalous workers compensation system for decades. The reasons have to do with the politics of the 1940s which, after a generation, were forgotten, but the residua have remained.
The system became marked by an elevated number of hearings, trials and appeals. Law, regulations and court decisions were seldom cited and the proceedings were seemingly governed by informal customs rather than law and fact.
That is currently changing, with restrictions on litigating issues without cause or preparation, but the generally casual atmosphere has remained. However, parties making efforts to diligently investigate all facts and research law to prepare claims – especially prior to the first hearing – will realize advantages and results.
5. Opportunities for employers
There are a number of critical points in a New York claim where an employer’s efforts can achieve unexpected results. The results can take many forms reaching a correct resolution months or years sooner, limiting unnecessary testimony, reducing adjournments to obtain material that should have been available at the first hearing and reducing unwarranted awards.
The Principal Employer Initiatives
- Use of OSHA for investigation of problematic claims. (29 CFR 1904.5 can be used to obtain HIPAA releases and schedule an early IME exam.)
- Enhanced preparation of the first report (C-2) with location and attachment of supporting documents for defense.
- On PPD claims,
- a search for prior medical conditions to be conducted 6-9 months after date of injury,
- an ADA conference with worker, with spouse present,
- offers of modified or full RTW prior to Sect 32 settlement discussions,
- for certain acute conditions, employer assistance and support for SSDB
- claims although no comp claims have been contemplated.
Initiative A (OSHA)
permits HIPAA releases and an IME exam, by the employer,
Far faster than is possible under the NY WCL by a carrier or TPA. The OSHA records remain separate and are not automatically released to the comp file
but, with proper efforts, can be used in in the compensation claim. The HIPAA releases produce information that is a highly effective method for keeping unrelated conditions from becoming merged into the comp claim.
The active role by an employer in the beginning of a claim is, in fact, appreciated by most employees.
Initiative B (enhanced C-2)
is designed to utilize the employer’s superior background knowledge and access to relevant documents. These assets are not developed simply by completion of a C-2. Often, a claim will come to a successful conclusion at the first hearing solely because a fact is identified, explored and developed before hearings start.
Initiative C
contains three separate parts for limiting PPD claims.
- A. The location of prior medical records which can support a reduction, or halting, of future wage loss payments, per the April, 2011 “Poli” decision.
- B. An ADA conference, so that the claimant, and spouse, may hear of RTW possibilities prior to any Sect 32 settlement offers. (Spouses are usually supportive of RTW rather than settlement and should be present at the conference.)
- C. An offer of limited or modified work which, if refused, can be construed as a voluntary withdrawal from labor. The offer also acts as an objective measure of wage earning capacity and can supplant Board guidelines for medical evaluation of PPD final rates. (WCxKit)
Initiative D
employer SSDB assistance for certain medical conditions such as heart attacks, can reduce comp claims filed later. Many workers comp heart attack claims are not filed until after a worker has consulted an SSDB attorney, most of who are also comp attorneys, and the time to file a compensation claim has not yet expired. Workers frequently resist filing claims against employers who have been supportive.
Author: Attorney Theodore Ronca is a practicing lawyer from Aquebogue, NY. He is a frequent writer and speaker, and has represented employers in the areas of workers’ compensation, Social Security disability, employee disability plans and subrogation for over 30 years. Attorney Ronca can be reached at 631-722-2100. medsearch7@optonline.net
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
Medical disability guidelines can assist an employer in planning for the future return of an injured worker. Medical disability guidelines are an essential planning tool because they provide an employer with a time frame as to how long an employee, on average, will be away from work. Large self-insured employers, TPAs, insurance companies as well as captives and associations that handle claims all use online medical duration guidelines.
Medical disability guidelines do not offer the medical provider or employer a precise number, but rather a range of time the guideline’s user can anticipate the employee will be off work depending by the difficulty of work. The range of time is based on a compilation of extensive data about numerous injuries. The collection of data is sorted by the nature and the extent of injury. The greater extent of data, the more accurate a disability duration prediction is. The field of occupational medicine continues to grow and expand, providing a constantly revolving and growing accumulation of data.
It should be noted that medical disability guidelines are designed to provide physicians, employers, and employees with ranges and guidance, not precise answers. Guidelines often have a minimum recovery time, a maximum recovery time, and an optimum/average recovery time. The specific employee's willingness and inclination to return to work can be measured in three ways – restrictions, limitations, and the willingness to tolerate the symptoms brought on by the injury.
The medical provider will set the restrictions on what the employee should or should not do. While the employee may be capable of doing the activity, to do so could poses a risk to the employee and possibly others. For example: an employee with an injured arm might be capable of driving a dump truck, but there is risk the injury could impair the employee's ability to do so, posing a risk to both himself and others.
The medical provider will also take into consideration limitations the employee has due to the injury. These limitations are often based on a capacity evaluation of what the employee is physically capable of doing and how long it should be before the employee should be capable. For example: an employee with an injured back will not have the physical capability to lift heavy objects. Limitations are normally in place for what would be considered the average time a person will be off work.
The restrictions closely conform to the minimum column of the medical disability guidelines while the limitations will often correlate with the optimum recovery time in the guidelines. The maximum amount of time an employee should be off work is reflected by the concept of tolerance.
The greatest variance in the medical disability guidelines arises from the willingness of the employee to tolerate the symptoms of the injury. The medical provider may look the medical disability guidelines and establish what is the normal recovery time for an injured person who has a particular nature and extent of injury. Individual factors such as fatigue and pain can impact an employees’ disability duration.
Personal factors can also play a role in the recovery and disability duration. Any comorbidities the employee has (diabetes, obesity, etc.) can distort the disability duration. The employee's motivation to return to work can influence the employee's tolerance level. The motivational factors can include income (satisfied with the tax-free income of workers compensation), job dissatisfaction, self esteem, health insurance provided by the employer, etc. These are not medical reasons for disability but impact the employee's willingness to tolerate injury symptoms, and therefore whether or not the employee disability duration falls within the medical disability guidelines. The maximum time frame is often placed at the 90 percentile where 90 percent of the people with the type of injury involved have returned to work.(WCxKit)
The medical disability guidelines are evidence based disability durations. They are multidisciplinary in scope with their findings continuously undated to reflect improvement in medical care and medical practice. They are best used to answer the question "how long will the injured employee be off work."
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
The role of the employer after an accident is vital. Unfortunately, it is a misconception that it consists solely of filing a report (C-2) with the carrier and Workers Compensation Board within 10 days. That might be the barest minimum legally possible, but it is rarely adequate for anyone involved in a claim and certainly not for the employer and employee.
An employer trying to complete the Board’s prescribed form for reporting an injury is immediately confronted by puzzling requirements. Many of the questions are for small details which are never part of a compensation adjudication (the employers industrial code) while others allowing a woefully small amount of line space for what might require a lengthy explanation (how did the accident occur). Other parts of the form seem to assume that an accident must have occurred, even though many employers are equally certain that it did not. (WCxKit)
(Attach additional documents to the C-2, where necessary to explain fully what happened.)
The employer should realize that its role is much larger than a single C-2 form. To assist in the proper resolution of a claim (even though that sometimes means a dismissal) the employer should be aware that they frequently have far more information than is requested. The information may be forwarded to a carrier and the Board, taking care that confidential medical information may require special handling.
An employer should make the carrier aware of relevant information which it possesses about the employee’s physical limitations at time of hire, so that these are not automatically assumed to be a consequence of a new injury.
The employer can also list for the carrier known prior injuries, especially those resulting in a lawsuit or compensation claim. The employer can also list prior employers, with dates of work and name address and phone number of the employers.
The employee may have periods of absence due to illness or injury. These should be made known to the carrier. Since a claim is being filed for medical disability, such information must be available to treating doctors and independent examiners.
The employer’s role also extends to maintaining a relationship with the employee. The law imposes upon the employer (not the carrier) the obligation to see that appropriate medical treatment is provided. Calling the employee to make sure that they are under care is entirely appropriate and much appreciated by the worker’s family.
The employer can also begin return to work measures. Asking the worker about the treating doctor’s opinion about possible return to work is not intrusive. In fact, it is essential. (WCxKit)
Being involved means a lot more than the completion of a single form. Remaining an active presence results in faster adjudication, quicker return to work, less wage loss and fewer contested issues.
Author Attorney Theodore Ronca is a practicing lawyer in Aqueboque, NY. He is a frequent writer and speaker and has represented employers in the areas of workers compensation, Social Security disability, employee disability plans, and subrogation for over 30 years. Mr. Ronca has 21 years experience in searching and retrieving medical records and many other types of documents for defense workers Compensation claims. Contact Attorney Ronca at 631-722-2100 or medsearch7@optonline.net
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
