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16 Things Companies Can Do To Reduce Workers Compensation During Layoffs and RIFs

Rebecca Shafer, J.D. — Wed, 08 Feb 2012 00:05:10 +0000

In 1989 the federal law known as the Worker Adjustment and Retraining Notification Act (WARN Act) went into effect. The intent of the WARN Act was to provide employees with time to plan for their future employment with another company when the employer had to do a mass layoff. The WARN Act has in many ways morphed into the Workers Compensation Claims Preplanning Act (that is not a real title), which provides ample time for dishonest employees to plan and execute fraudulent workers comp claims.

The WARN Act requires employers with more than 100 workers to give a 60 day notice before laying off workers. Employers must issue a WARN Act notice if a facility closing or other Reduction in Force (RIF) will cause more than 50 employees to be without a job. The WARN Act also applies to companies that are staggering the layoffs if the employer is laying off more than 500 employees in any 30 day period, or more than one-third of the workforce if the company has less than 500 employees. If the employer does not provide the notice timely, the employer is required to continue the pay and benefits of the layoff workers for 60 days from the date the employees are notified of the layoff. Plus, in some cases the employer can be fined $500 per day per employee for not giving the layoff notice timely. Please consult your labor law attorney for additional information on WARN Act requirements. WCxKit

Statistics show that workers comp claims spike by an average of 50 percent after a plant closing or other mass layoff is announced. This jump in claims always results in a future jump in the employer’s workers compensation premiums, as claim frequency is the primary factor in the calculation of the employer’s workers comp premium.

Unfortunately, there are times when a RIF is necessary due to a slow-down in business, a need to cut costs, a need to change the organizational structure, or a change in the company’s business strategy. However, the employer does not have to pay bogus work comp claims as a cost of doing business. There are numerous actions an employer who is planning a RIF should take prior to the announcement of the RIF. We recommend employers who must RIF employees to take the following actions.

1. Keep intentions to yourself and only communicate with those who need to know. The less time unethical employees have to plan their fraudulent claim or to think about doing so, the lower the number of bogus work comp claims.

2. If it is becoming obvious that the company needs a RIF, do not put it off. The longer you wait, the greater the distortion the rumor mill will create. The long wait provides ample time for unethical employees to not only plan their workers comp claim, but also to share their plans with other employees that would not be considering work comp fraud, until they learn others are going to file bogus workers comp claims.

3. When a RIF is announced, place a strong emphasis on the unemployment compensation benefits the employee will be receiving. Employees who are less anxious about their source of income are less likely to commit work comp fraud if they know they will have another source of income while they look for another job.

4. Learn how your state handles unemployment compensation in conjunction with workers compensation. Some states allow both at the same time, other states allow one or the other, and some states allow an offset (reduction) in workers comp benefits for employees drawing unemployment compensation.

Prepare for all workers compensation claims that may be received

5. Consult with the third party administrator (TPA) or insurer so the TPA can plan to handle the additional workers comp claims quickly so there is no waiting. If there is a delay in beginning claim investigations, the likelihood of properly defending the claim is reduced, evidence is lost and affirmative defenses are less likely. TPAs should handle these claims aggressively and early which requires sufficient staff.

6. If not already done, a "dedicated" or "designated" adjuster assigned to handle the claims for your company is needed. If you expect a large number of new workers comp claims, it is preferable to handle all of them in the same claims office. This way the claims adjusters are familiar with working conditions.

7. If you have been utilizing more than one defense firm, pick the best attorney and pre-arrange for one attorney (best) or one firm (acceptable) to handle all work comp litigation that occur after the announcement of the RIF.

8. If an employer is closing the facility or making a major remodeling, invite the defense attorney(s) to the facility so the defense attorney(s) can familiarize themselves with the facility.

9. Video record the areas/equipment/machinery that would most likely be included in any injury scenario, especially if the plant is to be renovated or demolished.

10. Video record job functions for the medical providers, especially those that would most likely be included in any injury scenario.

11. Make a list of all key personnel, managers and supervisors, including the home address, home phone number and cell phone number, who can testify if necessary.

12. Make sure all personnel records are up to date, especially health insurance records and sick time documentation (for example: the employee who took sick time for the back injury that occurred at home may now claim an aggravation of the pre-existing condition to continue the medical care and to draw indemnity benefits).

13. An exit physical should be considered especially if the employees work in a high decibel area or have been exposed to chemicals or other irritants while on the job. This action should be reviewed with your defense attorney and claims supervisor as to the benefits versus the risk.

14. An exit interview can identify potential future workers comp claims. Provide the employees with a form to complete to list any known medical condition.

15. Do not forget the employees who were already out of work and drawing indemnity benefits before the RIF announcement. Their incentive to return to work has been removed in situations where their department or plant is being closed. Every possible effort should be made to get these people back to work before the RIF.

16. Work with an offsite transitional duty vendor so that employees who are on transitional duty can be employed elsewhere until they are fully recovered and at MMI. Be prepared to place ALL employees who are on transitional duty in a paid position elsewhere. Charitable positions are also an option as is home-based employment.

It is essential that all workers comp claims reported after the announcement of a RIF be completely documented and thoroughly investigated promptly. Once the facility is closed and people and evidence is no longer available, it is much more difficult for the workers comp adjuster to handle the claim properly.

It should be noted that not all workers comp claims that occur after a RIF is announced are fraudulent. There will be legitimate injuries that occur. There also will be employees who have worked through other minor aches and strains who now feel they must report their work-related medical condition. (WCxKit)

When you are planning a large scale RIF, you will have a lot going on. The control and prevention of fraudulent work comp claims is necessary to not lose some or all of the financial benefits the company obtains from a RIF.

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.

2012 NEW WORKERS COMP BOOK: www.WCManual.com

WORK COMP CALCULATOR: www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP: www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

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.

Amaxx Details 2012 Workers Compensation Management Program Updates

Rebecca Shafer, J.D. — Mon, 06 Feb 2012 00:28:30 +0000

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.

2012 NEW WORKERS COMP MANAGEMENT GUIDEBOOK: www.WCManual.com

WORK COMP CALCULATOR: www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP: www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

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.

Employers Put Med-Legal Conferences in their Cost Containment Arsenal

Rebecca Shafer, J.D. — Thu, 19 Jan 2012 00:37:04 +0000

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.

NEW 2012 WORKERS COMP MANAGEMENT GUIDEBOOK: www.WCManual.com

WORK COMP CALCULATOR: www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP: www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

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.

5 Things to Do When You Are Caught in the Middle

Rebecca Shafer, J.D. — Sun, 15 Jan 2012 17:45:06 +0000

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.

NEW 2012 WORKERS COMP BOOK: www.WCManual.com

WORK COMP CALCULATOR: www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP: www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

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.

Things Claimants Say That Make An Adjusters Eyes Roll

Rebecca Shafer, J.D. — Fri, 13 Jan 2012 14:17:27 +0000

Always as a disclaimer, I feel it is right to warn that I am writing this from a claims adjuster point of view. And not the normal claims adjuster, but this particular article is written from the “annoyed claims adjuster” point of view.

In the light of a new year, I thought it might be time to start anew. When in this business for a long time, a lot of old habits die-hard. This is true with certain buzzwords and injury scenarios. Adjusters pretty much do the same job day in and day out. The injuries may be familiar, but the personality of the claimants can vary widely. Since spending a majority of the day on the phone, after a while even the most polite claims adjuster gets sick of talking on the phone. This can ring especially true when a claimant hits upon one of the buzzwords or scenarios listed below. Little more can make adjuster’s eyes roll faster than mentioning some of the words below. The same can be said for demanding outrageous services, such as household assistance or assistant care for a minor injury. But there are plenty of other things sure to annoy, so relax and enjoy my list of surefire ways to irritate the adjuster.(WCxKit)

1. Saying “tore the rotator 'cup’ ”

One of my personal favorites, nothing makes me laugh more than when claimants accidentally fudge a diagnosis. I understand that they are trying to talk “shop” with me but please do it correctly. I am not exactly sure where the rotator cup is, but my shrewd levels of problem solving can figure out that I think you mean rotator CUFF. Make a note of it.

2. “I slipped a disc”

Ah, another favorite. I have been to countless seminars about lower back pain and injury. I have probably handled hundreds of spinal injury cases, ranging from minor to severe, and from non-operative to operative. Is it true that a disc can protrude out and cause pain? Sure it can. In fact, the disc can herniate, tear, bulge, protrude, fragment, etc. I have yet to attend a seminar about a disc that “slips.” Where does it slip? Does it slip on the floor? Does it slip due to some magic force? I am not sure where this buzzword came from, but it will greatly annoy the claims adjuster for sure. And I wish it would go away.

3. “Workman’s comp”

The last time I checked my calendar, it was 2012. I am pretty sure that women in the workplace can get injured as well. So if a woman gets injured, it is “workwoman’s comp?” I think that any other word can offend less than workman’s comp. You can use worker comp, work comp, comp, work disability, as a matter of fact use anything instead of workman’s comp. Workman’s comp is a horribly dated term, and just plain annoying in general. FYI…. About 60% of people who search on the web use the term "workman" so it's a common error and one which we know won't go away anytime soon, although we can hope.

4. Claimants that state they know they should be paid a certain amount for wage loss and disagree with the correct calculation

Throughout the sands of time, I have discovered that there are a lot of people out there that know a lot more than I do. I never claimed to know every facet about everything. But if a claimant tries to challenge my ability to do my job, I hope they know what they are talking about. In almost all jurisdictions, what a claimant is paid in lost wages is governed by the State that which jurisdiction is deemed. If all I did was incorrectly pay people, especially by underpaying them, then why do I still have a job in this business? I know that people hear rumors and alleged facts from other people about what they got paid when they were hurt, but that does not make them a licensed adjuster that ultimately has to report to the State what wages were paid and how we arrived at that amount.

5. Trying to settle the claim for $1,000,000 or more

I like to get free money. In fact, I like it a lot. I like it more than working itself. As a negotiator, I feel satisfied if I can negotiate a lower car payment, or a lower interest rate on a credit card. I also see the same commercials on TV from Plaintiff law firms, which promise thousands upon thousands of dollars rewarded for the pain and suffering from injury. But that does not mean that the case is worth a million bucks. I hope that nobody is injured so badly that it would legitimately take over a million dollars to resolve their claim. If that were the case, there would not be the luxury of spending the million dollars, because the claimant is incapacitated both physically and medically. Try to be reasonable, and we can settle the claim. Also the claimant may be able to squeak out more than what I think the claim is worth. But the call is about a minor back injury and a demand of a million dollars to settle, call that plaintiff law firm and see if they can help get that amount from elsewhere.

6. The claimant reports being able to only lie on the couch all day immobilized

In addition to being a fan of free money, I daydream about the time in life when all I have to do is lay on the couch. Do not get me wrong; some injuries are bad enough to be immobilized. This is more targeted towards those people again with minor injuries who present it to be this major ordeal that has rendered the claimant totally disabled from doing anything, especially working.

7. Fibbing about not treating before for this type of injury

Injured workers fear that the claim may not be believed or accepted, so there is an attempt to try and protect the wage loss by saying this is the first time to have shoulder pain, or knee pain for example. Part of a normal investigation is asking if there are prior injuries or treatment for the injured body part. All the claimant has to do is be honest. If I play 27 holes of golf in one day, my back is sore. If I try and do too much while packing boxes or moving something I may strain myself enough to have to go to the doc and get a prescription or two. But at least I am honest about it. We are going to be obtaining all medical records that we can find about the claimant, and if we do stumble upon some prior medical history, this is not going to bode well. It is not necessarily going to derail the case, but it will definitely raise a red flag the claimant is hiding something, and I am going to keep on digging until I feel I have exhausted all my resources. (WCxKit)

Summary

This article is meant to be lighthearted and fun, but there is a grain of truth to it as well. If you talk to anyone in this industry I think the common consensus will be the same. So all violators out there take note.

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Top Industry Exec Offers Workers Compensation Year-In-Review

Rebecca Shafer, J.D. — Sat, 07 Jan 2012 22:10:26 +0000

Two-thousand-eleven has been an interesting year in the workers compensation industry. New software has helped many administrators take better control of their costs, studies on safety have led to an increase in preventative measures and legal changes have led to unusual and sometimes controversial administration in some states.

Here at Roundup we asked one of our favorite experts, Curtis Smith, executive vice president of Medcor, Inc., a national on-site health services company, what he thought the top WC issues were for 2011. What follows are his conclusions:

Conflicts of Interest Inherent in the Industry

The very organizations employers depend on to help manage and reduce costs depend on claims for their core revenue – and this can lead to potential conflicts of interest, according to Smith. He offers these examples: contingent commissions for brokers and consultants, TPAs (third-party administrators) and MCOs (managed care organizations) who select network providers and share revenue from provider discounts. Smith also cautions against pharmacy chains that put pharmacies on-site in large worksites for convenience also employ the practitioners who write the prescriptions.

Prescription Drug Abuse

Thousands of people incur illness and injury each year from abuse of prescription medications, especially pain medications. Addictions and overdoses are increasing, as are deaths, Smith wrote. Addictions often arise from treatment after a work-related injuries but the medical community is not policing or restricting doctors who write these prescriptions. What’s more, TPAs are not excluding these unrestricted doctors from networks of approved providers for fear of litigation.

Prescription Drug Costs

The same medication can cost 10 times as much in workers compensation cases as it does in general health applications. Medications’ fee schedules have been negotiated down and controlled in group healthcare far more than in workers comp situations. Consequently, drug companies and others are moving into the comp space to take advantage of increased profitability, Smith said.

Increased Litigation in the Industry

The fundamental premise behind the workers compensation system is falling apart in many states (e.g. California and New York) where an increasing percentage of claims are contested and litigated. Huge settlements out of proportion to true economic need are forcing employers to be defensive and deny claims; denying and resisting legitimate claims forces employees to seek counsel and litigate. The comp system is turning into a battleground of plaintiff and defense attorneys working the system.

Injury Triage

Smith said he would be remiss if he did not mention injury triage. “This truly is an effective way to reduce unnecessary claims and costs, to identify serious cases, and to provide early intervention for all cases,” he wrote. Financial and health outcomes are improved with the use of triage. “It’s also innovative – wining several U.S. patents — are there any other WC methods that have been patented in the last 10 years? Or ever?” he asks. Thousands of companies are using triage and many competitors have joined the market, providing a variety of service and pricing models. Yet, many employers (even most) still don’t use it and the claims-driven industry still resists it.

Even those who offer injury triage often do so begrudgingly to satisfy their employer-clients, to block another triage provider from taking claims away, or to acquire business – but they are slow to introduce triage to an existing book of businesses, or, once introduced, often let implementation and utilization languish so claims can continue to flow.

In conclusion, look to hear more about these important topics in 2012. Though they may not be resolved in short order, they are certainly going to be on the minds of those of us in the industry in years to come.

Curtis Smith is Executive Vice President of Medcor and can be reached at csmith@medcor.com or 815-363-9500 Ext 5558. Visit Medcor at www.Medcor.com

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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.

7 Things Workers Compensation Adjusters Do All Day

Rebecca Shafer, J.D. — Fri, 23 Dec 2011 01:07:13 +0000

Do you ever wonder what your workers compensation adjuster does all day? If you see the adjuster living easy, you may be surprised. The adjuster's day is full of activities, requiring the adjuster to prioritize which actions are needed the most. Some of the daily routine you would see from the adjusters would include the following activities.

So, what will you see during your visit to the claims office?

1-The phone rings constantly

The typical workers comp adjuster has 100 to 125 indemnity files, depending on the jurisdiction and the experience level of the adjuster. Each of those 100 to 125 files has a claimant, one or more medical providers, and an employer. That alone makes for 300 to 375 plus potential parties that will want to speak with the adjuster. On top of that you have plaintiff attorneys, defense attorneys, triage nurses, nurse case managers, surveillance companies and state work comp boards that may call the adjuster. On a slow day the adjuster may only spend half of her time on the telephone. (WCxKit)

2-The e-mails come in fast

In this day where everyone expects instant service, the use of e-mail to convey messages and documents has surpassed paper mail. With attorneys, employers, employees and nurse case managers sending information by e-mail, it is normal for the adjuster to get 50 to 100 e-mails per day. While many of them can be copied right into the claim file, a significant portion of them require a response or other action by the adjuster.

3-The paper mail is voluminous

While the amount of paper mail has declined over the years, a two inch or five inch stack of new mail to be reviewed each day by the adjuster is still the norm. The mail has to be evaluated and the appropriate response taken on each piece of mail. Sometimes the response is only to send it to be scanned into the electronic file, but often a written reply or a phone call is needed.

Included in the paper mail are the faxes that come in each day. While most attorneys and employers are transmitting documents via e-mail, most medical providers are still using paper forms, paper bills and paper reports. These items are often easier for the medical offices to transmit by fax than by e-mail, so receiving numerous faxes each day add to the paper mail stack.

4-The consultations are frequent

A major portion of those telephone calls mentioned above are for the purpose of making decisions on what to do. The adjuster will often gather information by consulting with others. The adjuster will discuss the claim with the nurse case manager, the defense attorney, the employer, and other sources to make a judgment on the best course of action on a particular claim.

When the adjuster is not on the phone discussing a claim or reading the e-mails or reading the paper mail including faxes, the adjuster will often enter into consultations within the claims office. The adjuster will confer either with her supervisor or fellow adjusters on various aspects of a particular claim to gain insight or opinions of other claim professionals that have dealt with a particular situation or set of facts.

5-The decisions are major

The primary reason the adjuster enters into the consultations noted above is because the decisions the adjuster makes can have an impact on the life of the injured employee and all of the decisions have a financial impact on the employer. If the adjuster makes the wrong decision, either the employee or the employer or both will be hurt financially.

6-The appreciation is missing

While you are sitting there observing what the adjuster does all day, you will notice that the adjuster's job often benefits both the employee and the employer. But it is the rare employer or even the rarer injured employee who expresses any appreciation for the work the adjuster does on the work comp claims. The most the adjuster hopes for is the claims supervisor will say “good job” when the claim is concluded. (WCxKit)

7-The adjusters best practices

While the adjuster is in constant modes of communication as noted above, the adjuster has a set of job requirements that have to be met.

1. Making contact with the employee, the employer and the medical provider on every new claim

2. Responding to all the communications noted above in a timely manner

3. Setting and maintaining accurate reserves on all of the assigned files

4. Making sure all indemnity payments are made timely

5. Making sure all medical bills are paid

6. Keeping in touch with the employees, the employers and the medical providers on a regular basis

7. Submitting the appropriate forms to the state work comp boards/industrial commissions

8. Identifying fraudulent claims

9. Pursuing subrogation when a third party is the cause of the employee's injury
10. Attending mediations, either in person or by phone

11. Evaluating settlement opportunities and decisions

If you sit chair side by the adjuster, do not count on the adjuster having any time for chit chat, so just observe. They will have planned for your visit, and will have time to show you through your files. As you can see from the above the adjuster's job fills the entire day, and then some. If you do sit and observe what the adjuster does all day, you will probably leave amazed at the dedication and hard work of the work comp adjusters.

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. 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.

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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.

Five Times to Pay Attention to Subrogation Potential

Rebecca Shafer, J.D. — Tue, 13 Dec 2011 01:22:51 +0000

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.

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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.

An Adjuster Pinpoints Eight Medical Provider Red Flags of Over Treatment

Rebecca Shafer, J.D. — Thu, 01 Dec 2011 21:01:32 +0000

Back again with the final part of the series on medical provider red flags. This could be 50 red flags, but these are some of the most common. This is to provide continued awareness that not all medical clinics are on your side. The caveat again is that this is not the norm. This article is just meant to raise awareness. Because these issues, while uncommon, really do happen. That is about as politically correct as I can make it. Here are the physician red flags you should be watching for. This article is summarized from an interview with an adjuster I met recently.

1. The medical records are “template” style, or barely exist at all. Out of all of the red flag issues we discuss, this one does not indicate a shady doctor. It could just be that the doctor is very poor at note taking. But the two go hand in hand. Great doctors do great analysis, and back up opinions with objective medical facts. They arrive at this point by walking through the medical records, and creating a great conclusive medical report. Doctors that get by by pairing up subjective history from a patient’s mouth are another story. (WCxKit)

2. Missing dates of service, or no date labels on the medical notes. I suppose if the “template”style medical record, is paired with one that is similar to a fill-in the-blank system (Patient came in with complaints of _______ which they attribute to work causing them _____ pain out of 10, with 10 being the worst pain imaginable) and pair it up without a date of service, I guess you could use that medical record for every date of service you ever have. If anyone is watching, a physician will not get far by doing this. But, if nobody is paying attention, thousands of dollars could be paid and for who knows what. Make sure the notes are clearly labeled, dated, and legible. If not, you need to contact the physician’s office right away.

3. Different handwriting or inks on same dates of service. Granted again, that may be the nurse or the medical assistant jotting some notes down before the doctor jots the notes down, but if you get the feeling that something is not adding up, then call them. Their patient may be contacting them and coaching them what to put in the record, which we all know is not OK.

4. The medical provider office will not send medical records or state that they do not keep a medical “record”. I cannot think of one legit company that does not keep a note or record of some sort, for whatever reason. Even the most trivial of companies store records of some sort. So using that as a comparison, the medical record is very important. And for a clinic to say they do not keep a record is unbelievable. As a matter of fact, you should not pay any bill ever without a medical record attached to it. How do you know what is being paid and for what? If a doctor’s office ever tells you that they do not keep a record on a patient, my advice is to alert your counsel and have them step in right away.

5. The medical notes showed continued high levels of pain. I have never broken my arm, but I anticipate that it hurts quite a bit. Enough to be uncomfortable anyway. So if it is 2 months later and you still have “10 out of 10” pain, that is just not correct. If the pain is so unbearable, and you have treated with this doctor for 2 months, why go back there? And how is the worker driving to these appointments? And how can the worker go to the bank and cash your check, all with “10 out of 10” pain that has not lessened? The doctor should be stating in the medical notes that the objective indicators for pain do not match the subjective complaints of “10 out of 10” pain. If the physician is not doing anything about it, or the person is no better, then you have to find out what is going on medically and get that person to a specialist or set up an IME to address these ongoing complaints.

6. Consistent improper billing practices. Your Carrier/TPA usually cannot process a payment off of an invoice. Usually the bill has to be printed on an HCFA-1500 form so the Carrier/TPA can process it. This is standard. A lot of offices that handle any type of insurance work know this. So if they keep trying to submit their bills improperly, something is going on. Why are they doing this? Have any others had this sort of problem with this provider? Coding errors, print errors, ICD-9 code errors, etc. should be correct and correlate to the claim. A few errors are to be expected. But if it is constantly going on and on and on, you have to dig a little deeper.

7. Conflicting medical reports or conflicting subjective complaints that are not addressed. Let us say you are the adjuster and you are reviewing a stack of medical records on your claimant. One day your claimant states they are in very bad pain, 8 out of 10. It is hard to bend, and walk. The next day they show up for therapy and they tell the therapist they are doing great, and they think treatment is really helping them. 2 days later they go back to the doctor and say they feel the same, about 7-8/10 pain. Then the same day they have therapy and tell the therapist they feel great, and are looking back to getting back to work. I believe in the fact that people have good days and bad days. But if you are hurt, and in legit pain, your symptoms should not yo-yo up and down like that. Therapy can flare pain up a bit, but over the course of a few weeks the pain should be gradually lessened. If you start to notice yo-yo pain complaints and pain out of proportion to the injury, think about getting your IME in order because the claimant is trying to extend their time out of work.

8. Consistent excessive referrals or quick referrals to physical therapy where it may not be needed. I know of a very popular occupational clinic. A very large one. And I have handled a ton of claims where the clinic is the treating provider. And over the course of a year or 2, I wager to say that everyone that walks through their doors with a comp case had a referral to go to the same physical therapy facility after the first or second visit. These were strains, sprains, lacerations, contusions, etc. Every injury you could think of and they were all sent for therapy. We had to call and talk to the doctor to find out the rationale. This took a lot of time, but after a while they go the point and started to go by the medical norm for a referral for physical therapy. This is meant to be a very loose example, but a lot of times personal doctors or practices also own therapy companies or diagnostic laboratories, or they have partial ownership in them, so they get to make money twice; once when you go to see them, and again when you go to their therapy facility. So trust your instinct. If you think a referral is questionable, call and talk to the doctor. Make that doctor defend their decision and ask them questions. After all they have a service to provide to you, and you have rights too in these work comp scenarios. Depending on your jurisdiction anyway. NOTE: Make sure your company is aligned with a high-quality independent physical therapy network, perhaps even a national network, and put that in the account handling instructions, then monitor compliance and make sure the adjuster is helping monitor compliance.

Summary

Again this is not every doctor, at every clinic, attempting to get extra. These questionable doctors are few and far between. But they are out there, and your adjuster and counsel know of some of them. Physicians will say that they can only treat what the patient is telling them, and if the patient states they are in pain, then no matter what doctors are going to do what they can to help them. So part of this problem is on the doctor, and part is on the claimant or patient. However, all of it can be questioned by you in a workers comp scenario. Keep names of doctors and group practices that you had trouble with in the past. If something does not seem right call and talk to the doctor about it and share your concerns. Remember the doctors or practices that caused you problems–chances are you will cross paths with them again. Continue to stay proactive, and trust those instincts.

Your responsibility as an employer is to establish procedures, select vendors, and make sure you are actively involved in who treats your employees and the results they get from treatment, assuming this is allowed in your state. Working with a good TPA is important; ask them how they control these issues and learn what they are doing to prevent over treatment.

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.

Our WORKERS COMP BOOK: www.WCManual.com

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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.

Six Things An Employer Should Tell the Adjuster About the Workers Compensation Claim

Rebecca Shafer, J.D. — Mon, 21 Nov 2011 23:43:02 +0000

Let me first point out this article is written from the Claims Adjuster’s point of view. This will point out a disturbing new trend in the world of insurance where the employer is not being honest about injury details or other information surrounding the injury. Not all of you will fall in to this category, but some unknowingly may. So take that in to consideration, and I hope it impacts you to change the way losses are handled.

Over the years I have investigated workers compensation losses and have heard bizarre stories of personal injury and the circumstances surrounding accidents. If someone asks me if I have seen everything in workers comp, I have to answer an emphatic no Chances are a bigger and more unbelievable instance has yet to cross my desk, and it will be my job as the adjuster to determine what happened. For those employers without the luxury of video surveillance, I have to go by witness accounts ( if there are any) and attempt to piece the circumstances of the injury together.

Sometimes this is a difficult task. Given the job environment in recent years, I have noticed a new trend where employers are being dishonest with me about the details of an injury. This is probably happening for many reasons, but in any case it is never acceptable nor helpful. The carrier is on your side and needs to hear the truth. Below I discuss a few questions I ask on claims where I have heard questionable responses in the past.

1. What do you know about the injury details?

Every employer has a designated person to call a claim in to the carrier. This person’s name is at the bottom of the report. The first phone call I make after getting the claim is to this person. Today, we will call her Sally. I call Sally and ask her if this is all that is known about the injury. She says yes, and that all details are included in the injury report she completed.

That may be correct, but I know the report is missing information. So I rephrase the question about the exact timeline of events. Who was injured? Did the worker tell someone? Did the worker go to the clinic alone or did someone drive? Do you know about any prior injuries to the claimant’s knee ( for example)? Keep in mind one and two word answers do not assist in creating my report. If you the employer do not know the particulars about the injury then be clear on that at the outset. I will attempt to find someone who is. Perhaps this will be a floor supervisor, field manager, or you can direct me to the appropriate person.

2. Are there any witnesses?

I can name countless times where an employer reports to me there are no witnesses to an injury. Then I interview the claimant who provides several names as witnesses. Next, I talk to those individuals and ask about their account of events, and more times than not they have seen something or arrived shortly after the accident after hearing the claimant’s calls for help. If there are witnesses, I will learn about it from the claimant and others interviewed.

Perhaps the employer did not ask about witnesses at the time of reporting and was not aware of any. Maybe the internal injury questionnaire does not have the space to write witness names no witnesses. In some cases, the employer may intend for the claim to sound less substantial.

Whatever the case may be, if there are known witnesses, name them. The employer should know the employee will be ready to list as many witnesses as they can remember to substantiate the claim. In the end, finding out there are witnesses makes us question the validity of the employer not the claimant. It makes us question you. And in the case where the employer’s internal report does not have a space for witnesses, that should be immediately added as it will help in any claims going forward.

3. Why was the claim not called in a timely manner?

Sometimes I get a claim with an injury date months earlier or even a year. Maybe this is an error. But if someone approaches you as an employer and reports being hurt, a claim should be immediately filed. Do not wait and see if they are actually injured or not. Do not wait to see if they file it under personal insurance to avoid a WC claim. Do not let it sit on a desk for 3 months or more. Call in the claim.

The employer needs to call it in because I will question the claimants about dates. If the claimant reports telling the boss on that date a year ago then again four more times. And that was all before the paperwork is filed, then that is not going to behoove you to the carrier. In fact, the employee also will be displeased , and it is going to make them that less motivated to return to work in the first place.

Maybe the report was completed on the injury date and was sent to your agent or broker. That works well, if the agent calls the claim in to us. Agents receive a lot of paperwork from their clients. They do not know the priority of addressing various documents. Maybe the claim was sent to the wrong agent. Or the wrong person at the agency got your fax, and there was no confirmation call to the carrier. Just call it in, and if it is sent to your agent, follow up with them. The sooner the claim reaches the carrier the better.

4. Do you know of any outside activities the claimant is involved in?

I like to ask employers this question to see how much they know about their employees. In one case, an employer revealed the injured worker helped coach his son’s soccer league. So I conducted some surveillance and recorded the claimant coaching and standing for long periods of time on the sidelines coaching. That kind of tip proves very helpful in a case and investigation. However, if you as an employer cannot be sure about a tip, then tell us. Even a lead can be helpful, because we can investigate the tip. The bottom line is we trust what the employer tells us as we do not know the claimants at all, so answering questions in the most honest and complete way is critical to the success of our investigation.

5. Were the guards in place?

For those employers with moving machinery, just admit if the guard was off at the time of injury. The employee is going to tell us either way. The guard is there to protect workers, so the worker is fully aware if it is missing. Maybe this leads to a design flaw that our subrogation department can investigate so we can recoup claims dollars spent on this injury.

I know a lot of employers remove or modify machine guards in order to be more productive or in order to have the machine fit whatever kind of material you are working on for your client. Please only have those machines do what they are supposed to do. Modifying the guards can lead to very serious injury, and the costs associated with that loss are far more than any profit you can attain by changing the functionality of machinery. Not to mention the potential impact it has on the life of the worker who may lose a finger or hand, or worse. I have seen a lot of severe injuries from this. And if you do not think it will happen to you as an employer, the only advice I can give you is that every person I talk to that had this type of injury involving a guard removal or modification told me the same thing: “I have done it like that a million times before and never had any problems until now.”

6. Did you complete an internal accident report and investigation?

As an employer if you have internal reporting or accident investigations then I commend you. You are on the way to becoming more proactive at handling losses. We discuss frequently about reporting, trends, and identifying injury areas.. If you are not internally reporting, then that is okay also. Although, the employer will find it beneficial to do so in the end.

For employers who do not do any type of reporting, please do not tell me you do and then provide me nothing. I will want to see that report to get its information, and I will keep asking for it to put it in my file. If you did not do one, just tell me you do not have one. I will keep calling and emailing until the employer finally tells me there is not an internal report. This does not assist in creating my report. (WCxKit)

Summary

In the world of workplace injuries a lot of people on the outside think that the carrier has to worry only about the injured worker’s honesty. Sadly the carrier has more to be concerned with in the claim. It is a combination of the two other parties involved in the claim. I have had cases where the claimant has not been honest. I have had claims where the employer has not been honest. In any case, the truth will prevail. If all parties are honest in the beginning, it makes handling the claim that much easier for everyone involved.

Contributed to Work Comp Roundup by an Ajuster who wishes to remain anonymous however he works for a major 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. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

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