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Claims Resolution and Settlements: Knowing When and How to Settle a Workers Compensation Claim

Negotiations
The effective adjuster  has developed the talent, through practice and experience, to negotiate the claim by emphasizing the strengths of his/her case.  Prior to starting the settlement negotiations, the adjuster outlines in the Action Plan the strengths and weaknesses of the claim, obtains settlement authority, and develops a strategy to stress the reasons the claim should be settled for the amount the adjuster recommends.  

As part of  any negotiation, the adjuster should establish a settlement range for the claim based upon the strengths and weaknesses.  The initial offer starts at the bottom of the settlement range and is not increased until the employee or the employee's attorney has made a counter offer.  

The adjuster  negotiates in increments with counter offers until an agreement is reached within the settlement range.   The adjuster never increases the offer upward more than the employee's counter offer has decreased.   If the adjuster sees the claim is not going to settle within the settlement range established, the adjuster should cease negotiating; advising the employee or the attorney their demand is outside the justifiable settlement range and no further offers will be made until a more reasonable settlement demand is made.

Waivers and Releases

Each state  has its own forms or documents to be executed when the claim is concluded. The adjuster should settle all aspects of the claim — current indemnity benefits, future indemnity benefits, current medical benefits, and future medical — to prevent future financial exposure to your company.   This requirement should be specifically stated in your account handling instructions. 

The method  to close out future benefits is different in each state.   For example, in California the employee must execute a Compromise and Release (C&R) to receive a lump sum for the payment of future medical expense and close out the exposure for the future medical care.  The C&R must be approved by a workers' compensation judge.

If the employee  will not be returning to work, the settlement release in addition to the standard language of  "to be a complete, entire and final release and waiver of any and all rights to any and all past, present and future benefits" should also include language stating the separation from employment is voluntary.

Also, all other  civil actions outside the realm of workers' compensation the employee might consider should be included.   If the above California C&R was for an employee who filed a psych injury claim for sexual harassment, and the Release is not modified to include the civil matter of sexual harassment, the employee would be free to bring a sexual harassment lawsuit against your company even though you have paid and settled the work comp claim with the C&R.

Due to the  complexity of making sure all financial exposures to your company are resolved at the time of settlement, it is recommended you have your in-house counsel prepare the Waivers and/or Releases in any complex or high value claim. 

In those states  mandating a particular release agreement form, be sure the adjuster utilizes the state mandated form.  In the states not mandating a particular release format, a Workers' Compensation Release should be obtained. 

If there is  any possibility of the employee attempting to circumvent the workers' compensation settlement with an age discrimination claim, sex discrimination claim, Americans with Disabilities Act claim or other type of claim against the employer, a General Release should also be obtained from the employee in conjunction with the Workers' Compensation Release.  

All settlement  releases should contain language stating Medicare's interest was protected to the best of the parties' ability and Medicare's interest was considered at the time of the settlement (see section below on Medicare Set Asides). (workersxzcompxzkit)

In the states  permitting subrogation, the release should also convey all rights of subrogation from the employee to the employer.

  \
Author Rebecca Shafer, President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact:  RShafer@ReduceYourWorkersComp.com   or 860-553-6604.

FREE WC IQ Test: http://www.workerscompkit.com/intro/
WC Books: http://www.reduceyourworkerscomp.com/workers-comp-books-manuals.php
WC Calculator: http://www.reduceyourworkerscomp.com/calculator.php
TD Calculator: http://www.reduceyourworkerscomp.com/transitional-duty-cost-calculator.php 

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.


©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com 
Posted in Settling WC Claims, TPA and Claims Administration, WC 101 |


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A Day in the Life of a Busy Workers Compensation Insurance Adjuster

If you have ever wondered what your workers comp adjuster does in a day, please read this fictional, but true-to-life account of an adjuster's typical day. Let's take a look at what a typical adjuster does during the day and reflect on how we can help him/her help us better manager our programs. Although this blog refers to workers compensation adjusters, the work day of others is probably about the same. One noted exception is a "field adjuster" who may work on the road, for example, in auto claims.
 
Most adjusters who have been on the job for a realize their workload will always be greater than they can ever attend to properly. This won't stop most of them from trying to cover everything that needs to be done. It is not unusual for the dedicated adjuster to arrive at the claims office early and be one of the last employees to leave at night.
 
It is usually the workers comp adjuster who arrives first at the office and makes a pot of coffee for herself (or himself) and her co-workers. After a few sips of coffee, the adjuster turns on her computer and brings up her diary (her computer calendar) of all the claims she needs to work on during this day. However, before she starts to work on any of her claims, she turns to the telephone and retrieves all her voice mails from claimants (employees), employers, medical providers, attorneys, nurse case managers, her supervisor, various vendors and others who have called her about her claims. (WCxKit)
 
The adjuster than compares her voice mail messages with her diary to see where she can combine the diary and voice mail to save time on the files. After she combines the diary and the voice mails, she prioritizes the claims and creates her work agenda in the order of importance.  
 
During her workday, the workers comp adjuster has frequent and sometimes complex contacts with many parties. For the next couple of hours the adjuster will be on the telephone contacting employers, employees and medical providers to obtain additional information about the progress or status of the claims. 
 
If the adjuster is good at multitasking, she will be entering file notes on each claim as she is talking to each person. If she is not comfortable with multitasking, she will write up her files notes immediately following each phone call and before she starts the next phone call.
 
By the time the adjuster is done with her phone calls for the morning, the daily mail should have arrived at her desk (or have been scanned into the computer system). The adjuster then turns to reviewing each item of correspondence and entering her file notes on each medical report, attorney's letter, etc. 
 
The adjuster never get through her morning phone calls that she makes and the daily mail without receiving additional phone calls from people. Depending on the claim office philosophy or the adjuster's preference, the adjuster will stop working on the incoming mail and take the phone calls as they arrive, or allow them to start accumulating again in her voice mail. 
 
It is an old claims office adage – “Your interruptions will get interrupted.” The adjuster must decide for herself if she is more proficient by taking each phone call as it arrives, or by grouping them and returning the phone calls once in the morning and once in the afternoon.
 
Between telephone calls and correspondence, the adjuster's morning is packed with other things to do.
 
If the supervisor has assigned a new workers comp claim to her, she must put on hold all the items on her agenda and make her three-point contacts with the employer, employee and medical provider. If she has a worker’s comp board hearing, she may have to leave everything and attend the hearing. If she has a settlement conference, she may attend the settlement conference in person, or by telephone. If she has a crisis of some type on any of her files, she will stop work on her daily agenda and deal with the crisis. Our third party-administrators and insurance companies have many adjusters who are the primary contact for many of us in the workers' compensation field.
 
After a quick lunch, often eaten at her desk in order to save time, the workers comp adjuster starts her afternoon round of phone calls, mail review, outgoing correspondence and file reviews. In the middle of all these activities, the adjuster will often take time out to discuss complicate claim issues with other adjusters or to provide mentoring to inexperienced adjusters. Over the cubicle wall discussions of claims and procedures will occur throughout the afternoon as she assists other adjusters with their claims. (WCxKit)
 
Every day the adjuster is interpreting and applying the workers comp statutes, the insurance policy coverage and her employer's work policies and procedures. The exercising of judgment and initiatives is a routine part of the adjuster's daily task. The adjuster not only makes many decisions during the day, but also has to communicate effectively those decisions both verbally and in written communications. 
 
In the states with complicated state forms to file on every claim, the adjuster will often set aside a specific time each day to be sure the state mandated forms are completed and filed either electronically or by mail as required within her state. 
 
By the time the adjuster turns out the office lights at night, she will have had an impact on the lives of several claimants as she has assisted them in obtaining the medical and indemnity benefits they are owed. She will have also had an impact on the insurer as she has provided the benefits the employee is entitled to while protecting the assets of the insurer from being overspent. It's not easy being a workers comp adjuster but it is often a satisfying and fulfilling job.
  \
Author Rebecca Shafer, J.D., Consultant, President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing.  Contact: Info@ReduceYourWorkersComp.com  or 860-553-6604.  
WC Calculator:  http://www.LowerWC.com/calculator.php

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.
  
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact  Info@WorkersCompKit.com
Posted in Settling WC Claims, TPA and Claims Administration |


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How to Talk to Your Workers Comp Claims Adjuster

Are you nervous talking to your workers compensation adjuster?  Don't be. The adjuster works for the insurer (whether the adjuster is a staff adjuster working directly for the insurer, or the adjuster works for a third party administrator (TPA) who is handling the workers comp claims for the insurer) and the insurer wants you to be happy with the claim service. The adjuster knows that ultimately your happiness with the quality of the his/her claim handling is key to the continuation of your company's insurance with the insurer. 
 
While the smart adjuster wants you to be happy with the work product, the adjuster also realizes he/she is the claims professional and it is the adjuster's responsibility to direct and control the claim. WCxKit.  The sharp adjuster welcomes your input and the information you provide while continuing to manage the claim. 
 
To create a strong working relationship with the dedicated adjuster (an adjuster whose entire workers comp claim inventory is for your company) or the designated adjuster (an adjuster who handles all of your company's workers comp claims plus claims for other employers), please keep in mind some basic guidelines.
 
Establish Rapport
Whether you are working with a dedicated adjuster or a designated adjuster, having rapport with the adjuster goes a long ways toward having a good working relationship. Rapport is more than asking about the weather at the start of your conversation. It is knowing your adjuster and something about him/her other than work, whether WCxKit it is asking about vacation or the his/her child's school program. By showing an interest in the adjuster as a person, you build a bond designed to make difficult issues easier to discuss.
 
Be Focused
After a minute or two of establishing rapport with the adjuster, be ready to address the claim you are calling about.   Prior to calling the adjuster, review your file notes on the claim in question. It will be helpful to you to jot down the questions you want to ask the adjuster about the claim and the reasons for asking. Knowing your reason for asking each question allows the adjuster to provide a focused answer. Without an explanation, the adjuster will draw his/her own conclusions and may unknowingly give you an answer not fully covering what you need to know.
 
Be Respectful
It is always wise to remember the workers comp adjuster is the claims professional. The adjuster should be current in the handling of the claim and handling the claim in accordance to the Best Practices that are included in your service contract with the insurer or TPA. If for some reason the adjuster has not handled the claim correctly (in your opinion), don't berate the adjuster or question the adjuster's competence WCxKit. (if you want any more work done on your claims).   You need to learn why the adjuster has not acted and to get the adjuster back on track. The easiest way to do this is to ask questions.
 
Ask Open Ended Questions
The best way to ask questions is to ask open-ended questions allowing the adjuster to explain what was done, what was not done and what is planned for the future. If you ask only yes or no questions, you get yes or no answers, making the adjuster feel like your questions are an interrogation. 
 
For instance, it is much better to ask: “I don't understand how this accident happened, how did [insert employee name] describe what happened?” rather than to say “You failed to take the employee's recorded statement?” The first approach gives the adjuster the opportunity to say “I have tried several times to reach the employee, but he has not returned any of my phone calls.” The second approach, however, puts the adjuster on the defensive and reduces the desire of the adjuster to do a good job for you. 
 
By asking open-ended questions, you give the adjuster the opportunity to explain the status of the claim and the course of action the adjuster plans to take. If for some reason the adjuster is not volunteering the information you need, explain why you are asking followed by an open-ended question. For example “Nobody saw this accident happen, what can we do to be sure it is compensable?”
 
Have a Positive Attitude
Always remember the adjuster is working for you and wants to do a good job. Be positive in your approach with the adjuster in both your words and tone of voice. When the adjuster has met your expectations, praise “it sounds like you are doing a good job” and appreciation “thanks for your efforts on this claim” It will motivate the adjuster to continue to strive to do a good job for you and your company.
 
Be Willing to Listen
Sometimes the efforts of the adjuster just come up short. As you ask about any “failure,” giving your reasons and asking your open-ended questions, listen carefully to what the adjuster says. Often the adjuster has a valid reason activities have not been accomplished or the claim is not going the way you wish. By carefully listening to the adjuster, you will often be able to identify problems and suggest solutions to assist the adjuster in producing a better quality claim product.
 
Cooperate and Plan
After you have discussed all the questions you have about a workers comp claim, and have a complete understanding of where the claims currently stands, plan your further activity on the claim. Ask the open-ended questions “So I will know when to follow up with you, what is your plan to move the file forward?” “When do you expect to accomplish your action plan?” “Who else do we need to keep in the loop and how will that be done?”   
 
Summary
Talking to your workers comp adjuster should be a pleasant experience providing you with the claim information you need for your company.   This can be easily accomplished by establishing rapport with the adjuster, keeping focused on the claim you are inquiring about and remembering the adjuster is the claims professional. The easy way to obtain information is to state why you are asking a question and then asking an open-ended question allowing the adjuster to explain the claim to you. Always keep a positive attitude with the adjuster and listen carefully to what the adjuster is saying about the claim. This will allow you to work with the adjuster to bring the claim to a conclusion. 

  \Author Rebecca Shafer,  Consultant / Attorney, President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing.  Contact: Info@ReduceYourWorkersComp.com  or 860-553-6604.  
 
FREE IQ Test:   http://www.workerscompkit.com/intro/
WC Books:  http://www.LowerWC.com/workers-comp-books-manuals.php
WC Calculator:  http://www.LowerWC.com/calculator.php

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.
  
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact  Info@WorkersCompKit.com 
Posted in TPA and Claims Administration |


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Dont Miss These 35 Ways to Reduce Work Comp Claim Costs

It’s not ALL on the insurer and/or employer to process workers comp claims. A joint effort is required by the employer, employee, insurer and TPA because when workers compensation claims are filed and processed quickly they are much less likely to become long-term claims. There is a much higher probability of claims “getting out of control” when control is not exercised at the start of the claim. Everyone has a part to play.

7 Standard Employer Tips
Employers who expedite their workers compensation claims handling:
1.       Have a strong safety program to prevent many accidents from occurring. Safety programs are known to reduce the severity of the accidents that do occur.

2.       Post all state required notices where all employees will see them and know what to do in the case of an injury.

3.       Post the approved the medical provider(s) [in the states where the employer selects the medical provider], or post the suggested medical provider(s) [in the states where the employee selects the medical provider] with the notation the employee can select their own doctor.

4.       Report the claim immediately after the accident (not the next day or the next week) to the insurer or TPA who will handle the claim. If you do not already know who the adjuster will be for the work comp claim, ask the claims office for the adjuster's name and phone number, then call the adjuster and ask if he/she has all the information needed. (WCxKitz)

5.       Remain actively involved in the workers comp claim. Make sure the employee's supervisor and any witnesses are available to talk to the adjuster. Advise the adjuster of any contact you receive from a medical provider or an attorney representing the employee.

6.       Stay in contact with the employee.  By keeping the lines of communication open with the employee, the claim will move faster and the risk of an adversarial situation is diminished.

7.       Have an active and effective return-to-work program. Provide the doctor with a written outline of the employee's job duties and physical requirements. Numerous studies show when employees return to work on modified duty or light duty the overall cost of both medical care and indemnity benefits are reduced.  

11 Proactive Employer Tips
Employers who are on top of the claims process also take these proactive steps: 
1.       Coordinate between the risk management department and the human resources department to provide immediately to the adjuster.

2.       Review the employee's job application (which should include pre-existing medical conditions both non-work related and work related).
3.       Prepare the required payroll information and submit it to the adjuster within 48 hours of the accident report.
4.       Provide a list of all previous work comp insurers and TPAs.
5.       Provide a list with basic details of all prior workers compensation claims with previous TPAs or insurers.
6.       Give an explanation and details of any disputes the employee has with the employer.
7.       Provide a list of any absences from work, other than vacations and single sick days.
8.       Provide the employee's personnel file (where state law permits). (WCxKitz)
9.       Timely filing of all state required forms [timely being defined as quickly as possible, not within the 30-day window given by the state].
10.    Large employers need to consider an on-site nurse or doctor to treat the employee immediately following the injury rather than the delay entailed by the employee going to the emergency clinic or even waiting to get an appointment with a doctor.
11.    Educate the employees on what they can do to expedite their work comp claim.

9 Employee Recommendations
Your employees are just as anxious as you are about getting their workers comp claim processed and paid quickly.   Post these recommendations and give them to your employees in a pamphlet when a workplace injury occurs.
1.     Report any accident immediately to your supervisor or manager.
2.     Offer your assistance to your employer in completing the Employer's First Report of Accident form required by your state.
3.     Seek medical assistance immediately from the employer's required medical provider [or the suggested medical provider(s)].
4.     Obtain from your employer the name and phone number of the adjuster who handle your workers comp claim.
5.     Obtain from your adjuster the claim number for your claim and use it on all correspondence, and have it available whenever you contact the adjuster.
6.     promptly complete and return all forms provided to you by the adjuster and your employer.
7.     Attend all scheduled medical appointments and provide your doctor with accurate information on the nature and scope of your work duties. (WCxKitz)
8.     Advise your employer and the adjuster of any changes in your medical status or work status.
9.     Do not engage in any physical activities that will slow your recovery.
 
8 Tips for Insurers and TPAs
Insurers and TPAs speed up the processing of workers comp claims by employing these proactive steps: 
1.     Tighten up their “Best Practices” to require three-point adjuster contact the same day the accident is reported.
2.     When the employee's medical treatment does not require emergency care, the insurer or TPA can bring in the nurse case manager to direct the employee [where permitted] to the best medical provider for the nature of the injury.
3.     In non-emergency situations the nurse case manager can discuss with the medical provider the injury and the treatment to be provided prior to the initial medical visit.
4.     Utilize a vocational rehabilitator to coordinate between the medical provider, the employer and the prompt return to work of the employee.
5.     The adjuster can provide the medical provider with all necessary forms, including blank return-to- work slips prior to the first medical visit.
6.     The adoption of electronic data interchange (EDI) can reduce the time for transmission of information between employers, physicians and state workers comp boards.
7.     Supervisory reviews by the insurer or the TPA can be done within 14 days of the lost time claim being reported, rather than at 30, 60 or 90 days, or when the claim file reaches a dollar threshold amount.
8.     If the nurse case manager or the adjuster has any questions about the medical progress or the medical treatment, a peer-to-peer review (doctor to doctor) should be requested. Ask your TPA if they have a medical director to work closely with you on your claims if you don't have your own medical director. Claims are medical injuries – don't forget that! (WCxKitz)
Summary
Your company will save money when you expedite the workers compensation claim process.   Every step you take to report and handle the claim earlier results in lower claim cost. The costs associated with speeding up the claim are minor compared with the costs of allowing the claim to get out of control by moving along at its owns pace.
  \Author Rebecca Shafer, J.D. and Consultant, President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing.  Contact: Info@ReduceYourWorkersComp.com  or 860-553-6604.  
 
FREE WC IQ Test:  http://www.workerscompkit.com/intro/
WC Books:  http://www.LowerWC.com/workers-comp-books-manuals.php
WC Calculator:  http://www.LowerWC.com/calculator.php
TD Calculator:  http://www.LowerWC.com/transitional-duty-cost-calculator.php 

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.
 
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com 
Posted in Communication with Employees, Coordinating Medical Care, Management Commitment, Settling WC Claims, TPA and Claims Administration |


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Who’s Who in the Claims Office – Know The Players

If you never worked in a workers’ compensation claims office, but have dealt with one or more claim offices, you may have wondered who does what in the claims office. The following is a glossary of claim office positions and the type of work done by the people with these job titles. Every insurance carrier and every third party administrator (TPA) will structure their claim office a little differently. Not all  workers’ comp claim offices will have all the claim positions listed here, as each claims organization will be structured to be suit their own business needs.
 
Claims Clerk
The clerical staff within the claims office is often the engine running the office. The clerical staff is normally responsible for the intake of new claims whether electronic, telephonic or mail, the case creation – “setting up the claim file,” the input of the data into the risk management information system and often, initial contact letters and acknowledgment forms to the state, the employer and the employee. (WCxKitz)
 
The clerical staff is also responsible for in-coming and out-going mail, matching correspondence to claim file folders (or scanning paper correspondence into the risk management information system) and opening & closing of files. Additionally, a clerical person is responsible for issuing payments, both automatic issues (like weekly indemnity checks) and one-time payments. 
 
Depending on the size of the claims office the clerical staff may be broken down into various levels like Clerk 1, Clerk 2, Clerk 3, Secretary 1, Secretary 2, etc., with pay grade advancements to match their job title growth.
 
Medical Only Adjuster
The medical only adjuster is often an experienced clerical person who has shown the aptitude and ability to do more than basic clerical work. The medical only adjuster will contact the medical providers to obtain the medical reports and medicals bill. Once the information is available, the medical only adjuster will review the medical bills to ascertain the relationship between the injury and the medical treatment. The medical only adjuster will request payment of the medical bills and verify there will be no further treatment prior to closing the medical only file. A standard workload, depending on the jurisdiction, for a medical only adjuster is to have 350 to 500 open medical only files at any one time.
 
Adjuster Trainee
Most new adjuster trainees are recent college graduates with a background in insurance, business or a related field. Occasionally, insurers or TPA's will recognize they have a bright clerical person who does not have a college degree but has shown the intellectual ability to take on the challenge of adjusting claims. (WCxKitz)
 
The new adjuster trainee will normally go to either an  in-house training program or to a specialty school to learn the basics of  workers’ comp insurance adjusting. Most states require the adjuster trainee to take a pre-determined number of hours of workers' compensation class training before they can take the state licensing test. 
 
Once the new adjuster is licensed, the claim office will assign to the adjuster trainee the simple  workers’ comp claims. The adjuster trainee is often asked to investigate thoroughly these claims for the experience of learning to contact employers and employees, take statements, investigate the details, etc. The adjuster trainee will have a claims supervisor who will be reviewing the work performed, providing directions and managing the process. A normal workload for an adjuster trainee is 75 to 100 open  workers’ comp claims.
 
Adjuster
The adjuster is the workhorse of the claims office. The  workers’ comp adjuster is responsible for the complete claim process including coverage verification, contacts, reserving, investigation, medical management/cost containment, disability management, litigation management, subrogation, subsequent injury fund recovery, disposition and settlement. Also, if the adjuster works for a TPA, the adjuster is responsible for reporting all information to the insurer or principal. 
 
The adjuster is usually the primary contact of the employer with the insurer or TPA. In addition to working  with the employees – “claimants” on each claim, the adjuster will build relationships with the various parties involved in the claim including the employers, the medical providers and the attorneys — both plaintiff and defense attorneys. (WCxKitz)
 
A supervisor will normally review the work of the adjuster on a regular basis, but will not be involved in the decision-making or claims handling process except on the more expensive files and the files with questionable compensability. It is normal for the  workers’ comp adjuster to have 125 to 150 open files at any one time.   Depending on the insurer or TPA, the adjuster level may be broken down into additional levels like Adjuster 1, Adjuster 2, etc.
 
Senior Adjuster
The designation senior adjuster is for highly experienced adjusters with many years on the job. These adjusters are masters of the  workers’ comp world knowing how to investigate every type of claim, knowing the intricacies of their state workers’ comp laws, and knowing when to settle and when to fight a claim.
 
The senior adjusters often act as mentors to the adjuster trainees or younger/less-experienced adjusters. The senior adjusters are normally assigned the most difficult claims and the claims with the highest exposure. A normal workload, depending on the jurisdiction, for the senior adjuster is 125 to 150 open claims. (WCxKitz)
 
Supervisor
The  workers’ comp supervisor is responsible for a team of adjusters and the work product produced by those adjusters. The supervisor will normally have three or four adjuster trainees on their team, or four or five adjusters, or five to eight senior adjusters. The supervisor is responsible for making sure the adjusters meet all best practices or service standards on each file.
 
The supervisor, in addition to day-to-day discussions and directions to the adjusters, will keep the inventory of all claims assigned to them on a diary (also known as a futurity at some companies). A diary is a calendar reminder system. All the files of the adjuster trainees will normally be reviewed by the supervisor every month while the claim files of the adjusters will be reviewed every 60 or 90 days. 
 
Assistant Manager
If the claim office is large enough, it will have an assistant manager between the levels of  workers’ comp supervisor and branch manager.   The assistant manager is often responsible for assignment of claims to the adjusters, for compliance with regulatory requirements, and management of the  workers’ comp supervisors. (WCxKitz)
 
Branch Manager
The branch manager  of the claims office is responsible for everything that goes on in the claims office. The selection and hiring of employees, the workflow of the clerical staff, the prompt and proper resolution of claims, and the liaison between employers and insurers are the responsibility of the branch manager. Ultimately, the successful operation of the claims office lies with the skill level of the branch manager.
 
 
  Author Rebecca Shafer,  Consultant & Attorney, President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact:  RShafer@ReduceYourWorkersComp.com   or 860-553-6604.

FREE WC IQ Test:  http://www.workerscompkit.com/intro/
WC Books:  http://www.LowerWC.com/workers-comp-books-manuals.php
WC Calculator:  http://www.LowerWC.com/calculator.php
TD Calculator:  http://www.LowerWC.com/transitional-duty-cost-calculator.php 

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.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com 
Posted in Risk Management, TPA and Claims Administration, WC 101, Workers Comp Kit |


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What Does Three Point Contact REALLY Mean

THE MOST IMPORTANT PART of the initial handling of a  workers’ compensation claim is the contacts with the parties involved in the claim. The contacts are often referred to as “three point contacts” which refers to the three principal players the adjuster is involved with in every  workers’ comp claim. The three principals are the employee, the employer and the medical provider.
 
In order to have successful handling of a  workers’ comp claim, it needs to be investigated both timely and thoroughly. The contact with the injured employee, the employee's supervisor and the employer's claims coordinator, and the medical provider all provide valuable information to the adjuster in the handling of the  workers’ comp claim.   Each of the contacts, if properly managed, allows the adjuster to maintain control of the developing claim. (WCxKitz)
 
Definition of Contact
A recent audit of a claims office found the definition of “contact” was not spelled out in the claims handling requirements or the company's Best Practices. The  workers’ comp adjusters were sending form letters to the employer and the employee saying “call me” on the day they received the assignment. Their supervisor was accepting the form letters as contact with the employer and employee. The adjusters and supervisor were bending the meaning of contact to their own purposes and not making proper three-point contact.
 
Three point contacts are always be handled by telephone, except in severe cases where an in person contact would be justified. With most adults having cell phones and/or home telephones, there is no reason for not making voice contact. If the principals cannot be reached by telephone, a contact letter should be sent while continuing the effort to reach the principals by telephone.
 
The insurers who have quality Best Practices consider voice contact as “the exchange of information between the principals and the adjusters.”  Leaving a message on the employer's voice mail or a message on the employee's home answering machine is not considered contact in the true meaning of three-point contact.(WCxKitz)
 
Timeliness of Three Point Contact
Each workers' compensation insurer and each third party administrator (TPA) has set their own time frames as to when three-point contact should be completed. Some insurers are requiring their adjusters or TPA to make three-point contact within 2 hours or 4 hours of the time of the accident. Other insurers and TPAs are being less stringent and requiring the three-point contacts to be completed within 24 hours or 48 hours of the time of the assignment. 
 
Workers’ comp adjusters prefer the 48-hour goal of making three point contacts as that is a relatively easy goal to make. Various studies however have shown that immediate (same day) contact has the most positive influence on the outcome of a case.
 
While the goal of the adjuster should be to make the three-point contacts the same day as the assignment is received, in reality the other parties to the claim may not be available. Persistence is an absolute must for the adjuster. If the adjuster has left a voice mail for the employer, employee or medical provider's office, the adjuster should call again if the other party has not responded by the end of the workday. The persistent adjuster will leave at least two voice mails the day the assignment is received and will follow up with a contact letter if a response is not received. The adjuster should continue to try daily to reach each of the principals of the claim until voice contact is made with them.(WCxKitz)
 
Employer Contact
Upon receipt of the new assignment, the  workers’ comp adjuster immediately verifies coverage for the insured/employer. If there are no coverage issues or questions, the adjuster's next step is to make contact with the employer.
 
The purpose of the employer contact is several fold. The Employer's First Report of Injury has essential information the adjuster needs, but normally does not contain all the information that would be of value to the adjuster in accessing the claim. By discussing the accident with the employer's claim coordinator, the adjuster can learn additional information that may be helpful in the development and handling of the claim. Some of the information the  workers’ comp adjuster can obtain from the claims coordinator includes
1.     Prior claim history of the employee
2.     Verification of the facts on the Employer's First Report of Injury
3.     The return to work status or the disability status of the employee
4.     Description of job duties
5.     Availability of modified duty or light duty work
6.     Length of employment
7.     Identification of employee's supervisor and witnesses to the accident
8.     Subrogation potential
 
If there are any questions about the circumstances of how the claim happened or any issue of any kind, the adjuster will need to also interview the employee's supervisor about the  workers’ comp claim. A recorded statement from the supervisor may be necessary if the facts of the claims are questionable, if the claim appears to be severe, or if there is the potential for subrogation.  
 
If there are still questions about the claim after the adjuster has spoken to the employer's claims coordinator and the employee's supervisor, the adjuster should also interview any witnesses to the accident.
 
Employee Contact
The adjuster'sprompt contact with the employee will build rapport and assist in establishing a non-adversarial working relationship with the employee. When the adjuster establishes early contact with the injured employee, the probability of future attorney involvement is decreased. The adjuster is also in a better position to identify any compensability issues and to make timely payment of benefits, both medical and indemnity. If the claim is severe, the early contact with the employee will allow for immediate medical management.
 
When the adjuster makes the initial contact with the employee, the adjuster should consider a recorded statement if the accident is severe or there is potential for subrogation. Also the adjuster should consider a recorded statement if there has already been inappropriate medical treatment or excessive medical treatment, if there is pre-existing condition, if the claim is for a serious occupational disease, if there were other employees injured in the same accident or if there any question of compensability. Whether the interview is recorded or not, the initial conversation with the employee should cover:
1.     The facts of the accident
2.     The identity of any witnesses
3.     A description of the employee's job, including job title, job requirements, equipment utilized, etc.–  (this will assist the adjuster in arranging for an early return to work on modified duty or light duty)
4.     The details of the injury and the medical provider's proposed treatment plan. This should include the medical provider's diagnosis and prognosis, the employee's comments about pain, medications, prior injuries, treatment issues, etc.(WCxKitz)
5.     The employee's attitude about the employer, the accident, the medical treatment, the willingness to return to work, etc.
 
The adjuster, during the initial contact with the employee, should advise the employee of all state required forms that will be sent to the employee and in those states that require a medical authorization, advise the employee of the importance of signing and returning the medical authorization immediately. The adjuster should request a copy of any off-work notes from the medical provider. The adjuster should also advise the employee of the actions the adjuster will be taking and encourage the employee to contact the adjuster with any questions, issues or problems.
 
Medical Provider Contact
The medical provider whether an occupational injury doctor, a hospital emergency room or a walk-in clinic, should be contacted by the adjuster as part of the three-point contact. The adjuster purpose in contacting the medical provider's office is to obtain the necessary information to determine the process the claim. They would include:
1.     The diagnosis
2.     The prognosis
3.     The estimated length of time before the employee can return to either light duty or full duty work
4.     The date(s) of the next medical appointment(s)
5.     Information on any referral to another medical specialist
 
The adjuster should advise the medical provider to send to the adjuster the complete medical records including the medical history provided by the employee, the doctor's notes, the results of any testing and a copy of any off work slips provided to the employee. (WCxKitz)
 
Summary
The importance of three-point contact cannot be overstated. Getting the claim file off to a proper start has a major impact on the course of the claim and the adjuster's ability to handle the claim fully and properly. By completing a timely and a thorough three-point contact, the adjuster sets the tone for the outcome of the claim.
 
Author Rebecca Shafer, Consultant/ Attorney, President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact:  RShafer@ReduceYourWorkersComp.com   or 860-553-6604.

FREE WC IQ Test:  http://www.workerscompkit.com/intro/
WC Books:  http://www.LowerWC.com/workers-comp-books-manuals.php
WC Calculator:  http://www.LowerWC.com/calculator.php
TD Calculator:  http://www.LowerWC.com/transitional-duty-cost-calculator.php 

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.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
Posted in Communication with Employees, TPA and Claims Administration |


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21 Questions to Ask in Your RFP for a TPA

Breezing Through the TPA Selection Process OR Having a Nightmare
 
If you hire the right Third Party Administrator (TPA) to administer your workers' compensation claims, the operation of your self-insurance program will be a breeze. If you hire the wrong TPA, the administration of your workers’ comp program will be a nightmare. Here are some suggestions on what to ask the TPA candidates in your Request for a Proposal (RFP) before you contract with them to handle your workers’ comp claims.
 
1. Do you have an office in each state where my business(s) are located?  If the TPA does not have a location in a state where you do business, their adjusters will be un-licensed to handle your claims in that state (a few states do not require the adjuster to be licensed). Also, it could cost your company money by the adjuster not knowing the state specific requirements.
 
2. Where are the TPA claims offices?   The claim offices need to be in the same metropolitan area(s) where your offices are. If they have an office in the same state, but 200 miles away from your business location, it will make attending board hearings and settlement conferences an issue.
 
3. What are the Best Practices followed by your company?  If the TPA does not have a published set of Best Practices that they are willing to provide to you, do not expect consistent high quality if you hire that TPA.
 
4. Who are your current clients? A reference list allows you to contact both present and former clients of the TPA to ascertain what their ability is and what their reputation is for service, claim knowledge, and claim results.
 
5. What is your claim intake process? The state-of-the- art is to have electronic transmission of the Employer's First Report of Injury to the TPA, but you also want the ability to email claim reports and, in emergencies, to telephone claims reports to the TPA.
 
6.  What is the maximum number of indemnity claims you assign to one workers’ comp adjuster? In states with multiple state forms to be filed on every claim or in states where the workers’ comp board is actively involved in every claim, 125 indemnity claims is a full load for an experienced adjuster. If the state has minimal paperwork and minimal workers’ comp board involvement, 150 indemnity claims is a full load. 
 
7. Can my company have a designated adjuster in the claims offices where we have less than enough claims to keep one adjuster busy?   Can we have dedicated adjuster(s) in the claims offices where we have more than enough claims to keep one adjuster busy? You want your work claims being handled by the lowest possible number of adjusters. The adjusters who handle claims for no other company will strive to give you their best service, as they know your judgment is critical to their success.
 
8. What is the experience level of each of the adjusters in your offices? In addition to the number of years they have been an adjuster, what technical qualifications do they have? In addition to the number of years the adjuster has been working, has the adjuster taken any other training in order to improve themselves and the work product they deliver?
 
9.  Will we be allowed to select our own adjuster(s) from among those on your staff? The TPA may resist this request as they do not want to offend other clients and they want to control their resources to their benefit. However, you should make this a condition of your contract, as it is better for you to select the best adjuster available then to be given the adjuster no other company wants.
 
10. Who will control the litigation when a workers’ comp claim is disputed? You want to be able to hire the best defense attorneys around, not for the adjuster to select a golfing buddy/attorney.
 
11. What is the claim management information system used your company? You want to know if it is the state of the art, or was in last updated for Y2K.
 
12.  Will your claim management information system integrate with the computer claims system our company is already using? If not, you will have to operate on duplicate systems which is both time consuming and adds additional cost to managing your program. You want the TPA's system to be flexible enough to work with your existing system without having to replace your claims system.
 
13. Will my company be provided with on-line access to claim information? It is a lot easier to review the file notes and supporting documentation than to play telephone tag with the adjuster trying to find out what is happening on a particular file.
 
14. If we see data errors in your claim management system, for instance a wrong location code, will we be able to correct them, or will we have to advise your company to correct the errors? Regardless how hard they try, the TPA will make mistakes in data input. If you can correct them without going through a complicated process or having to wait on the TPA to correct them, your data integrity will be much more reliable.
 
15. Who is responsible for maintaining the interface between your claim management system and our company's computer claims system? It is your choice whether your company or the TPA is responsible for the transfer of data. You want to establish the protocol on this before the TPA starts handling claims.
 
16. Will my company be able to run ad hoc reports from your claim management system?  The ability to generate computer reports to answer questions you have about performance or financials makes life a lot easier than trying to find the information in a menu of reports which may or may not be on point.
 
17. What security measures does your company take to protect the confidentiality of the information in your claim management system? Access to your claim information should require multiple levels of account and user identification. 
 
18. What financial information will we be able to see on each claim? At a minimum you should see the total reserve for medicals, indemnity and expenses, the total paid already for medical, indemnity, and expenses, and the amount remaining/not spent in each reserve type. The better claim computer systems will also breakdown expenses into legal expense, rehabilitation expense and other expenses.
 
19. At what dollar level will your adjusters consult with our company before settling a claim? While you should ask the question in your RFP, the correct answer from the TPA is “at the level your company determines you want to be notified.”   Your company should provide the direction, supervision, and control of the high dollar exposure claims. The precise dollar level depends on your comfort and faith in the abilities of the TPA's adjusters and supervisors.
 
20.  How often does your supervisors review the open workers’ comp claims and provide direction and supervision to the adjusters?   This is a trick question, with the correct answer depending on the level of experience and ability of the adjusters. At a minimum, the supervisor should review each open file every 90 days, with some exceptions for payment of death benefits only or open for lifetime medical only. (workersxzcompxzkit)

21. Will you grant total access to our claim auditors? You should include in your RFP the requirement that your company will be allowed to audit all or any part of the claim handling by the TPA.   Every claims program should have a file quality review at least every other year to be sure the TPA is following the best practices agreed to.
 
Bonus Question: Describe your internal quality control system and explain how it will benefit our company. Provide an example of how your QC system improved the process. The system should be a proactive system that catches problems before they happen, and it should reward excellent adjuster performance and knowledge.

Bonus question: Describe your internal quality control system and explain how it will benefit our company. Provide an example of how your QC system improved the process. The system should be a proactive system that catches problems before they happen, and it should reward excellent adjuster performance and knowledge.  \Author Rebecca Shafer, Risk Consultant/Attorney, President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact:  RShafer@ReduceYourWorkersComp.com   or 860-553-6604.

FREE WC IQ Test:  http://www.workerscompkit.com/intro/
WC Books:  http://www.LowerWC.com/workers-comp-books-manuals.php
WC Calculator:  http://www.LowerWC.com/calculator.php
TD Calculator:  http://www.LowerWC.com/transitional-duty-cost-calculator.php 

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.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
Posted in Lowering Premiums & Experience Mod, Risk Management, TPA and Claims Administration |


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Newest Strategy is Stratified Custom PPO Networks for Workers Compensation

Broadspire, a Crawford Company and leading third party administrator of workers’ compensation claims, liability claims and medical management services, has introduced the BOLD network, a custom preferred provider organization (PPO) strategy that includes targeted selection of medical networks on a state-by-state basis to produce superior outcomes for clients.
 
“For decades, traditional PPO network solutions have been a steadfast component of the workers’ compensation industry. But while preferred provider discounts still help reduce claim costs, they do not completely address today’s complex challenges,” said Danielle Lisenbey, chief operating officer, medical management services. “Our new state-stratified, multi-tiered approach allows us to partner with the best network by region, industry and sometimes even by company.”
 
The BOLD – Broadspire’s Original Landmark Design – network features:
  •  Regional networks – Broadspire works to find the best network in each state or region. Regional networks typically have better relationships with local providers, which often translate into more favorable rates.
  • Specialty networks – Broadspire also contracts with special networks that concentrate on workers’ compensation needs such as durable medical equipment (DME) and physical therapy.
“Instead of casting a wide net in hopes of a good outcome, this level of customization can produce superior penetration rates and savings when compared to the rest of the industry,” Lisenbey said.
 
Included among Broadspire’s networks and partners are: Aetna, Align Networks, Black Diamond, Express Scripts, Healthcare Solutions, HFN, MedFocus, MTI, Next Imaging, Rockport, Signature Networks, Three Rivers, Total Medical Solutions, Universal Smart Comp and United Health. Broadspire’s PPO website, www.BroadspirePPO.com, features the ability to search for providers and networks by state. 
 
In addition, through the use of objective metrics, Broadspire is able to identify needs and cost drivers to build network solutions that are unique and specific to clients. Some examples of cost-saving solutions include:
  •  A DME formulary with integrated clinical protocols
  •   Physical therapy protocols and utilization review guidelines
  •   Diagnostic imaging & retrospective guidelines
  •   Clinical home health guidelines and vendor integration
  •   Coding methodology for medical and non-medical transportation.

“The key to our documented success is working with the right strategic partners and applying proprietary clinical intervention triggers to make the greatest difference in reducing claim costs,” Lisenbey said. “We measure our success by our ability to improve our clients’ bottom line, and our medical network strategy continues to evolve to meet the ever-changing demands of managing workers’ compensation costs.”   (workersxzcompxzkit)

 
About Broadspire: Broadspire, a leading international third party administrator for large self-insured organizations, offers a broad array of customized claim and medical management services designed to increase employee productivity and contain costs. Broadspire's U.S. offering of workers’ compensation, auto and general liability claims administration, medical management and absence and care management, is available bundled or individually. In addition, Crawford provides liability, motor and property claims management services in Europe under the Broadspire brand. Broadspire is based in Atlanta, Ga., with a network of 85 locations throughout the United States (www.choosebroadspire.com) and Europe (www.Broadspire.eu), including the United Kingdom (www.broadspiretpa.co.uk).
 
About Crawford: Based in Atlanta, Ga., Crawford & Company  www.crawfordandcompany.com)  is the world's largest independent provider of claims management solutions to the risk management and insurance industry as well as self-insured entities, with a global network of more than 700 locations in 63 countries. The Crawford System of Claims SolutionsSM offers comprehensive, integrated claims services, business process outsourcing and consulting services for major product lines including property and casualty claims management, workers’ compensation claims and medical management, and legal settlement administration. The Company’s shares are traded on the NYSE under the symbols CRDA and CRDB.
  
Contact:  Stephanie Zercher at 404.300.1908; stephanie_zercher@us.crawco.com

FREE WC IQ Test: http://www.workerscompkit.com/intro/
WC Books: http://www.reduceyourworkerscomp.com/workers-comp-books-manuals.php
WC Calculator: http://www.reduceyourworkerscomp.com/calculator.php
TD Calculator: http://www.reduceyourworkerscomp.com/transitional-duty-cost-calculator.php 

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.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com 

Posted in Coordinating Medical Care, Medical Cost Containment & Managed Care, TPA and Claims Administration |


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Utilization Review An Adjusters BEST Cost Control Weapon

A utilization review allows the adjuster to know if the medical care being provided to the employee is medically necessary and appropriate for the treatment of the injury or occupational disease and is one of the best weapons an adjuster can use to control workers’ comp costs.  
 
The  unintentional consequence of workers’ comp paying 100% of all medical expenses is, unfortunately, the employee is unconcerned about the cost of medical care he received. To be fair,  the employee normally does not know the medical ramifications of the treatment provided.   Both the employee (and often the adjuster) do not know if prescribed medical treatment  is repetitive of  care already provided, is not appropriate, or inadequate for the injury.
 
Utilization reviews vary in usage by different work comp insurers. Some insurance companies require a review of all planned treatments. Others require a utilization review only for specific types of medical care such as hospital admissions, inpatient surgery, ambulatory procedures, skilled nursing and rehabilitation services, planned prescriptions, and durable medical equipment.  
 
In most companies, the utilization review is conducted by a registered nurse (RN), who determines if the treatment is medically necessary. If the RN believes the medical treatment should be denied, or is unsure if the medical treatment is necessary, a physician conducts a second review of the information before approving or denying care.
 
Either the utilization review is in-house by the insurer or third party administrator, or done by an outside organization specializing in utilization review services. Ideally utilization reviews should always be completed within 7 days and preferably within 3 days. In some situations an expedited review may be needed;  for instance when the physician wants to immediately admit an employee to a hospital for further care.
 
Utilization review includes pre-certification reviews (also referred to as utilization management or prospective review), concurrent review, retrospective review, and re-review (also referred to as an appeal). The purpose of each type of review is to control the cost of the medical treatment without interfering in the employee's medical recovery. After each type of utilization review, all parties are notified of the review decisions.
 
Pre-certification Review
When first hearing the term “utilization review” most people think of what is actually the “pre-certification review.”  In a pre-certification review, before medical care is provided, the RN collects  all the necessary information including symptoms, diagnosis, test results, and the reasons the physician is requesting the medical service. The RN compares the information provided against the normal criteria for treating a specific type of injury or occupational disease.
 
If the medical service is necessary, it is approved. If the medical service is not necessary, then a physician at the utilization service reviews the medical information again to verify the denial of the service is correct.
 
Concurrent Review
Concurrent reviews occur during the time the medical treatment or service is being provided. The employee either can be an inpatient in a hospital or have on-going outpatient care. The RN approaches the concurrent review in the same way as the pre-certification review.
 
This type of utilization review is often overlooked by the workers’ comp adjuster, especially for outpatient care. The concurrent review verifies the medical necessity of the treatments and/or services provided to the employee and verifies the employee is receiving the right, most cost effective care. The workers’ comp adjuster who consistently utilizes the concurrent review of outpatient treatment shortens the time the work comp claims are open.
 
When the concurrent review is for inpatient care, it can shorten the hospital stay be limiting it to the amount of time the employee needs to be hospitalized. It can also be very helpful in identifying the medical care needed when the employee is discharged from the hospital. 
 
Retrospective Review
The retrospective review is used for either inpatient or outpatient services. A retrospective review, as the name implies, occurs after the medical services are provided. The procedure for the retrospective review by the RN as the other reviews. 
 
While physicians and hospitals recognize the need for  pre-certification reviews and concurrent reviews and accept them, they are less accepting of the retrospective review, especially if the medical care or medical service is denied. When a retrospective review denies a service the physician or hospital provided, they do not get paid, as they cannot bill the employee. [They often will request a re-review].
 
Re-reviews
When a medical service is denied by a pre-certification review, a concurrent review, or a retrospective review, the employee or the medical provider can appeal the denial. When a re-review is requested, the physician at the utilization review service goes over all available medical information to determine if the denial should be reversed. Often the physician will bring in a second physician specializing in the type of medical care needed. The specialist will confirm the denial or reverse it. (workersxzcompxzkit)
 
Summary
Utilization review is a win-win process for all involved. The self-insured employer or the workers’  comp insurance company can eliminate the cost of unnecessary medical services through the utilization review process. The physician and employee benefit by not wasting time on medical care that does not expedite the employee's recovery. 
 
  \Author Robert Elliott, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact:  Robert_Elliott@ReduceYourWorkersComp.com   or 860-553-6604.

FREE WC IQ Test: http://www.workerscompkit.com/intro/
WC Books: http://www.reduceyourworkerscomp.com/workers-comp-books-manuals.php
WC Calculator: http://www.reduceyourworkerscomp.com/calculator.php
TD Calculator: http://www.reduceyourworkerscomp.com/transitional-duty-cost-calculator.php

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.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com

 

Posted in TPA and Claims Administration |


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Eight Focus Areas for Best Practice Cost Containment of Workers Compensation

To maximize your company’s potential for workers’ comp cost containment we recommend focusing on these eight areas.
 
But, you say, this is just another checklist. Yes, it is. However, checklists are very useful tools to help those involved in the complex process of managing workers’ compensation claims, implementing best practices, and controlling costs, to very quickly triage those areas where they need to improve. Workers’ Comp Kit Blog, in over 1,300 blogs, provides suggestions and answers on how to implement all of the areas listed here, as faithful readers know.
 
1.     Management Commitment and Resources
  • Is there a lack of awareness of resources such as books, conferences?
  • Do you need additional personnel e.g., workers’ comp coordinator(s) for large multi-division company?
  • Is your cost allocation immediate and cost sensitive?
2.     Work Closely with Third-Party Administrator(s)
  • Proactively use account instructions.
  • Examine the TPA's internal quality control; ask – do they give “grades” and bonuses to adjusters for superior performance.
 3.     Intake Procedures are Key
  • Be sure you have tight post injury response procedures.
  • Be involved – don’t leave this to your insurance company or TPA.
  • Immediate reporting is very important.
4.     Nurse Triage
  • Start management at tiime of injury. Have the triage nurse identify type of treatment that is needed.
  • Coordinate medical care early.
 5.     High Standards for Medical Provider Quality
  • Rank your medical providers.
  • Lower duration means better outcomes, less litigation, and lower medical costs! Ask for specialized networks with better outcomes.
 6.     Peer-to-Peer Physicians
  • Get your medical doctors to discuss each claim with the treating doctor.
  • Get pharmacy benefits management proactively when MDs at TPA review the claim while it is just beginning.
7.     Return-to-Work Policies: Clear and Organized
  • Start transitional duty immediately after the incident; inform the injured employee of your return-to-work policies.
  • Let injured employee know you expect a return to work as soon as the worker is medically able. (workersxzcompxzkit)
  • Consider off-site RTW programs such as charitable, home-based, cross-divisional, and alternate employers.
 8.     Improved Communication is a Simple Way to Improve WC Programs
  • Target communication to your employees.
  • Target additional communication specific to supervisors, management, TPAs, and medical providers.
  • Communicate, communicate, communite
  • First day phone calls, weekly meetings (that's er …. every week)…
Author Rebecca Shafer, Consultant, President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact her:  RShafer@ReduceYourWorkersComp.com   or 860-553-6604.

FREE WC IQ Test: http://www.workerscompkit.com/intro/
WC Books: http://www.reduceyourworkerscomp.com/workers-comp-books-manuals.php
WC Calculator: http://www.reduceyourworkerscomp.com/calculator.php
TD Calculator: http://www.reduceyourworkerscomp.com/transitional-duty-cost-calculator.php

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.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com 

Posted in Risk Management, TPA and Claims Administration, WC 101 |


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