This is a great time of year. The weather warms up, snow melts, golf courses open for business, grass grows, and the overall mood just seems to improve once springtime hits. Typically one will engage in some sort of spring cleaning activity, whether it is cleaning out the garage, cleaning the house, sorting old from new, etc.
Wouldn’t it be great if every spring some facets of the work comp system could get cleaned up as well? Maybe an update to something applicable to this century would be nice, instead of using the same old Laws and Statutes that were set in the early 1900’s. Let’s take a peek at a few items that could easily be spruced up if we had the chance this spring:
1. Processing and paying medical bill reconsiderations based blindly upon their own merit is a terrible habit
As a claims adjuster, it is your responsibility to process and approve the payments on applicable medical bills that are pertinent to your claim. It is your job to sift through what is work related and what is not. After those choices have been made, the bills are sent to your cost containment or medical bill review department and they set the amount that should be “paid.”
Of course, if a provider charges $250 for something and your MBR department sets the payment at $20, chances are the provider will send you the bill again since they will think that the $20 must have been some sort of error. So, they send you a bill for $230 this time, and it arrives in your inbox yet again, coded as a reconsideration. Here is where an adjuster faces the fork in the road: Do you (a) send the bill for MBR again for processing or (b) just pay it figuring the MBR department must have missed something, or maybe you coded something wrong.
If you chose (b) then shame on you. Providers are not morons, they know they have nothing to lose by sending the bill back again, whether the $20 is the correct amount in that applicable medical network or not. I saw some metrics which showed that 81% of resubmitted bills were not submitted again for bill review!!!! Providers are banking their hopes on the fact that you, the overloaded, overworked adjuster, just ok’s full balance due payment, based only on the fact that the bill comes in labeled as a reconsideration, and not a new bill.
Every provider has a reconsideration process of some sort, but most of them see it as a numbers game. The more bills they send back out for reconsideration the better chance they have of getting more money paid towards services billed. The more money they bring in for the provider, the more it makes their department look awesome, and they probably get rewarded in some fashion for accomplishing this.
Rejoice in the fact that you, the adjuster, are not alone. You and 81% of your claim cronies are guilty. This amounts to insane leakage, because not only are you paying a bill incorrectly, but you are paying way more than you should for those services in general. You might as well just take some money and throw it out the window, because when the bill review and bill payment process breaks down that is all that you are doing—throwing money out the window.
2. If your compensability technique is “Trusting your instincts” then you are not doing a good enough investigation
It is funny when an adjuster is able to take what seemed like a compensable claim and discover that it is indeed not work related. The first thing out of their mouth is usually “I just knew that something was not right. My gut was telling me this was not legit.”
Sure this could be correct. Years in this business can give you a sixth sense to when some BS is around the corner. But the truth is that you were able to dig into this claim because a thorough investigation was done by all parties, not just on the adjuster’s end.
The first heads up was probably from the employer. The employer caught wind of something because they were alert to the chatter out on the workfloor, combined with the always overlooked fact that the employer has a far longer relationship with this claimant than the adjuster does. The employer contact or floor manager may see this guy every day, for months or years on end, and they are the ones that pick up on something not fitting the daily routine of said injured employee. Then the manager is smart enough to report that odd feeling to the person that deals with the insurance company and their adjusters. That way when the adjuster calls as part of their three-point contacts, the employer contact relays to the adjuster on the file that something may not be right. Nothing sends the red flag up quicker for an adjuster than the employer saying that something is just not adding up.
This scenario is often overlooked because if the manager doesn’t speak up or the employer contact decides not to relay that oddity to the adjuster, then the adjuster is out on their own to make their own conclusions. The input from an employer on an injury is priceless. Their role in the claims investigation is more important than several other keys in an investigation. This proves how much of a team effort it is to have an effective safety or loss prevention team in place. Everyone has to do their own due diligence in the investigation of a claim, no matter how insignificant the claim may be. Even the most minor of claims can spiral into a disaster.
3. Challenge the right claim that is in litigation and fight it as far as you can take it
Workers Compensation Statutes/Laws have been around forever. Some of these get updated from time to time, but only when the employer and carrier fight a claim to the bitter end. Now this could not be done on every claim that is in litigation and in fact finding that “Just right” claim to dig your heels in and fight it as high up the Court ladder as you can us few and far between. But every now and then, a scenario happens when your Legal counsel advises that the opinions given by the first level of Magistrates is just not correct, so they recommend filing the appeal. This process will vary from State to State, but if after several hours of legal discussion you think you have a claim worth appealing and fighting, then give it a shot.
Plenty of States now have new wage loss laws, vocational laws, and new applicable compensability Statutes because somewhere along the line the carrier and their Legal counsel felt they got an unfair shake from the Judge, and they want to try and go beyond the Judge’s ruling to the next level for an Opinion to be overturned.
For this process to even begin it means that the carrier initially lost the defense of the case. The Judge did not rule in the carrier’s favor, and the carrier will owe whatever benefits they owe to the claimant. Really you have nothing to lose by fighting it further in appeal, should this be the “Just right” case to do that on. So don’t roll over on all of them should you happen to be on the losing end of the stick. If all employers, carriers, TPAs, and attorneys just gave up after the initial ruling, then no law changes would ever occur.
- Use the diary system to your advantage
- Avoid the copy/paste method of claim review
- Let the adjuster handle the file! You are there to provide guidance when needed
- If the adjuster is not returning phone calls/emails, it is not the supervisors job to return them
- Were safety protocols ignored?
- In this situation I would say yes, but was this employee properly trained on the use of this equipment? Did he complete a formal training program and did he log enough hours operating this equipment to know how to properly use it?
- Was a disciplinary consequence given as a result of the disregard for safety protocol?
- If this answer is no, then here is where it can be messy. If the worker was not given a consequence, then it’s apparent that the supervisor’s statements were not taken seriously. Plus it is probably true that no matter what the situation, if there are no formal consequences that are dished out then how do you enforce a safety violation such as this?
- Did the employee acknowledge the correction, and then disregard it again?
- Here in this situation the answer is yes. He stated he could not operate the machine correctly due to his subjective pain complaints. So does this qualify as willful misconduct or subordination despite the verbal correction that was given? It would depend on the jurisdiction, but I think an argument could be made here. Whether or not it has legal grounds for a denial of comp depends on applicable case law.
- Have other employees been disciplined for this action in the past and if so what was the consequence that was given and how was it documented?
- This is where having a formal discipline program is going to help you out. If other employees have been disciplined for this in the past, and all workers that operate said machinery know the consequences of operating in an unsafe manner, then you have some ground to stand on. Documented cases of discipline will help bolster your argument that this employee knew better than to operate the way he was operating, and he chose to do so anyway despite the verbal warnings to correct his behavior. The more concrete evidence you have of enforcing safety protocol the better chances the employer has of prevailing on a willful misconduct defense.
- Was the injured worker in the course and scope of employment?
- Again the answer here is yes, since he was performing the light duty tasks assigned to him. That is, unless you have proof of him horsing around on the equipment. And even if you do have proof in some jurisdictions the only burden of proof the employee needs is that he was injured in the course and scope of employment. Even if this were the case, personally I would still make an argument anyway rather than just accepting the case on the merit of being injured in course/scope of employment.
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Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: firstname.lastname@example.org.