The Importance of Claims Settlement The proper conclusion of the workers' compensation claim has a major impact on the financial cost of your workers' compensation program. By properly establishing the value of the claim and by understanding the various aspects of the final settlement value, your company can control your claim cost. If you need assistance on how and when to settle your workers' compensation claims, please contact your broker or one of the consultants in our directory at http://reduceyourworkerscomp.com//workerscomp-directory.php You faithfully followed every step in the Best Practices for Handling Workers' Compensation Claims your Risk Management Department and the insurer/TPA agreed to when your work comp program began. Despite all your efforts, the employee is still off work and the medical costs keep mounting. What do you do to conclude the claim and what is the proper time to bring the case to conclusion? Best Practices Throughout In order to properly settle any workers' compensation claim for the best possible amount, the proper handling of the claim is needed throughout the entire claim process. The adjuster cannot do a mediocre job throughout the course of the claim handling and then expect to get an excellent settlement. An excellent financial settlement almost always follows excellent claim's handling where the adjuster complies with all the previously established Best Practices of Risk Management Department.
Sample Best Practices: http://reduceyourworkerscomp.com//best-practice-profile-ranking.php
Action Plan As part of your Best Practices, you require the adjuster to have an Action Plan in the claim file. The Action Plan must be in depth. It cannot be a simplistic "pay medicals, settle PPD." The Action Plan should outline step by step all the activities to undertake to bring the claim to conclusion. (workersxzcompxzkit) The Action Plan keeps the adjuster focused on what needs to be done to settle the claim and prevent the claim file from lingering unnecessarily. The Risk Management Department workers' compensation coordinator should review the settlement Action Plan completely prior to authorizing any financial settlement of the claim. "FRAUD PREVENTION" PODCAST click here: http://www.workerscompkit.com/gallagher/mp3 By: Private investigator with 25 years experience. WC Calculator: http://www.reduceyourworkerscomp.com/calculator.php
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker about workers' comp issues. ©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
Medical Issues
Both the work comp adjuster and your work comp coordinator need to have a solid understanding of common medical problems faced by employees recovering from on workplace injuries. When either the adjuster or your work comp coordinator does not understand the nature of an employee’s medical issues they need to either research the medical issue by contacting the treating physician or your insurance company’s/TPA’s medical director BEFORE SETTLING THE CLAIM.
A discussion explains the medical issue and how it will affect the employee long term. A complete understanding of the medical issue(s) facing the employee is necessary for a proper evaluation of the value of the claim. The internet may also be used (judiciously) for research.
Often a stumbling block to the successful settlement of a work comp claim is the lack of understanding by the employee of the medical issue(s) currently being experienced. The nurse case manager on the file should always be present at the employee’s conference with the treating physician when the future prognosis and future treatment and care are discussed. The nurse case manager can assist the employee in obtaining answers to all questions about the medical condition. This helps to alleviate the employee’s fear about the future, making it easier for the adjuster to settle the claim.
Disputed Issues
Disputes are unavoidable in the handling of work comp claims. Disputes arise from almost all aspects of the claim including whether or not the medical issue is work related, the amount of the temporary total disability benefits, the medical benefits provided, the disability rating and the value of future medical benefits. While disputes cannot be totally eliminated, the adjuster can reduce the number of disputed issues and reduce the contentiousness of the disputes.
As part of the Best Practices established by your Risk Management Department, you require the adjuster to make immediate contact on each new claim reported, plus you have required the adjuster to maintain regular contact with the employee throughout the course of the claim.
The employee is primarily concerned about all aspects of the claim being handled promptly and fairly. The rapport built up by your adjuster with the employee through regular contact eliminates many disputes. If the employee contacts the adjuster whenever there is a problem or a question rather than an attorney, the end result of the claim will be much better. If the employee does not hear from the adjuster in months, the employee will have no confidence in being treated fairly by the adjuster to resolved problems.
When the employee is represented by an attorney and a dispute does arise over what will be paid, the adjuster must have a thorough understanding of the work comp laws in their state. http://reduceyourworkerscomp.com//laws_and_regulations.php
Most jurisdictions have previously resolved every imaginable type of dispute over wage benefits. What is and what is not covered can usually be found in either the written statutes or case law. The knowledgeable adjuster can point out to the employee’s attorney the governing law or ruling defining and determining what is owed/not owed. (workersxzcompxzkit)
The area of disputes most often in contention is medical benefits. When the employee’s doctor selected by the employee’s attorney wants to continue treatment beyond what is necessary, or the employee wants to try the latest unproven experimental treatment, it is essential for your IME doctor to be highly proficient in his/her specialty. Your IME doctor must be able to testify if necessary as to why the medical treatment sought by the employee/employee’s attorney is not justifiable.
TO DOWNLOAD OR LISTEN TO FREE AUDIO PODCAST click here: http://www.workerscompkit.com/gallagher/mp3
By: Anthony Van Gorp, private investigator with 25 years experience.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or broker about workers’ comp issues.
©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
We all know the time from the moment of injury to final resolution can be lengthy. A competent business manages the process in an organized manner by monitoring all claims to ensure adjusters start working the claim as soon as it is reported. Clearly define the role of your adjuster and injury coordinator to ensure a delineation between the roles. The injury coordinator provides input into overall "big picture" strategy on claims. Adjusters determine compensability pursuant to state law on individual claims. 9 Ideas for Managing Ongoing Workers' Comp Claims 1. Adjusters must contact the employee, the employer, and the doctor immediately after the work-related incident occurs. Don't let the process manage you, YOU should set up the injury protocol and manage each step of the process. 2. Medical restrictionsfor modified work MUST be obtained on the FIRST medical visit. These are useful not only for modified duty placements, but also for adjusters, medical directors and nurse case managers to gauge improvement. Initial restrictions are a baseline for improvement determinations. 3. Adjusters must ensure the employee receives medical treatment and medication. Some TPAs have triage nurse that are contacted immediately after the injury to help determine whether self-care or provider care is appropriate. They use sophisticated protocols to help determine whether the injury needs to be treated NOW (call 911), in 6 hours, 12 hours, or put heat on the injury, let it rest and go back to work later today. 4. Adjusters must notify injury coordinator if the employee misses medical appointments. Some TPAs will call the employee before the medical appointment to make sure they remember the appointment, have the employer's paperwork and there are no obstacles to getting to the medical appointment. Remember, not all people have reliable transportation, and do not own cars. When injured, transporation may be a problem. 5. If the injury is questionable, adjusters must assign investigation to the incident and immediately discuss this with the injury coordinator. The minute red flags are seen in the claim, investigation should be considered. 6. Adjusters should assist in determining which transitional jobs best accommodate the physical limitations of injured employees, by facilitating communication between employee, employer, adjuster and medical provider. Employer SHOULD take the lead in some cases, however if they don't, the adjuster can take the initiative. 7. Visit a claims' handling office at least once a year to view claims handling and to develop a rapport with the adjuster. Sit "chair-side" for an afternoon – you'll be amazed at how much you learn. (workersxzcompxzkit) 8. Invite the adjuster to visit your facility to meet you, to learn job categories and physical demands of the jobs, and to observe or discuss transitional duty jobs. Include lunch! 9. Get a Plan of Action that is detailed about what steps are required to get the employee back to pre-injury condition. "Get employee back to work" is not a sufficient POA! After every roundtable or file review meeting, the POA should be distributed to each party for monitoring and follow-up. Author: Rebecca Shafer, J.D. designs and develops workers' compensation cost containment programs, and is the developer or Workers' Comp Kit®, an on-line automated tool kit with an assessment, benchmarking and improvement plan. Rebecca can be contacted at: 860-553-6604 and email: RShafer@ReduceYourWorkersComp.com http://www.ReduceYourWorkersComp.com. We accept articles about WC cost containment. Contact us at: Info@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker about workers' comp issues.
©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
If a member of executive management walked into your office today and asked if you are using your TPA as effectively as possible to reduce claim costs, would you be able to answer with an emphatic "YES?" You might answer in the affirmative, but would you be able to demonstrate it clearly? Even if this never happens, why not ask yourself the very same question? The claim management program you have in place with your TPA must be dynamic, flexible and responsive to changing needs and trends. Gone are the days when "what worked last year will certainly work now." Claim costs are a significant item on the balance sheet, so an effective, state-of-the art claim management program has never been more important. To drive better outcomes, you must continually reassess, refine and monitor your program. Focus your review on the following key areas: 1. Claims handling, from intake to settlement, and everything in between – a. Are you using the TPA's most efficient method to report claims, i.e. reporting via the Internet? Is the TPA planning any claim intake upgrades? Are Best Practices in place for claim intake and are they being met? b. Are claims consistently being handled as aggressively as possible? Are your account instructions facilitating the claim process, or hindering it? Are the appropriate resources and services being used, i.e., investigation, surveillance, medical directors, defense counsel, etc.? c. Is your TPA meeting all Best Practices? Are there any elements in your program that make it harder for your TPA to meet them? Some of the best intended custom processes actually have the opposite effect, resulting in delays and inefficiencies. 2. Service model, including staffing and caseloads – a. Does the structure of your program meet current needs? Does it make sense to consider designated, dedicated or regionalized staffing options? What are the pros and cons? Ask the TPA for client service delivery success stories. b. Are the best adjusters on your claims? Are caseloads reasonable? Are the adjusters properly supervised (typical adjuster to supervisor ratio is 5 to 1)? Some TPA's, for a slightly higher per claim fee, will cap adjuster caseloads at a lower number on your program. c. Does your TPA have adjusters who are highly experienced and technically superior in certain industries or on certain types of complex claims? Can they be used on your claims, if appropriate? 3. Medical management services, when and how – a. Is medical management integrated into your claims management program (sometimes referred to as a "clinical model"), or are they at odds? Adjusters and medical management must partner on claims to drive the best outcomes. Is your program designed to make that happen? b. Are you using the right medical management services, on the right claims, at the right time? This is one area where you want to avoid an "all or nothing" mentality. Using medical management on ALL claims is not the way to improve outcomes, nor is requiring the TPA to ask for authorization to use medical management on any claim. For the best results, claims should be triaged at intake, and again at appropriate intervals, to make sure medical management is engaged as soon as needed for exactly what is needed. c. Is the TPA's provider bill review program producing above average results? Is there anything YOU can do to improve the results (for example, posting PPO physician panels in workplaces, where allowed)? Are you soft channeling injured employees to PPO physicians, where allowed? d. Are you using a Pharmacy Benefit Manager (PBM) to reduce escalating pharmaceutical costs and utilization? The savings potential is great and should not be overlooked. e. Also consider Physician Peer Review (PPR) and Utilization Review (UR) services to reduce costs. 4. Risk Management Information System (RMIS), including reports and benchmarking studies – a. Are you making the best possible use of the TPA's RMIS? Have you, and other team members, received hands-on training on all system features and functionality? Are there any system enhancements available that would be of benefit to you? b. Have you automated the distribution of reports to your divisions and locations? Are you using customizable data fields that enable you to target loss control efforts? Ask your TPA for examples of how client "super users" leverage the power of the system. c. Are you partnering with your TPA on benchmarking your losses against their book of business and externally, against industry peers? (workersxzcompxzkit) Reach out to your broker and industry peers for ideas on how to make your TPA claim management program as effective as it can be. Also, ask your TPA if they have a client advisory group in which you can participate. Think about how good it will feel to answer "YES!" with no hesitation when executive management asks if you are using your TPA as effectively as possible…and, it will feel even better when you are able to demonstrate it! We are articles* on WC cost containment. Contact us at: Info@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker about workers' comp issues.
©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
An injury coordinator is the person at the business that coordinates activities between the employer, injured worker, doctors, and insurance company. Usually they handle other duties as well; however, in companies where there are many claims, they may be dedicated to the role of Injury Coordinator. 1. The injury coordinator provides a written post-injury response procedure to all workplace staff. These procedures list the steps each participant must take when a workplace injury occurs. Participants will include the employee, supervisor, witnesses and physician and any other persons with knowledge of the injury or part of the response team. These procedures list steps each participant must take at the time of a work-related injury. 2. The injury coordinator coordinates the paperwork process when employees are injured, including receiving, processing, and archiving the work ability form, the witness report of injury, a supervisor report and an employee report as well as all subsequent documentation. 3. Communicates workers' compensation policies to the employee population by posting a transitional duty policy, providing employee brochures or offering wallet cards. 4. Informs in-service employees on post-injury response procedures. 5. Stays in touch with injured employees with a first-day phone call and a get well card. (workersxzcompxzkit) 6. Structure the company's communication program using documents found in your corporate injury management manual or develop company-specific documents. Employee communications may need to be translated into additional languages. Contact your insurance resource to determine how to proceed. Most importantly - it doesn't have to be perfect, it just has to be started! My biggest challenge as a consultant is helping the client recognize that they can "do it." Author: Rebecca Shafer, J.D. Rebecca designs and develops workers' compensation cost containment programs, and is the developer or Workers' Comp Kit®, an on-line automated tool kit with an assessment, benchmarking and improvement plan. Rebecca can be contacted at: 860-553-6604 and email: RShafer@ReduceYourWorkersComp.com http://www.ReduceYourWorkersComp.com. We accept articles on WC cost containment. Contact us at: Info@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker about workers' comp issues. ©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
Special Handling Instructions
One of the main goals in managing workers’ compensation costs is returning your injured worker to work as soon as medically advisable. For this, you need to review your special handling instructions, or SHIs to make sure the proper wording and instructions are in place for the adjusters. Knowing the SHIs allows you to design transitional duties or work-arounds for your employees and get them back on the job.
As you can imagine, documenting the process thoroughly is critical. Once you have an injury management program in place, write an email (you can also attach a Word document) to the account executive at your third-party administrator.
9 Steps To Remember When Making Your Request:
1. Your email asks for the most recent version of the account instructions.
2. You copy the claims VP at your broker.
3. You remind your recipient you have an aggressive return-to-work program.
4. Acknowledge your company can accommodate nearly all medical restrictions.
5. Mention you have a medical director reviewing all independent medical evaluations and examinations. This establishes the professionalism and thoroughness of your company.
6. Note your medical director reviews claims to add details and asks the third-party administrator for additional verbiage corrections or changes.
7. Collaborate with the third party administrator on the wording for any changes.
8. Summarize by asking again for their suggestions. (workersxzcompxzkit).
9. Don’t forget to say thank you and tell them you look forward to their participation on your cost containment team.
Most property casualty workers’ compensation brokers have someone in their organization that can help put together a post loss program, however, if you have severe problems, you might want to ask for their most experienced specialists. One has to be a problem-solver to help companies with serious problems correct any type of problem, including a workers’ compensation problem.
Author: Rebecca Shafer, J.D. Rebecca designs and develops workers’ compensation cost containment programs, and is the developer or Workers’ Comp Kit®, an on-line automated tool kit with an assessment, benchmarking and improvement plan. Rebecca can be contacted at: 860-553-6604 and email: RShafer@ReduceYourWorkersComp.com http://www.ReduceYourWorkersComp.com.
We are accepting short articles* (300-800 words) on WC cost containment. Contact us at: Info@ReduceYourWorkersComp.com. *Non-compensable.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker about workers’ comp issues.
©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
Stopping Fraud with Video Proof
3 Action Steps to Use When Contacting Your TPA
Once you suspect an injured employee of lying about an injury, launch an investigation. With video proof the injured employee’s range of motion is not as stated, you document these facts with a doctor.
The next step is legal and it’s time to contact your third party-administrator (TPA).
1. Send a letter stating the nature of the employee’s fraud by:
Overnight priority mail.
With a confirmation receipt and tracking.
Enclose the investigation report and video.
Enclose a completed transitional assignment form.
2. Next the injury coordinator needs to include a cover letter detailing the situation. This letter must include the employee’s name, claim number, your company name and contact information, with an explanation:
That the company’s policy is to verify that employees who tell us they cannot perform a transitional duty job are actually unable to perform such work because you accommodate any restrictions provided to the company by the treating doctor.
Tell your TPA the company paid for this investigation directly and will keep a copy in the files in case there are any subsequent employment-related claims.
Explain the investigator’s report indicates Mr. X can do strenuous yard work for an extended period of time. Thus, he has more ability than he has told his doctor.
Note the company will make good on its offer to give Mr. X a transitional duty position in the transitional duty program based on the report.
Explain if Mr. X refuses the job offer, your company will notify the TPA immediately and request they file a Motion to Discontinue Benefits according to state law.
Note a copy of the new job offer is attached.
3. Lastly, you must ask your TPA about legal recourse. One way of phrasing this is as follows:
“We are also interested in pursuing any criminal and/or civil action and ask you to request the head of your Special Investigation Unit to contact me immediately to discuss whether this claim rises to the level of fraud in our state.” (workersxzcompxzkit)
4. Request a Meeting with the SIU (special investigation unit) at the carrier to see if additional evidence is likely to be needed.
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, health care, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He can be contacted at: Robert_Elliott@ReduceYourWorkersComp.com or 860-786-8286.
WC Calculator: www.reduceyourworkerscomp.com/calculator.php
TD Calculator:www.ReduceYourWorkersComp.com/transitional-duty-cost-calculator.php
WC 101: www.ReduceYourWorkersComp.com/workers_comp.php
Follow Us On Twitter: www.twitter.com/WorkersCompKit
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker about workers’ comp issues.
©2008 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
9 Helpful Steps in Selecting a Third-Party Administrator (TPA) One of the most important decisions a company makes is deciding who will handle their workers' compensation claims. Depending on your insurance arrangement, an in-house insurance company or a third-party administrator can handle your claims – selecting the best one possible for your company is key in keeping costs down. Price and flexibility are both considerations in choosing to use a TPA. If your company integrates its disability programs, for example, (where sick leave is combined with short- and long-term disability) your insurance company may not be willing to handle the extra paperwork. Usually, ultimately, it's less expensive to buy the BEST claims handling service rather than the cheapest. Consider the following: 1. Who is the team that will service your account? 2. Has this TPA handled claims in your industry before? 3. Does the TPA proactively ensure internal quality control and correct any problems when they arise? 4. Do adjusters receive ongoing training to learn new laws, to fine-tune their expertise and learn new techniques? 5. Is there a Medical Director to provide updated occupational illness and injury medical information to adjusters? 6. Are specialists available to handle the most complex claims? 7. Does the TPA have an intake service, or will you have to supplement their service with an outside firm? 8. What medical management services are used? Are services well integrated, in-house services or outside services? (workersxzcompxzkit) 9. Do they have established relationships with investigators nationwide to use in all locations? Please note that these are just a beginning list of questions to ask a potential TPA. For more information, contact Workers' Comp Kit (http://www.workerscompkit.com/) or your insurance broker or agent. Author Rebecca Shafer,executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers' Compensation costs, including airlines, health care, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He can be contacted at: Robert_Elliott@ReduceYourWorkersComp.com or 860-786-8286.
More FREE tools to try: WC Calculator: www.reduceyourworkerscomp.com/calculator.php TD Calculator:www.ReduceYourWorkersComp.com/transitional-duty-cost-calculator.php WC 101: www.ReduceYourWorkersComp.com/workers_comp.php Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker about workers' comp issues. ©2008 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
Vendor Day — the best way to find out ALL services offered by your TPA. Most TPAs provide adequate services, but you need to know about those services in order to ask for the service!
A TPA (third-party administrator) is an independent company used to adjust claims. Sometimes your insurance company will use a TPA hired by your company if your insurance company allows you to unbundle.
TPA’s focus on administering workers’ compensation benefits in accordance with state laws. “Unbundling” occurs when an insurance company allows the employer to use a TPA.
As always, it is important to understand the process involved in handling workers’ compensation cases. One of the best ways to do this is to request a Vendor Day. The company, insurance company, broker or consultant can request this for a specific date, time and location.
A letter to your TPA should demonstrate that your company is in the process of implementing a program to reduce the cost of workers’ compensation. Explain that since your company has a new system, it will be using some of the TPA’s services more heavily, want to take advantage of ALL services and would like to learn as much as possible about all of those services.
Some of the vendors you need to meet with and understand include:
1. Nurse case management and Senior Nurse Reviewers
2. Bill review
3. Medical advisors
4. Surveillance
5. Recovery and subrogation
6. Loss control and risk management information systems
7. Any other service the TPA offers
In your letter, tell the TPA you would like them to provide samples of their services, available reports, and the cost of the service. And also let them know you need the information at least one week in advance of the meeting so your company can read it and prepare questions. (workersxzcompxzkit)
Workers’ compensation is an important part of your business and it is critical to stay on top of all aspects of the process. Trusting that “the insurance company will handle it” is not an effective tool. All tools are available in www.WorkersCompKit.com
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, health care, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He can be contacted at: Robert_Elliott@ReduceYourWorkersComp.com or 860-786-8286.
We are accepting short articles* (200-600 words) on WC cost containment. Contact us at: Info@ReduceYourWorkersComp.com. *Non-compensable.
WC Best Practices IQ Test: http://www.workerscompkit.com/intro/
WC Books: http://www.reduceyourworkerscomp.com/workers-comp-books-manuals.php
NEW Article: Return to Work in Unionized Companies
http://reduceyourworkerscomp.com//Return-to-Work-Programs-Unionized-Companies.php
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker about workers’ comp insurance issues. ©2008 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
Workers Compensation Diary of a Consulting Project -I will share some of my experiences from a work comp cost reduction consulting project. My goal is to advise the company about ways to reduce their overall workers' comp costs. The Importance of Visiting the Third-Party Administrator It's been my experience consulting projects work best and are most productive when they proceed in an orderly, logical way. Most workers' compensation assessments follow a predictable pattern. However, every now and then there is the one client/employer whose business and needs don't fit into a neat little box. Consideration must then be given to the "special" or "unusual" nature of the client's particular business and needs. Such was the case of a mid-western trucking enterprise. The company, incorporated in one state, has employees carrying on job duties nationwide. That is to say, the employees don't have a "place" or "site" to report to work. This becomes significant later on, as you will see. Observing How the Medical and Indemnity Claims Are Handled My first action of any consulting engagement is a visit to the third-party administrator (TPA) to dig for "soft spots" and observe and let each party touching the claim educate me about what they do, how the claim is handled, any problems they have with the employer, and problems they have with the employees, why claimants seem to retain an attorney, what resources they need to better handle the claim, what resources they currently are using. Think of it as "job shadowing." I call it "sitting chair-side." I always suggest visiting the TPA because invariably when I work with a risk manager to help reduce workers' comp costs, the RM has not visited the TPA offices with a fresh eye in quite some time. My role is to take a fresh look at the system in place to spot opportunities for improvement. Here are some things I observed: 1. An opportunity to improve the intake process by adding medical input to the process. 2. There were two companies at the TPA doing intake totally differently. The adjuster mentioned that another client was using another technique, and my company could possibly do this also. 3. The client is doing intake without medical triage. But, I don't jump to conclusions thinking it is a problem until my medical advisor reviews the files to see how they are being handled from a medical perspective; whether medical triage would be helpful or necessary. 4. The claims are reported by the employer to a vendor who reports the claims to the carrier. 5. The claim office manager initially evaluates the claim and then hands it off so administration can begin. 6. Administration reviews the initial details (zip code, confirms policy coverage, determines whether the employee is out of work) and assigns the claim a claim number and passes it to the appropriate adjuster (either medical-only or lost time). What it Means To Be "Site-Less" Although the employer is physically located in only one state, the injury took place in a different state, meaning the claim must be handled according to state law where the employee resides. Multiply that by 15 or 16 states where employees actually live, and you begin to see how complicated things can become. As I sit "chair-side" with the adjuster, I observe how lost time claims are handled and question whether it is impossible to have a return-to-work (RTW) program on site, since there is no "site" for the employees to participate in modified duty. A major challenge is discovered and thus, we must look for other options for injured employees, depending upon their skill sets and how these skill sets might transfer to modified duty. Med-Legal Meetings- As I sit with the adjuster I learn that in the state I am visiting, regulations permit a meeting between the defense counsel and the claimant's treating doctor to "get to the bottom" of medical discrepancies. Interesting. I will explore whether the attorney can be prepped by an MD. This visit is allowed prior to depositions and/or hearings, but is apparently generally used in the later stages of a claim. Options to enhance this meeting are worth exploring, and I begin by getting the regulations and calling the local attorney to introduce myself. Return-to-Work programs are a key and essential part of reducing costs and I am NOT prepared to consider the option of leaving employees out of work indefinitely because they lose motivation, become depressed, healing takes longer, and as they lose their daily routine they become isolated from the workforce. There are many other benefits also, but we can't do into all of there here. They are all listed in Workers' Comp Kit modules www.ReduceYourWorkersComp.com. This employer does not want a light duty program, and I will turn over every stone looking for other options. I may eventually suggest these options for the no-site nature of this employer: 1. Structured Volunteering. Perhaps at a school, hospital, Goodwill Industries or senior center. 2. Telecommuting from home via computer, doing home-based work. 3. Local network of work-hardening rehabilitation centers that simulate a work environment. Research Services - There are vendors providing both of these services. I have also asked the AE (account executive) from the TPA for copies of all brochures of all services the TPA offers and I am directed to their website. Hum. I would rather have hard copies I can mark up with my yellow highlighter. I put this issue on my list of "to-do" items for future follow up, then start researching the two intake triage companies I have just learned about. My logic has nothing to do with the economics. Well, OK, maybe it does a little bit, but primarily I want the employees back to work because staying out of work isn't good for them personally or their families. Anyone who works, knows that they have a pattern, a routine that they live by; when that routine is gone, their life changes — for the worse usually. It's better to have a destination to go to each day. If they don't have a destination to go to each day, they often become depressed and isolated. So, we'll be looking for other options for injured employees of this company. (workersxzcompxzkit) While the substance of my findings are interesting, the important point I want to make is the offices of your TPA's must be visited at least once each year to learn, learn, learn about the claim process and establish a relationship with your partners at the TPA/claim administrator's offices. 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, health care, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He can be contacted at: Robert_Elliott@ReduceYourWorkersComp.com or 860-786-8286.
Visit Our Websites: WC Calculator: www.reduceyourworkerscomp.com/calculator.php TD Calculator:.ReduceYourWorkersComp.com/transitional-duty-cost-calculator.php WC 101: www.ReduceYourWorkersComp.com/workers_comp.php
Do not use this information without independent verification. All state laws vary.
©2008 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
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