9 Steps to Integrate Your Absence Management Policies

Navigating the minefield of workers’ compensation and other absences can be a nightmare for employers. The patchwork of policies and procedures overseen by multiple departments or vendors can result in compliance problems as well as decreased morale for workers, plus a waste of money and resources.

 

By integrating leave programs, employers can see significant cost savings, fewer days away from work and improved productivity. But going from a mixture of rules and regulations to a single, streamlined system can be daunting, especially for smaller organizations.

 

 

The Challenges

 

There are a variety of federal, state and municipal programs. The Family Medical Leave Act, Americans with Disabilities Act, short- and long-term disability, and workers’ compensation are just some of them, along with state, county and municipal leave laws and employer-specific leaves. Some may overlap. Some involve payments, while others do not. And they change frequently — through amendments or the implementation of new leave laws. Keeping up to date with them all and ensuring you administer them properly is a challenge for even the largest employers.

 

There are likely multiple contact points, depending on the type of leave involved. Each leave involves forms that must be filled out and, sometimes, require payments. If outside vendors are used, inaccurate information sharing may result in payments being too little or too much. Employees may receive information from multiple vendors, causing confusion and frustration. Finally, it’s nearly impossible for an organization to analyze the data and understand the impact of absences — unless the systems are integrated.

 

Getting a streamlined, integrated system involves collaboration, more than anything. Where there are silos within a company, those within them must be willing to work with one another and share information. At the least, HR, legal, benefits and risk departments must cooperate.

 

 

 

Leave Integration Programs

 

Integrating occupational and non-occupational leave programs can take a variety of forms, from the simple to the highly sophisticated. The more advanced models include wellness, disease management and even employee assistance programs.

 

Whatever type of program is implemented, integrating leaves generally results in overall lower costs and possibly better outcomes. You can start the process by taking stock of what’s already in place at your company.

 

  • Look at your data. Starting an integrated leave program should begin with an assessment of the amount and cost of absences taken annually by employees. Employers who do so typically find their employees are taking off more time than they realized, pointing to the need to take action.
  • Talk to your partners. Third party administrators and insurers, along with any vendors you use should be willing to provide data and other information that sheds light on the management of your leave programs; as well as what they do for other employers..
  • Read the handbook. Take a close look at the policies and procedures already in place for various leaves. You may find some that duplicate or contradict one another.
  • Bring in the troops. Departments that have any responsibility for absence programs should be included in discussions right from the start of the integration process. You might find ways to automate some of the existing processes.

 

 

Building the Program

 

Once you’ve seen a picture of your company’s leave programs and looked at the data, there are several key factors that can help make for an effective IDM program.

 

 

1) Single Claim Intake Source.

 

This will reduce administrative costs and make it an easier, more pleasant experience for employees. Having one phone number is a great way to ensure all leave requests are captured in a single source. This could also allow for a single provider to contact the worker if their leaves constitute more than one, such as short-term disability and FMLA.

 

 

2) Communication 

 

Any and all changes to leave policies should be shared with managers, supervisors and employees. It’s imperative that everyone has the most up to date information.

 

 

3) Collaboration

 

As explained above, integrating your absence management programs should involve personnel from several different departments who must work together. Workers’ compensation, group heath, disability insurers, legal counsel, and any other organizations that manage employee health should discuss how they can combine their data and resources. During such meetings, goals should be set and roles and responsibilities should be discussed and agreed upon.

 

 

4) Data Sharing / Tracking.

 

Employers can look at trends for such things as frequency, duration, cause, occupation and business unit to determine if and where changes could be made to reduce costs and improve productivity.

 

 

 5) Updates

 

Changes in laws that affect any of your leave programs should be brought to the attention of all involved. The team can assess the changes and determine how to proceed. There should be a process established to update leave programs depending on changing needs of your company. In addition to tracking legal and internal changes are technological advancements that should be considered. For example, having an app for employees to report absences might be useful.

 

 

6) Uniformity.

 

It is crucial that leave policies be administrated consistently and clearly.

 

 

7) Evaluating The Program.

 

Depending on how the program is handled, you want to be able to see the effectiveness. It may involve a software system or outsourced organization. Ideally, you should be able to identify lost time, costs and return-to-work rates, and see what if any changes should be made.

 

 

8) Keep Good Records.

 

Proper documentation will ensure your company is not on the losing end of a complaint.

 

 

9) Consider Outsourcing

 

Many employers have taken this option due to the complexity of coordinating leave programs. It may not be appropriate for your company, but you might at least want to shop around.

 

 

 

Conclusion

 

Integrating your leave policies can reduce costs, improve outcomes, and streamline efficiencies. It is not a quick process; but companies that have done so report improved compliance, increased control and higher employee engagement.

 

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

14 Ways to Prevent Workplace Fatalities

One of the leading — and most preventable — causes of workplace fatalities is being struck by objects. Whether it is falling, flying, swinging/slipping or objects on the ground level, fairly simple precautions can all but eliminate these incidents.

 

Struck-by incidents were recently named the leading cause of work-related deaths in North Carolina last year, at 19. Nationally, the government estimates 10 percent of workplace fatalities each year are due to struck-by accidents. Awareness, education, training and the use of personal protective equipment are generally all that are needed to prevent these tragedies.

 

The vast majority of struck-by fatalities involve trucks, cranes or other heavy equipment. The main hazards are vehicles, falling or flying objects, and constructing masonry walls. Here are ways companies can mitigate the risks.
Vehicles

 

Workers can be pinned between construction vehicles and walls, hit by swinging equipment such as backhoes, or crushed under vehicles that have overturned. Vehicle safety practices should be mandatory at any site that involves vehicles and/or heavy equipment.

 

  • Perform a safety check. All vehicles should have proper safety devices. Before every shift, supervisors and/or workers should make sure all vehicle and equipment parts and accessories are in safe operating condition. The vehicle or equipment should be taken out of service until needed repairs are made.
  • Have a clear view. Vehicles should not be backed up if the driver is unable to see what is behind him. If that’s not possible, an audible alarm should be operational or a designated person should direct the vehicle from the outside. The driver should ensure there are no individuals near his vehicle before dumping or lifting materials with it.
  • Set the vehicle before leaving. Parking brakes should be engaged when the vehicle is not in use, and wheels on an incline should be chocked. End-loader buckets, scraper blades, dump bodies etc., should be lowered on the vehicle when it is not in use.
  • Don’t overload. Workers should adhere to the vehicle’s lift capacity.
  • Set up barriers. For construction sites near public roadways, there should be barricades and/or flaggers and good traffic signs set up. Personnel at these sites must be clothed so they are easily visible to other drivers, including reflective material at night.

 

 

Falling / Flying

 

Being under an elevated work area can lead to falling object injuries, while activities such as pushing, pulling prying or grinding may cause objects to be airborne and strike a worker. Workers under or around such areas, as well as those doing overhead work need to be vigilant about safety.

 

  • Check equipment to make sure it is operating properly. Make sure small tools, such as saws have protective guards that are in good condition.
  • Hard hats should be required of all workers in such conditions. Safety glasses, face shields or goggles are advisable in areas where flying particles could be an issue.
  • Look up. Work should not be done where loads are being moved overhead. Barricades should be set up with warning signs posted.
  • Secure the site. Consider protective equipment such as toeboards, debris nets or canopies to catch falling objects. When the work is completed for the day, make sure all materials and tools are stacked and secured to prevent them from falling. Make sure loads are secured and lifted evenly.
  • Compressed air. Compressed air used for cleaning should be reduced to 30 psi. It should only be used with appropriate guarding and protective equipment, and clothing should not be cleaned with it.

 

 

Masonry Walls

 

Positioning slabs and walls or shoring up structures involves heavy loads that must be supported and can lead to catastrophic results if precautions are not taken. A trained professional should dictate when a concrete structure is strong enough to place construction loads on it.

 

  • Brace the structure. Make sure permanent supporting elements are in place or concrete has been tested for sufficient strength for whatever will be loaded on it. Until such time, brace the structure.
  • Limit the numbers. Anyone who is not essential to the construction or lifting operations should be prohibited from the work area.
  • Secure wire mesh. Make sure mesh cannot recoil by securing the ends or turning the mesh roll over.
  • Check the weight. Avoid loading up lifting devices beyond their weight capacity.

 

 

Conclusion

 

Providing training to all workers at risk of struck-by incidents is vital to protecting them. A few simple and inexpensive steps are all that is needed to save lives and protect your company’s bottom line.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

3 Factors In Determining If Employee is Independent Contractor

A common issue in the compensability of a workers’ compensation claim includes a determination of whether the injured party is an employee or independent contractor.  This is important for employer stakeholders to understand as the issue is often subject to litigation.

 

 

Important Factors to Consider

 

The law concerning employee relationships is defined by each state or jurisdiction, which results in differing interpretations.  It is important to understand the law in the jurisdiction where the claim arises or could be venued.  When in doubt, always consult with an attorney.

 

Here are some common elements found under state workers’ compensation law to consider:

 

1) Financial control.

 

This deals with issues concerning whether the employer has the right of control in the various business aspects of the relationship with the injured party.  Careful inquiry and examination must include:

 

  • How the person is reimbursed for their time. While the issuance of a 1099 tax form is key, it is not always determinative on the issue.

 

  • How the party and employer handle unreimbursed business expenses. In all instances, a true independent contractor are more likely to have unreimbursed expenses than employees.

 

  • The investment of the worker’s time. In a true independent contractor relationship, the only investment the person will have is the actual time they spend on work.

 

 

2) Behavioral Control

 

This inquiry involves the understanding on what instructions the employer will give to the person performing work.  Key questions that need to be asked include:

 

  • When and where to do the work?

 

  • What tools or equipment to use?

 

  • What workers to hire or to assist with the work?

 

  • Where to purchase supplies and services?

 

  • What work a specified individual must perform?

 

  • What order or sequence to follow?

 

Issues of “behavioral control” are often central to investigations in construction workers such as siders, roofers and other work that can be considered seasonal.  Allowing an “independent contractor” to use company tools can be fatal to an assertion the party was not an employee.

 

 

3) Types of Business Relationships

 

Courts will also examine the nature of agreements—both verbal and written.  This includes documents signed between the person and employer.  Merely calling someone an “independent contractor” does little to avoid establishing an employee-employer relationship, and thus compensability should an injury arise.  Having a written document calling someone an independent contractor can give a false sense of security and shattered hopes of defeating a claim at hearing before a compensation judge or industrial commission.

 

  • Written contracts. Courts give little deference to what a person is described as in a written agreement.  The devil is always in the details.  A potential employer should not forget to memorialize the arrangement in writing.  It is still an important piece of evidence.

 

  • Insurance agreements and other fringe benefits. An employee-employer relationship can be established if the person in question receives tangible benefits beyond payment for the labor they perform.  In many instances, court have declared a person to be an employee for purpose of workers’ compensation based on the payment of other benefits or perks such as pension plans, 401K contributions, vacation pay, sick pay or other forms of PTO.

 

  • Tenure of service. The longer a person works an employer, the greater the risk there is for them to become an employee.  In order to avoid this situation, the written independent contractor agreement should be for a defined period, or specific to a particular project.

 

 

Conclusions

 

Central to the determination of whether someone is an independent contractor revolves around issues of control.  The more control a company has over an individual, the more likely they look like an employee and resulting injuries are compensable.  It is important to be aware of these issues to avoid unnecessary costs in your workers’ compensation program.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

How To Implement An Effect Work Injury Response Plan

 

It goes without saying that in workers’ compensation risk management proactive response to a workplace injury or incident is important.  However, what is often lost in the discussion of this topic is what takes place following the critical minutes following an injury and after the employee receives initial medical care and treatment.  Taking time to think about your long-term response can save your program dollars and can increase productivity in the workplace.

 

 

Lack of Communication and the Post-Injury Dilemma

 

Take a moment to think about a work-injury from the perspective of an injured employee.  The employee is frustrated with a number of issues.  These can include:

 

  • Not understanding the workers’ compensation benefit process and payment structure. They do not want to get an attorney because everything seems right or they do not want to be viewed as a troublemaker.  They are receiving all the benefits they are entitled to, right?

 

  • Time spent filling out forms and seeing a number of medical doctors and vocational rehabilitation counselors. When they do see their doctor, it is a rushed appointment and sometimes not all of their questions are answered.

 

  • The major disruption in their life caused by physical disability. Their routine is in utter chaos.  Instead of spending time with friends at work, they sit at home and recover.

 

  • There is a reduction in income, but not everyday living expenses. Hopelessness and despair set in.

 

Missing from most post-injury response plans is an effective and consistent line of communication between the employer and injured parties.  Workers’ compensation stakeholders serious about their bottom line need to consider the implementation of pro-injury communication with their disabled workforce.  Lack of information breeds contempt.

 

 

Implementing an Effective Plan

 

It is important to plan and implement an effective post-injury response immediately after a work injury occurs.  Suggestions to improve these lines of communication and avoid distrust of the injured employee can include:

 

  • Assisting the injured worker in contacting immediate family about the injury and advising these parties about the status of the employee. In some instances, written authorization may be required given state and federal privacy laws.

 

  • Contacting the injured worker immediately after they are out of danger and in a stable condition. Sending a get well card or making a telephone call are a good, visiting the employee at their home or in the hospital is even better. Proactive employers can also offer to take someone home from a hospital or clinic after their release.  Random acts of kindness build trust.

 

  • Empathizing with the employee and explaining to them the workers’ compensation process can also be helpful. Developing literature about the workers’ compensation system can also be helpful if done right.

 

The open lines of communication should not stop there.  Additional follow-up steps can also be taken to build trust and confidence in the employee with the eventual goal of full recovery and return to work.  Other measures should include:

 

  • Weekly conferences with the injured worker to check on their physical and emotional status. These meetings can be in-person at a location convenient to the employee or via telephone.

 

  • Allowing the injured party to visit with friends and co-workers on the employer’s premises can develop a sense of worth.

 

  • Offering a broad selection of return-to-work opportunities.

 

 

Conclusions

 

Effective injury response goes beyond having a First Aid kit on hand and calling 9-1-1.  For proactive stakeholders, it requires exceeding the minimum expectations to build a bridge of trust and promote a positive relationship with the injured worker.  While this takes effort, it can reduce costs in your program and pay dividends via cost savings.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

CMS Provides Another Piece of the Puzzle on Future LMSA Policy

While the Centers for Medicare and Medicaid Services (CMS) has yet to formally issue a policy regarding review of Liability Medicare Set-Asides (LMSAs), since a June 2016 announcement that it was considering expanding the WC MSA review process to liability and no-fault, CMS has nonetheless provided pieces of the puzzle which will ultimately make up a liability and no fault MSA review process. The most recent piece of the puzzle is an announcement by CMS that effective 10/1/2017, no Medicare payments are to be made to medical providers where a Liability Medicare Set-Aside (LMSA) or No-Fault Medicare Set-Aside (NFMSA) exists.

 

 

Directive To Deny Payment For Care Covered Under LMSA or NFMSA

 

The announcement comes via the issuance of a CMS MLN Matters article directed to physicians and other medical providers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries. It directs these MACs to deny payment for medical care that is covered under an LMSA or NFMSA as identified in the Common Working File (CWF).

 

To clear up some of these technical terms, MACs process Medicare Part A and B payments to medical providers on behalf of Medicare. A Common Working File (CWF) is maintained by the CMS Benefits Coordination and Recovery Center (BCRC) and contains information on a particular claimant’s Medicare eligibility and, importantly, when Medicare should be considered secondary such that payment to a medical provider should be denied and directed instead to the primary plan.

 

BCRC presently keeps records of all WCMSAs that have been approved by CMS and funded through settlement (This is why CMS requires final settlement documents be submitted to BCRC post-settlement). The WCMSA funding information is placed in the CWF so that the MACs deny payment for medical care associated with the WCMSA until the WCMSA is exhausted. This directive from CMS makes this same process applicable to LMSAs and NFMSAs.

 

 

How Can Medicare Deny Payment Based on Processes That Don’t Exist?

 

In response to this announcement, you would be correct in asking, how can CMS deny payment for medical care based upon an LMSA an NFMSA process that does not yet exist? Putting aside that some CMS Regional Offices have reviewed and approved LMSAs at their own discretion for quite some time, this does pose a very good question. CMS responds as follows:

 

CMS will establish two (2) new set-aside processes: a Liability Medicare Set-aside Arrangement (LMSA), and a No-Fault Medicare Set-aside Arrangement (NFMSA).

 

 

New Set-Aside Process Will Be Put In Place At Future Date

 

So CMS readily admits the new set-aside processes will be put in place at some point in the future. Such future date has already been tentatively set based upon CMS’s release, in December 2016, of its request for proposals for the new Workers Compensation Review Contractor which includes an optional provision to expand reviews to LMSAs and NFMSAs effective July 2018 (See prior blog post: CMS MSA Review Expansion to Liability Planned for 2018). Consequently, this directive to the MACs is implementing medical payment processing changes which will be required to be place once the LMSA/NFMSA review process is made available.

 

It is important to keep in mind that CMS has yet to release any guidance on such an expansion of the WCMSA review process to liability and no-fault and particularly how such a process would differ from that created for WC. Also note that CMS does not state that effective 10/1/2017 the MACs are to deny payment for all post-liability settlement injury-related medical care, rather, they are to “deny payment for items or services that should be paid from an LMSA or NFMSA fund.” The funds must exist for denial to occur. Accordingly, over 2017, as more pieces of the puzzle come together on CMS’s Liability and No-Fault MSA review policy, Tower MSA will provide further interpretation and guidance on what will be one of the most significant developments in MSAs since CMS formalized the WC MSA review process in 2001.

 

 

 

Author Dan Anders, Chief Compliance Officer, Tower MSA Partners. Dan oversees the Medicare Secondary Payer (MSP) compliance program. In this position, he is responsible for ensuring the integrity and quality of the MSA program and other MSP compliance services and products. Based upon his more than a decade of experience in working with employers, insurers, TPAs, attorneys and claimants, Dan provides education and consultation to Tower MSA clients on all aspects of MSP compliance. Contact: (847) 946-2880 or daniel.anders@towermsa.com

 

Workers’ Compensation Prescription Drug Spending Decreased 7.6% in 2016

St. LOUIS, Apr. 4, 2017 – Express Scripts (NASDAQ: ESRX) lowered prescription drug spending for workers’ compensation payers by 7.6 percent in 2016, according to the 11th edition of its Workers’ Compensation Drug Trend Report.

 

“In a year when many payers wrestled with drug price increases that dominated the news, Express Scripts protected clients from this impact,” said Dr. Brigette Nelson, senior vice president of workers’ compensation clinical management at Express Scripts. “By practicing pharmacy smarter, we helped clients balance appropriate care for injured workers while keeping costs down.”

 

 

Decrease in Opioid Use Drives Down Trend

 

In 2016, opioids remained the most expensive therapy class at $391.35 per user per year (PUPY). Thirteen of the top 25 workers’ compensation medications were opioids.

 

However, for the sixth year, overall opioid trend decreased. In 2016, trend decreased 13.4 percent due to a combination of Express Scripts’ clinical solutions, aggressive client management, and state and federal opioid regulatory trends.

 

This stark decrease in overall pharmacy trend — heavily driven by decreased opioid utilization — proves key stakeholders are taking action to combat the epidemic of opioid abuse and misuse:

 

  • Payers: Through point-of-sale programs, physician outreach, patient education and advanced analytics, Express Scripts’ solutions enable payers to combat the safety and cost concerns associated with opioid use from every
  • Prescribers: Scrutiny of opioid prescribing patterns drove the creation of new guidelines from the Centers for Disease Control and Prevention (CDC), as well as the Surgeon General’s Report on Facing Addiction in America.
  • Regulatory: Many states have adopted or are considering formularies, opioid prescribing limits or other medical treatment

 

 

Bending the Curve on Compound Spending 

 

For the third year in a row, spending on compounded medications decreased. In 2016, trend was -28.6 percent. These drugs still remain very costly, yet with a 31 percent decrease in utilization, it is clear that effective management strategies can reduce unnecessary costs and waste associated with more than 1,000 clinically unproven ingredients.

 

 

Optimizing the Dispensing Channel

 

Medication dispensed directly to injured workers by prescribers may result in additional costs as the drugs are typically repackaged or relabeled and often are not subject to the same pricing regulations as those dispensed by a pharmacy. Injured worker safety is also a concern.

 

“Physician-dispensed medications lack the point-of-sale safety edits which occur at a retail or home delivery pharmacy,” Nelson said. “This puts injured workers at risk for potential drug interactions or duplication of therapy.”

 

According to 2016 data, the average cost of a physician-dispensed medication was $219.25, compared to $110.16 for a pharmacy-dispensed medication. Express Scripts Workers’ Compensation clients therefore paid an average premium of about $109 for physician-dispensed medications and bypassed pharmacist review at the point of sale.

 

When prescriptions are filled through more costly channels, such as an out-of-network pharmacy or third-party biller, payers incur additional cost, with no additional value. This results in waste in the healthcare system.

 

For long-term medication needs, drugs delivered directly to an injured worker’s home cost payers 15 percent less than those purchased from a retail pharmacy, while adding convenience for the injured worker.

 

 

Continued Vigilance for Specialty Medication Trends

 

Spending on specialty medications to treat conditions such as hepatitis C and HIV stabilized in 2016. While these drugs represent less than 1 percent of all medications used by injured workers, the extreme high cost per prescription requires payers to stay vigilant.

 

“Managing specialty spend requires clinical expertise and strategic guidance,” Nelson said. “Clinicians at Express Scripts and our specialty pharmacy Accredo® have disease-specific experience to ensure safety, promote adherence and provide individualized clinical counseling for injured workers with the most complex conditions.”

 

The comprehensive review of trends in prescription drug spending for workers’ compensation plans is available at express-scripts.com/corporate.

 

 

About Express Scripts

 

Express Scripts puts medicine within reach of tens of millions of people by aligning with plan sponsors, taking bold action and delivering patient-centered care to make better health more affordable and accessible.

 

Headquartered in St. Louis, Express Scripts provides integrated pharmacy benefit management services, including network-pharmacy claims processing, home delivery pharmacy care, specialty pharmacy care, specialty benefit management, benefit-design consultation, drug utilization review, formulary management, and medical and drug data analysis services. Express Scripts also distributes a full range of biopharmaceutical products and provides extensive cost-management and patient-care services.

 

For more information, visit Lab.Express-Scripts.com or follow @ExpressScripts on Twitter.

 

Media Contact:

Ellen Drazen, Express Scripts 314-684-5355

evdrazen@express-scripts.com

Get Serious About Developing Your Return-To-Work Policy

Imagine the following conversation:

 

Q: What is your policy on “Return to Work?”

A:  Ahh, we are all for returning injured workers back to work?

 

Sadly, this is the typical response of most employer representatives when it comes to an important topic.  A topic so important it can save your workers’ compensation program countless dollars and reduced litigation costs.  If you are one of the many employers or employer representatives who is serious about return-to-work, now is the time to develop a policy that meets the needs of your workforce and keeps the best interests of everyone in mind.

 

 

The Role of Return-To-Work

 

The role of return-to-work in workers’ compensation is multi-faceted.  It involves an employer seeking to do what is best for their employees.  It also includes people ready to seek creative solutions to complex problems.  Time spent on return-to-work is valuable in a number of ways.  These include benefits to the employee and employer:

 

  • Benefits for Employees: Most injured workers would rather be in the workforce than stay at home.  The seclusion of home has many negative psychological consequences and prolongs recovery times.  Additional benefits to the employee include increased earning capacity, a consistent and regular schedule, positive and productive mindset, a strong sense of self-worth and increased security.

 

  • Benefits for Employers: There are numerous considerations beyond increased workers’ compensation premiums that should compel proactive employers to invest in these programs.  Other considerations include controlling the hidden costs of prolonged injury, reducing future exposures (including claims for retraining or permanent total disability) maintaining productive work operations and containing costs.

 

 

Developing a Proactive Return-To-Work Policy

 

Here are some important considerations to developing an effective and proactive return-to-work policy.

 

  • Purpose: The policy should outline the general philosophy of the company. It should include how it views all employees regardless of ability.  It should also inform workers of their rights and responsibilities following a work injury.  It should note that policies covering workers’ compensation issues do not impact or supersede other legal obligations the employer may have under the Americans with Disabilities Act (ADA) or disability/leave programs such as the Family and Medical Leave Act (FMLA).

 

  • Eligibility: This part of the policy will outline the rights and responsibilities of the employer and employee.  It should cover important aspects of being out of work or returning to duty with restrictions or a modified position.  Important elements to cover include time off to attend doctor appointments and restriction requirements, if applicable.

 

  • Availability of Positions: It should be the goal of every return-to-work program to move a worker back to his or her pre-injury position and wage.  In many instances, this is not practical given physical limitations following the work-related incident.  In this case, notifying the employee of other job opportunities within the pre-injury employer and other positions is important.

 

  • Transitional Work/Assignments: Many state workers’ compensation laws govern the employee’s eligibility for ongoing wage loss benefits should he or she decide not to accept transitional or modified positions.  It is important to spell out the rights and responsibilities of the parties in these situations.  Other elements include legal requirements on how the employee is going to receive the offer of modified work and what procedures are required if they dispute the physical requirements of the position.

 

There is no set template for a return-to-work policy.  Other elements may include information on position expectations, termination of assignments, the number of hours open for a position (part-time or full-time) and rate of pay.  Interested stakeholders should also consult legal counsel given the employment issues that come into play in these complex matters.

 

 

Conclusions

 

Return-to-work is a complex issue that requires more than a mere moment of consideration by employers serious about reducing workers’ compensation costs.  When reviewing your best practices, it is important to consider the development of a policy regarding this issue.  Doing so can substantially reduce your workers’ compensation program costs.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

How To Know When To Expect Your Employee Back To Work

Employers want to know how long an employee will be off work following a workers compensation injury. There are a lot of factors that go into the answer including the nature and extent of the injury, the employee’s age, the employee’s physical conditioning, and the overall state of the employee’s health.

 

The most common types of injuries are sprains and fractures. There are several factors that determine the disability period for sprains and fractures. The first factor to consider is the nature and extent of the injury. A moderate sprained ankle heals much quicker than a compound femur fracture. To get an idea of how extensive the medical provider considers a sprain, look for the adjective before the word sprain or strain.

 

The adjectives most commonly used with sprain and strains are: 

 

  • Slight – it happened, but there is not much to it.
  • Moderate – more extensive than slight – middle range
  • Severe – more extensive than moderate – really hurting

 

To understand how extensive a fracture is, again look for the adjectives the medical provider uses to describe.

 

Fractures are normally described as:

 

  • Simple: it has cracked, but has not done anything more than a little bit of damage to the surrounding tissue
  • Closed: basically the same as a simple fracture
  • Compound: the bone has broken in more than one spot, or the fracture has created significant tissue damage
  • Open compound: the broken bone is exposed through a wound in the skin
  • Compression: in the vertebrae where a brittle bone, due to age or osteoporosis, has cracked

 

 

Other adjectives to describe fractures include (per Wikipedia):

 

  • Complete fracture: A fracture in which bone fragments separate completely.
  • Incomplete fracture: A fracture in which the bone fragments are still partially joined. In such cases, there is a crack in the osseous tissue that does not completely traverse the width of the bone.[1]
  • Linear fracture: A fracture that is parallel to the bone’s long axis.
  • Transverse fracture: A fracture that is at a right angle to the bone’s long axis.
  • Oblique fracture: A fracture that is diagonal to a bone’s long axis.
  • Spiral fracture: A fracture where at least one part of the bone has been twisted.
  • Comminuted fracture: A fracture in which the bone has broken into a number of pieces.
  • Impacted fracture: A fracture caused when bone fragments are driven into each other.

 

 

Consider Age & Conditioning

 

In addition to the nature and extent of the injury, the employee’s age is a factor. A 25 year old employee with a simple fracture will heal more quickly than a 55 year old employee with the same injury.

 

 

The employee’s physical conditioning before the injury will play a significant factor in the employee’s disability recovery time. The 50 year old employee who runs in the Boston Marathon will recover from an injury faster than a 20 year old employee who spends all his free time in front of a video game monitor.

 

 

The overall state of an employee’s health will also impact the disability time. An employee with truncal obesity, diabetes, or other comorbidity issues will recover from an injury much slower than an employee who has the same injury, but no other on-going medical issues. Additionally, the non-smoker will recover from an injury faster than a smoker, all other factors being equal.

 

 

For more information, please see:

 

 

Please note that all disability times are normal ranges, and the medical facts will determine the disability period. Hospitalization times vary greatly depending on the severity of the injury. The total disability time range is the expected length of time before the medical provider will allow the employee to return to light duty work. The partial disability time ranges is the approximate amount of time the employee should be in a light duty job.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

20 Common Adjuster Mistakes And What To Do About It

One thing seldom heard from the either the insurance company or from the third party claims administrator (TPA) is “we / I made a mistake”. Mistakes happen. The difference between the excellent adjuster and the so-so adjuster is the number of mistakes made. Claims management , supervisors ,and managers also make errors in judgment, or unwittingly commit an oversight. There will not be a list of common claims handling mistakes on the insurance company’s website or TPA’s website. Therefore, we present what are common claims handling errors seen when the claims are audited by an independent claims auditor.

 

20 Common Adjuster Mistakes

 

  1. The failure to thoroughly investigate the claims including the establishment of the nature and extent of the injuries.

 

  1. The failureto properly document the average weekly wage and to properly establish the TTD rate.

 

  1. The failure to maintain the files on a diary (a regular scheduled file review by the adjuster to ensure all needed activity has been completed).

 

  1. The failureto recognize and document subrogation.

 

  1. The failureto have Action Plans.

 

  1. The failureto read medical reports.

 

  1. The failureto monitor and control medical treatment.

 

  1. The failureto conclude claims in a timely fashion when the opportunities were presented.

 

  1. The failureto know the workers compensation laws in their jurisdiction.

 

  1. The failureto file the appropriate state forms with the Industrial Commissions and Workers Compensation Boards.

 

  1. The failureto maintain contact and rapport with the claimants.

 

  1. The failureto record in the file notes the documentation received on the file.

 

  1. The failure to utilize Independent Medical Examinations when appropriate.

 

  1. The failureto utilize nurse case managers when appropriate.

 

  1. The failureto deny unrelated medical treatment or unrelated body parts when introduced into the claim.

 

  1. The failureto attempt to return injured employees to light duty work when the medical providers approved same.

 

  1. The failureto respond to important developments on the claims.

 

  1. The failure to provide proper litigation management on the litigated claims.

 

  1. The failureof management to provide supervision or guidance to the adjusters handling the claims.

 

  1. The failureof management to maintain continuity on the claims by changing the assigned adjuster on the claim during the course of the claim. (Occasionally it is necessary on a few files but not on a majority of the claim files).

 

What To Do About It

 

When mistakes occur in claims handling, the cost of the claim goes up. The insurance premium paid by employers is impacted by both the frequency and the severity of claims. While frequency of claims carries greater weight in calculating the insurance premium, the severity of the claims – what the claims cost – also impacts the insurance premium.

 

 

There are several things employers can do to limit the mistakes made on workers compensation claims, including:

 

  • Having a published set of Best Practices and insisting the claims office abide by them.’
  • Having a designated adjuster or dedicated adjuster(s) to handle all your claims.
  • Verifying the adjuster has reviewed the Employer’s First Report of Injury and has filed all appropriate forms on every claim.
  • Verifying the adjuster has obtained the proper wage/salary information for the calculation of indemnity benefits (calculate the indemnity benefit yourself and compare with what the adjuster is paying weekly or biweekly).
  • Providing to the adjuster any information you have or receive about the claim, whether it is medical documentation, the employee’s personnel file or even scuttlebutt heard around the office.
  • Establish a regular file review. (What get’s reviewed gets done).  If you do not have the time to review the adjuster(s) work yourself, hire an independent claim file auditor to review the files and identify the strong and weak points of the claims handling on your claims.

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

8 Ways to Prepare For The Next Healthcare Reform

The great healthcare debate in Washington, D.C., left many in our industry wondering what the ultimate impact would be on the workers’ comp system.  While the proposed republican bill has failed to pass, employers and payers can still take steps to ensure they are in the best position for the status quo – or whatever future legislation may be proposed.

 

Here are some areas to consider.

 

Employee Safety & Health

 

  1. Wellness programs. If your company does not have one, this is a good time to consider the idea. Healthier employees are less likely to sustain workplace injuries or illnesses and more likely to recover quickly when they do. If your company has a program, look at its effectiveness. How do you measure its success? What is the participation rate? What kind of feedback have you received about it? Even if your wellness program is doing well, it may be time to try some new features or change it up a bit to encourage increased buy-in. If possible, connect wellness initiatives with nurse case management.

 

  1. Focus on older workers. If you’ve thought about taking steps to increase safety and health among aging workers, now is a good time to do so. Improve the lighting, implement efforts to ensure hallways are free of obstacles, and look into assistive devices to reduce bodily strain.

 

 

Fraud Concerns

 

  1. Step up investigations. You want to make sure you’re not hit with claims that are not work related; so when an injury does occur, make sure you don’t skip steps to uncover what really happened. Talk to witnesses, review any video footage, look at the timeline of events.

 

  1. Scrutinize bills. To the extent possible, make sure your providers, attorneys, and others are not trying to cushion their potential income losses at your expense. If anything on a bill raises a question — ask about it. Any reputable vendor should be able to easily explain changes in billing.

 

 

Claims Management Processes

 

  1. Use workflow automation to better manage your loss trends and reduce claims leakage. You might consider data warehousing to integrate legacy systems and multiple data sources to identify fraud and cost shifting, and to better manage performance.

 

  1. Intervene early. Don’t let potentially high risk claims deteriorate. Work with your insurer or third party administrator to identify claims that could go south. Leverage clinical and specialty resources early in the claim cycle.

 

  1. Use quality providers. Make sure you’re working with high quality partners, to help expedite claims and get your injured employees back to function and work. Medical providers should be outcomes-based with good track records of delivering the best care. They should also have a comprehensive understanding of occupational health. If not, look for new providers or educate those in your network.

 

  1. Check the paperwork. Make sure your policies and procedures relating to employee health and safety are up to date and easily available to employees. If you have a drug-free workplace policy, for example, make sure it includes any recent related changes in your jurisdiction. Any relevant portion of the employee manual should also be reviewed and changed where needed.

 

 

Conclusion

 

At the moment it seems healthcare is going to remain unchanged.  However, whether or not there are future changes proposed, it behooves stakeholders to be prepared.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

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