Using Data to Make Your Next Benefit Decision & Other Top News Tidbits

Broadspires’ Danielle Lisenbey Featured in Influential Women in Re/Insurance 2017

 

The risk transfer business remains a male-dominated industry although that is changing quickly. Instead of focusing on lack of woman in our industry, we instead focus on the talent that does exist – and how this pool is growing and maturing by the day.

 

 

Using Data to Make Your Next Benefit Decision

 

By 2020, 83% of employers will offer a consumer-directed health plan (CDHPs). These plans are characterized by cost sharing between employer and member, where high deductibles and out of pocket limits are the tradeoff for lower premiums and tax benefits.

 

As consumers find themselves responsible for a larger portion of their healthcare bill, Express Scripts is committed to protecting patients by improving health outcomes while driving down costs. We do this by leveraging vast data insights that individuals can actually act on.

 

 

Preventing Falls: Make Your Health a Priority

 

Having a health problem can make you more likely to fall. Taking certain kinds of medicines may also increase your risk of falls. So, improving your health can help you avoid a fall. Work with your healthcare provider to manage health problems and to review your medicines. If you have your health under control, your risk of falling is lessened.

 

 

Arizona Full and Final Settlements: What You Need to Know

 

As of November 1st, Senate Bill 1332 will allow for Arizona full and final workers’ compensation settlements. This new law allows future medical claims to be settled full and final, meaning they cannot be re-opened or changed in any way. Prior to this change, injured workers reserved the right to re-open claims for added medical treatment if the injury worsened or required additional care.

 

Opioids in the MSA… Challenges and Strategies

 

If seeing the word opioids one more time doesn’t trigger some sort of reaction, whether sadness, anger, desperation,  or possibly hope at what appears to be traction to ‘Turn the Tide’ of addiction, then I can only surmise that you must live under a rock!  That certainly isn’t the case here, as in our world of MSP compliance, the word opioids is either read, spoken or written every single day.  It permeates our industry and our lives.

 

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO 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/

 

©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.

 

The Art – 7 Considerations When Using a Structured Settlement

They say the only certainties in life are death and taxes; but annuities can also be included on the short list. Among investments, annuities are one of the few that are virtually guaranteed.

 

That fact bodes well for injured workers concerned about their immediate and long-term financial needs. Well-designed structured settlements that are funded through annuities are tax-free, guaranteed, and incur no risk.

 

Workers’ compensation stakeholders who utilize them can ensure injured workers and their families are fully protected. The key is to find partners who have a deep understanding of these financial vehicles and the insight to identify the true needs of those affected.

 

 

When & Why Structured Settlement

 

Structured settlements are available to injured workers to settle their claims. They are an alternative to taking a set amount of cash in one lump sum.

 

While structured settlements have been around for decades, there are many misconceptions.  They may not be appropriate for every injured worker, they are certainly worth considering on every settlement case.

 

One reason injured workers may opt for a lump sum over a steady income stream is the belief they can get a better rate of return and end up with more money on their own. Unfortunately, there are ample studies showing that just isn’t true. The longer time goes on, the more people who have chosen a lump sum say they have less money than expected and not enough for living expenses. Along with the tax-free status is the time value of money. In the end, it adds up to being able to meet financial obligations long term with money paid out through a structured settlement.

 

Having the income stream from a structured settlement funded through an annuity — as most are — assures there are no associated taxes, which makes a significant difference compared to normal investments. To get the same net rate of return from a typical investment compared to a tax-free annuity would often require putting the money in a high-risk vehicle with a steady, high interest rate, something that is very difficult and rare.

 

One survey of 1,000 people presented them with a hypothetical scenario and asked whether they would prefer a lump sum payment or a structured settlement. The majority chose a single payment and cited financial independence, paying off a large loan, and flexibility as their reasons.

 

The fact is, changes in laws and regulations since the 1970s have made structured settlements very flexible, along with guaranteed elements. Structured settlements today come in all sorts of shapes and sizes, depending on a person’s needs. For example, many people, take a sizable amount of cash up front to pay medical bills and/or debts, then have the rest paid out in certain increments at over time. While the bases of structured settlements are the same, it’s important to understand current and future needs to get the right formula.

 

 

The Art – 7 Considerations When Using a Structured Settlement

 

Structured settlements need to be constructed differently for each injured worker, depending on his needs. There is no ‘cookie-cutter’ settlement. Each requires a basic life care plan with future needs and expenses included.

 

One or more annuities may be included in a structured settlement. These should be purchased from high-rated insurance companies to ensure financial strength.

 

Among the factors that may be included in are the following:

 

  1. Immediate expenses. Many structured settlements include upfront cash to cover such things as medical expenses, ongoing debts/loans, and attorneys’ fees.
  2. Monthly payouts. A typical structured settlement would also include a set amount per month for a specified number of years, and include a cost-of-living adjustment. For example, the amount could cover mortgage and other associated payments for 20 years.
  3. College education. If the injured worker has children, money would likely be included for college education. In addition to a monthly expenditure, a structured settlement could include, for example, an annual payment of $15,000 for a certain four-year period.
  4. Retirement funding. Some structured settlements also include a lump sum payment at the anticipated retirement year to supplement Social Security. Alternatively, a monthly amount on top of that previously established could kick in with retirement, to help pay for travel and purchases for grandchildren.
  5. Non-life contingent payments. Structured settlements can also allow for designated beneficiaries to continue receiving the future payments tax-free in the event of the injured worker’s premature death.
  6. Public Benefits. Even a small settlement can disqualify an injured worker from public benefit programs like Supplemental Security Income and Medicaid. A special needs trust funded with a structured settlement can help maintain eligibility and protect the employee’s long-term security.
  7. MSA. Medicare’s interests must be considered when someone settles past, present or future medical expenses to avoid jeopardizing these benefits or expose the injured worker to fines or penalties. In some cases, a Medicare Set-aside may be needed.

 

Summary

 

Injured workers and payers looking to close claims may find the best value for all sides through a structured settlement rather than a lump sum payment. When an experienced structured settlement expert is involved and the employee’s current and future needs are included, all stakeholders can see a win-win.

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO 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/

 

©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.

63 Items To Look For In Your TPA or Carrier Claim Report

Your company is self-insured and hired a Third Party Administrator (TPA) to handle your workers’ compensation claims.  As part of the servicing agreement with your TPA, the TPA agreed to complete a written report within 14 days of assignment on new workers’ compensation claim s with reserves over $10,000.   Here are some guidelines as to what the reports should contain.

 

All reports should be laid out in a consistent format for ease of reading. The reports should provide you with all essential information without you having to go on-line to read the entire claim file. The better adjusters will always use the same format, but if the adjuster does not, feel free to provide the following reporting sample outline for captions and sub-captions to the adjuster.   This is the minimum you should expect to see in the initial claims’ reports.

 

 

Coverage

 

Some adjusters will want to skip the coverage caption figuring your company would not have reported the claim if it was not covered. That can be a big mistake if your deductible, self-insured retention or other terms of coverage change at renewal or any other time).

 

  1. Policy number (if one is assigned) and policy dates
  2. Applicable deductible, self insured retention , endorsements
  3. Alternative or duel coverage

 

 

Description of Accident

 

  1. Date and time of day
  2. Place (Where the accident occurred on the premises, or other location if off the premises)
  3. What was the employee doing when the injury occurred
  4. Regular job for the employee or outside the norm for the employee
  5. Date the accident was reported to supervisor or manager
  6. Date the accident was reported to the claims coordinator for your company

 

 

Insured

 

  1. Name of Unit/Division/Branch
  2. Location (Street address, City & State), also the location code number (if one is assigned)
  3. The nature of the business/work performed at this location

 

 

Employee

 

  1. Full name
  2. Age/Date of Birth
  3. Number and relationship of dependents ( in states where dependents affect indemnity benefits)
  4. Detailed job description/occupation
  5. Length of employment, length of time in current job description
  6. Prior injuries, both work com and liability claims reported to the index bureau
  7. Summary of recorded statement or interview
  8. Social security (edited for confidentiality if required by state law)
  9. Education level of employee
  10. (If represented) Attorney for employee—name, address, expertise

 

 

Jurisdiction

 

  1. Statutory state benefits
  2. Federal (Longshore & Harborworkers Act, Federal Employment Liability Act, Jones Act)
  3. Potential Employers Liability exposure

 

 

Compensability

 

  1. Why the claim is compensable
  2. Why the claim is being controverted

 

 

Reserves

 

  1. Amounts for indemnity, medical, legal, rehabilitation and other expenses should be individually stated
  2. Adequacy for life of claim should be discussed

 

 

Indemnity Benefits

 

  1. Average weekly wage amount and how documented
  2. Compensation rate and how calculated
  3. Specific benefits due to permanent impairment, scarring (where allowed), etc.

 

 

Injury

 

  1. Nature of injury
  2. Attending physician(s) and specialists identified
  3. Hospitalization, discharged date or anticipated discharge date
  4. Type of future medical care and projected length of care
  5. Estimated length of temporary total disability
  6. Estimated Return To Work date, modified duty and/or regular duty
  7. Independent Medical Evaluation (if the jurisdiction allows more than one, if not the IME should be saved until the employee is at maximum medical improvement)
  8. Permanent impairment rating (expected or assigned)

 

 

Rehabilitation

 

  1. Vocational
  2. Physical
  3. Length of rehabilitation
  4. Facility or provider
  5. Reasons/justification for rehabilitation

 

 

Second Injury Fund (in states where it still exists)

 

  1. Nature of employee’s prior injury, disability or medical condition
  2. Statutory requirements to access the Second Injury Fund
  3. Self insurers’ rights of recovery

 

 

Subrogation

 

  1. Identification of responsible third party
  2. Negligence theory
  3. Expert testimony (if needed)
  4. Preservation of evidence
  5. Issues affecting pursuit of subrogation such as hold harmless agreements, contracts, business relationships, possibility of a cross-claim against your company
  6. Recovery amount
  7. Employee’s right of recovery

 

 

Litigation/Legal Expense

 

If the claim is being contested before a workers’ compensation board or in a court, the following information is needed:

  1. Defense attorney’s name, firm’s name, address
  2. Issue(s) in contention
  3. Probable outcome
  4. Legal budget

 

 

Action Plan

 

  1. Steps to be taken to move the file forward
  2. Barriers to resolving the claims

 

 

Diary for Future Reports

 

  1. Date an updated status report will be provided

 

 

Attachments

 

  1. List of attachments or documentation being provided, if any

 

 

Summary

 

The adjuster’s report should provide you with all the information needed to keep you totally informed about the claim in question.   If after reading the adjuster’s report you still have questions, add a caption or category to reporting format to answer your question on all future work comp claims.

 

The adjuster should provide status reports on a regular basis of 30 days to 90 days depending upon the developments on the claim. Status reports should not repeat the information provided in the initial reports, but only cover the categories where there has been a change or a new development that impacts the claim.

 

Proper reporting by the work comp adjuster will make your life easier in the management of your self-insured program.

 

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO 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/

 

©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.

7 Ways to Protect Employees from Work Related Auto Fatalities

Distracted- and drowsy-driving fatalities are down; however the overall number of motor vehicle crashes was up in 2016. The latest figures from the Department of Transportation’s National Highway Traffic Safety Administration reflect the number of motor vehicle fatalities in all 50 states and the District of Columbia.

 

Overall, there were 37,461 motor vehicle deaths last year. The fatality rate of 1.18 deaths per 100 million vehicle miles traveled represents a 2.6-percent increase from the previous year. The vast majority of crashes are linked to ‘human choices,’ according to the NHTSA. The figures point to the continued need for employers to keep their employees safe behind the wheel — especially the youngest and oldest workers.

 

 

The Facts

 

While there was an overall 2.2 increase in the number of vehicle miles traveled on U.S. roads last year, that doesn’t account for the 5.6 percent increase in fatalities. Distracted related deaths decreased by 2.2 percent and drowsy driving fatalities were reduced by 3.5 percent, but other factors increased:

 

  • Drunk-driving deaths were up by 1.7 per­cent.
  • Speeding-related deaths increased by 4 percent.
  • Failure to wear seatbelts contributed to an increase in deaths of 4.6 percent.
  • Motorcyclist deaths increased by 5.1 percent and were the highest since 2008.
  • Pedestrian deaths were up by 9 percent, the most since 1990.
  • Bicyclist deaths increased by 1.3 percent, and were the highest since 1991.

 

Workers who are especially at risk of motor vehicle fatalities include the young — aged 16 to 24 — and older workers, of at least 55 years.

 

  • Between 2011 and 2015, 470 workers in the younger age segment were killed in auto crashes at work. That accounted for more than 1/4 of all work related deaths in that age bracket.
  • Motor vehicle crashes account for nearly 1/3 of all work-related deaths among workers age 55 or older.

 

 

Develop Policies

 

All employers who have workers that drive for business should have specific policies to ensure safe driving.  These should include:

 

  • A ban on texting and hand-held phone use while driving.
  • A prohibition on driving while a worker is under the influence of alcohol, illegal drugs or certain prescription and over-the counter medications that may impact driving.
  • Periodic training provided to promote safe driving strategies and discuss changes in road rules.
  • Breaks during the work shift.
  • Allowance for workers to take short naps — 30 minutes or less — in a safe location if they are tired while driving.
  • Information on sleep disorders and other illnesses that may impact drowsiness.

 

Special attention should be paid to younger and older employees to ensure their safety on the road.

 

 

Protecting New Drivers

 

Young workers have the highest crash rate based on miles driven, largely due to their inexperience. They are typically less able than other workers to recognize and respond to traffic risks.

 

There are several steps employers should take to prevent accidents among the youngest workers.

 

1) Know the law. Young workers are restricted in terms of whether, when and how long they can drive for work.

  • Workers age 16 and under in non-agricultural jobs may not drive for work.
  • Workers age 17 may drive on public roads in non-agricultural jobs, but are limited by time and task: They must first complete a state-approved driver’s ed course and have no record of moving violations at hiring time; Their driving time may not exceed 33 percent of their workday, and 20 percent of their work week; Their driving must be done only during daylight hours.; They can only drive vehicles that are no more than 6,000 gross vehicle weight and have seatbelts for all occupations.; They are not allowed to tow another vehicle.; They cannot drive more than a 30 mile radius from the primary work place.  Workers under age 21 are generally not permitted to drive a commercial motor vehicle across state lines.

 

2) Do background checks. Before hiring a young worker to drive, make sure he has a valid state license and has no record of moving violations.

 

3) Take precautions. Before sending the worker out on the road, make sure the assignment follows state laws for such things as nigh driving restrictions and transporting other teens. Additionally, make sure the worker has been trained on the safety features of the vehicle to be driven.

 

 

Reducing Risks for Older Workers

 

While older workers are more likely to adhere to safety regulations – such as wearing seatbelts, they have twice the risk of dying when they do get into a work-related accident compared to younger workers.

 

Part of the reason they have accidents is due to a decline in their physical and mental abilities that coincide with the aging process. Eyesight, hearing, motor skills and cognitive function can deteriorate with age. Employers should consider the needs of older workers in their safety and health programs.

 

4) Reconsider the options. Reducing the amount of time older workers are driving can prevent accidents. Consider whether work can be done without having to drive. If they must drive, make sure their schedules are such that they can obey speed limits to complete the tasks.

 

5) Offer some leeway. Allow drivers to talk with their supervisors to adjust their driving hours if they have problems with night vision, for example, or if they are too tired or uncomfortable driving in bad weather.

 

6) Base driving on their actual ability. Conduct periodic assessments of drivers to determine their proficiency, and restrict driving based on them.

 

7) Inform. Older workers who take a variety of medications may be unaware of the effects they can have. Offer information about the potential effects of prescription and over-the-counter medications on driving.

 

 

Conclusion

 

Preventable motor vehicle crashes take an unnecessary human and financial toll on businesses every day. By focusing on the reasons and taking steps to alleviate them, payers can keep their workers safe and on the job.

 

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO 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/

 

©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.

Don’t Plan to Fail: Best Practices for Addressing Medicare Advantage Plan Reimbursement

Benjamin Franklin must have been contemplating Medicare Advantage Plan reimbursement when he uttered one of his famous lines: “If you fail to plan, you are planning to fail.” Over the past few years Medicare Advantage plans have increasingly been seeking reimbursement for payments made stemming from workers’ compensation, liability and no-fault claims, otherwise known in Medicare circles as Non-Group Health Plans (NGHPs). Despite these increasing efforts, many NGHPs have not planned how they should respond to such reimbursement claims.

 

With the goal of working with our clients to educate and assist with proper planning, earlier this month, Tower MSA was privileged to have Brian Bargender, Subrogation & Other Payer Liability Business Consultant for Humana, participate in a webinar to discuss reimbursement rights of Medicare Advantage plans, and best practices for investigating and responding to reimbursement claims. For those who were unable to attend, or would like a refresher, we are pleased to provide below a summary of Mr. Bargender’s presentation along with some final thoughts and takeaways.

 

 

Medicare Advantage Plan Background

 

Part C Medicare Advantage plans (MA plans) are alternative delivery mechanisms for traditional Medicare benefits (Parts A and B) provided by private companies under contract with CMS. Medicare beneficiaries have the option of choosing one of these Medicare Advantage plans during annual or special enrollments periods. The three largest MA plan sponsors (representing almost half of the available plans) are UnitedHealthcare, Humana and Aetna. As of 2017, one-third of Medicare beneficiaries are enrolled in MA plans.

 

 

Medicare Advantage Plan Recovery Rights

 

Pursuant to CMS direction, MA plans must enforce the Medicare Secondary Payer Act (MSP) and will be audited by CMS for compliance with the Act. Consequently, these plans are obligated to coordinate benefits such that MA Plan coverage is denied when a primary payer is covering treatment and when the MA plan pays, but later learns of primary payer responsibility, seek reimbursement for payments made relating to the particular workers’ compensation, liability or no-fault claim.

 

MA plans right to reimbursement, including double damages, from NGHPs under the MSP Act has been acknowledged in at least two significant federal appellate court decisions:

 

  • In re: Avandia, 685 F.3d 353 (3d Cir. 2012)
  • Humana Med. Plan, Inc. v. W. Heritage Ins. Co., 832 F.3d 1229 (11th Cir. 2016)

 

 

Medicare Advantage Plan MSP Enforcement Challenges

 

Despite CMS’s direction to MA plans regarding enforcement of the MSP Act, including coordination of benefits, the data available to the MA plans to perform this task is inconsistent and error prone. Consequently, MA plans have taken one of three approaches to MSP enforcement:

 

Inactive: Minimal effort
Reactive: Relying upon member and medical provider reporting of primary plans
Proactive: Claim screening and investigation

 

As Mr. Bargender explained, Humana is taking the proactive approach. Nonetheless, the challenges faced by Humana in identifying coordination of benefits situations has proven difficult as a result of gaps in medical provider and Medicare beneficiary self-reporting and data provided by CMS which is “too little, too late, often wrong.” Additional challenges faced by MA plans are incomplete direction from CMS and non-cooperation of Medicare beneficiaries and plaintiff attorneys to MA plan reimbursement claims. As such, Humana utilizes a multi-faceted approach of member questionnaires, public records, such as accident reports and workers’ compensation claims, and non-public records, such as data relayed by CMS, to determine possible MSP coordination of benefits and reimbursement opportunities.

 

 

Best Practices for Non-Group Health Plans and MA Plan Reimbursement

 

Humana’s proactive approach then has the ultimate goal of reimbursement for charges related to the claimed injury. Mr. Bargender shared the following basic precautions to be taken by NGHPs:

 

  • Train front-line staff on MSP basics – including MA & Part D
  • Assume older & disabled claimants have some form of Medicare
  • Be proactive when told claimants don’t have original Medicare
  • Watch for other payer info in medical records
  • Watch for notices from other payers
  • No-fault and accepted work-comp claims
  • Pay treating providers directly for outstanding medical bills
  • Be suspicious of billing gaps (other payer?)

 

And when it comes to Liability and disputed or denied workers’ compensation claims:

 

Find out who paid for medicals

  • Providers rarely wait for settlements
  • CMS “no payment” letters aren’t the last word
  • Request benefit ID card(s)
  • Ask to see other payer “no payment” letters
  • Medicare/Medicaid dual beneficiaries? …assume Part D paid Rx

 

Address MSP repayment before agreeing to settlement

  • Determine amount before settlement is finalized
  • Don’t assume plaintiff will reimburse MA plan or unpaid providers
  • What does settlement indemnification language actually accomplish?

 

In terms of negotiating and resolving MA plan claims for reimbursement, Mr. Bargender offered as follows:

 

Most MA plans are open to working with primary payers.

 

Focus on these:

  • Rationale for denying beneficiary’s underlying claim, not MA/Part D rights
  • Limits exhausted, treatment not allowed/capped, etc.
  • What’s related (was it in the demand or release?)
  • Errors in plan’s payment ledger
  • Extenuating circumstances

 

Not on these:

  • Reasonableness of amounts paid by MA
  • Claim filing time limits vs. MSP statute of limitations
  • Contract language” in the MA Evidence of Coverage document

 


Final Thoughts and Takeaways

 

In working with Mr. Bargender and the subrogation team at Humana, we have found them very helpful in promptly identifying specific reimbursement claim information where the claimant was enrolled in a Humana Medicare Advantage plan. Further, they are open to understanding the particular liability issues and bases for settlement, something not typically found with the Medicare conditional payment recovery contractors.

 

The primary takeaway from Mr. Bargender’s presentation is NGHPs must be proactive in identifying whether a Medicare eligible claimant is enrolled in a MA plan, and, if so, investigate whether the plan is seeking reimbursement for payments made related to the claim. As there exists no central database accessible to NGHPs in which to identify the MA plan a claimant is enrolled, the claims handler must be proactive in inquiring of the claimant whether they are enrolled in such a plan.

 

Tower MSA Partners will work with our clients to assist in identifying whether a claimant may be enrolled in a MA plan, identify the name of the plan and investigate whether such plan is seeking reimbursement stemming from the claim. We stand ready to assist you through general consultation on ensuring your MSP compliance program appropriately addresses MA plans or consultation on MA plan recovery* in a specific claim.

 

*While we did not delve into Part D Prescription Drug plans in this article, such plans arguably have similar reimbursement rights as Part C Medicare Advantage plans. NGHPs should also be aware of the potential for reimbursement claims from these plans.

 

 

 

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

The Most Common Belief Is NOT A Factor In Workers’ Comp Success

So imagine the scene. You’re at a party or a social gathering, and you’re talking in a conversation with someone that’s an acquaintance. Somebody that you know, but you don’t know really well. And you start talking about what it is that you do for a living.

 

 

“We’ve Been Really Lucky to Not Have Many Injuries”

 

And you mention that you’re a workers’ compensation professional. And the response during that conversation is, “Oh, we’ve been really lucky over the past number of x weeks or years that we haven’t had very many injuries at my company.” Or they’ll say, “We’ve been really unlucky, and we’ve had a rash of injuries over the past number of weeks, months, or years.” And you’re likely going to respond with the socially appropriate response that’s says, “Yes, we’ve been really lucky or unlucky, too.” But you’ll know in your heart, or you should know in your heart, that success in injury prevention and injury management has very little to do with luck.

 

 

Success in Workers’ Compensation Has Very Little to Do With Luck

 

Success in injury prevention and injury management has very little to do with luck. Hello, I’m Michael Stack, CEO of AMAXX. And there’s two points that I want you to take out of this video lesson today. One is internalizing that fact, that luck, while it may be a small percentage of your success, it’s a very small percentage. Your proactive planning, your culture, your system that you set up to prevent injuries as well as care for those employees after injury to get them successfully back to work is going to be the major dominating factor in the success or failure of your program.

 

 

First Step is to Clarify Workers’ Comp Vision

 

The second piece that I want you to take out is the reason that people say, luck is the major dominant factor in our success or failure in workers’ comp, it’s because there’s no vision, there’s no goal for what you’re trying to accomplish. Because that’s the first step on that path to workers’ comp mastery and workers’ comp success. So here’s how you get started with clarifying that vision for your organization.

 

I want you to answer this question:

 

If I were to wave a magic wand, and in one year from today, you have the perfect workers’ compensation, injury management and prevention program.

 

Answer these three questions:

 

  1. What does that look like for your organization? What does that look like for your organization? If you had this perfect program, draw that out in a paragraph sentence type format.
  2. What does that feel like for you, as the person that designed and implemented this program successfully? What does that feel like for your employees?
  3. What has that done for your culture? What has this done for your organization? What has it done for your employees’ values? What has it done for your employees’ attitudes? What has it done for the culture of your organization? And what has it done for your company’s bottom line?

 

If I were to wave a magic wand and in one year from today, you could have the perfect workers’ compensation program, what does that look like at your organization? What does that feel like for you and your organization? What has that done for your career, what has that done for your employees, what has that done for your company’s bottom line? If you can clearly define that vision, you are well on your way to success. Again, I’m Michael Stack with Amaxx. And remember your work today in workers’ compensation can have a dramatic impact on your company’s bottom line. But it will have a dramatic impact on someone’s life. So be great!

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO 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/

 

©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.

 

6 Tips to Battle Workers’ Comp Comorbidities

Proactive workers’ compensation claim management teams are constantly seeking opportunities to reduce workers’ compensation costs and promote efficiencies.  One such area to address these concerns is battling comorbidities and developing a healthier workforce.  Doing so in an effective matter will reduce the cost of claims and significantly benefit your program.

 

 

What Are Comorbidities?

 

From a medical point of view, a “comorbidity” is a medical condition that exists along with other injuries or ailments.  An example of this in the context of a workers’ compensation claim is a claimant suffering from a work-related injury who has another medical condition.  Common examples include high blood pressure, diabetes, cancer or mental health conditions.  Modern medicine even classifies smoking and use of tobacco as a comorbid condition.

 

It is important for members of the claims management team to identify claimants who have a comorbid condition.  This is because they may often require additional medical care and treatment, or there could be an aggravation of the underlying condition as the result of the work injury.  The ramifications of this include prolonged disability, increased medical care and treatment, addiction to prescription pain medication or permanent and total disability.

 

 

Dealing with the Immediate Issues

 

Once a claim handler is aware of an injured worker with a comorbid condition, it is important to position the matter to avoid future long-term exposures.  In the short-term, members of the claims management team need to monitor claims with care.  This includes a number of actions to keep on top of the claim:

 

  • Frequent contact with the employee to monitor progress and evaluate for referral to defense counsel;

 

  • Determine if or when the employee should be seen for an independent medical examination. Depending on the nature of the claim and comorbid condition, this may require the use of multiple medical experts.  This is frequently common in claims involving an underlying psychological and/or psychiatric condition; and

 

  • Opportunities to put the claim into litigation, as necessary.

 

 

Techniques for Successful Claim Management

 

It is also important to work with interested stakeholders to seek solutions that will develop a healthier workforce to mitigate future claims. Examples of being proactive in this area include:

 

  • Developing a smoking cessation and tobacco dependence program. It is well-documented that workers’ compensation claims involving a smoker/tobacco user cost significantly more when compared to their non-tobacco using counterparts.  While fewer Americans are using tobacco, a certain segment of the workforce continues to use these products;

 

  • Encourage employers to offer gym memberships (free or reduced) and other weight loss programs. Other options include encouraging people to take regular breaks to stretch and move around.  This is also an opportunity for employers to seek out medical insurance programs that offer discounts for members who undergo biometric testing; and

 

  • Increasing the level of education workers have regarding their eating habits. This includes the development of relationships with organizations and registered dieticians who provide information on better food selection, preparation and consumption.

 

 

Conclusions

 

Having an effective workers’ compensation program goes beyond knowing the law and working your claim files in an effective matter.  Proactive claim management teams need to address the underlying issues of a claim such as claimants with comorbid conditions to reduce costs in a program.  This includes addressing issues present on a file and promoting a healthier workplace to mitigate the risk of expensive future claims.

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO 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/

 

©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.

Reduce Work Comp Costs Through Advocacy Based Claims Management

Claims management teams are constantly seeking innovative solutions to running an effective workers’ compensation program.  This includes providing quality services to employees who sustain work injuries and being a zealous advocate for their clients.  Part of the solution that has benefited programs in an “advocacy based” model of claims management.  Studies have proven this as an opportunity to meet program objective and reduce costs in the form of quicker return to work.

 

 

What is “Advocacy Based” Claims Management?

 

Under this model of claims management, the members of the claims team seek to empower employees to improve injury outcomes and get them back to work in a timely manner.  This process requires interested stakeholders to be active in assisting injured workers at all steps of the claim. It also requires them to “go the extra mile” and empathize with the situations someone experiences following a work injury.   Part of the process can include keeping the employee informed with details so they can in turn make decisions in their recovery.

 

 

It Starts with Words

 

Words mean things—especially when you are recovering from a work injury.  This is a crucial step in understanding the tribulations someone suffering from a work injury is going through.  It also helps with perception being reality in a positive manner.

 

Changing the vocabulary used during the claims management process is important.  This helps refocus conversations and processes.  Examples include:

 

  • Claimant/employee: By not using these words and instead referring to someone as “a person injured at work,” it helps humanize the person and what they are going though; and

 

  • Claims examiner: Use of these words is often outdated and reminds someone of a faceless bureaucrat sitting behind a desk.  By referring to someone as a “claims representative,” it again humanizes the process.

 

 

Finding Common Ground

 

While members of the claims management team have a fiduciary duty to their insureds, they can also find common ground with people suffering from a work injury.

 

  • Prescription Drug Abuse: There has been a lot said and written about prescription drug abuse in the workers’ compensation system.  The common denominator among many persons who end up dying from using these medications is a personal injury.  Even people with the best of intentions can become victims of abuse by not having a strong advocate.  This can include members of the claims management team who help control the number of drugs consumed and by educating the people they work with about the dangers of these substances.  Other activities such as monitoring a person’s intake and working with their doctors to minimize the chances of abuse are key.

 

  • Injury response: A fast an effective injury response is another method claims management teams can employ to be an advocate on the workers’ compensation process.  This starts with providing employers with the necessary tools to respond after an incident.  Regular, frequent and personalized contact with a person recovering from a work injury are also key.  While it might take extra time, being active in the care a person receives buys good will and breaks down barriers in an otherwise adversarial process.

 

  • Establish expectations for all: All the main actors in a workers’ compensation claim need to take ownership over the care and recovery of an individual.  For the employee, this includes concentrating on following their doctor’s instructions on rehabilitation.  Employer representatives also need to be engaged and coordinate care with the claims management team.

 

 

Conclusions

 

Effective members of the claims management team need to be an advocate for the person involved in their claims.  This starts with empathy toward the person suffering from the effects of a work injury.  It also includes avoiding excessive use of prescription drugs and responding to an incident in a proactive manner.  Taking these steps can reduce claims and still allow for the claims representative to look out for the best interests of a workers’ compensation program.

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO 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/

 

©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.

Inside Tips & Tricks for Effective Social Media Investigation

Fraud, waste and abuse (FWA) continue to be a significant driver in workers’ compensation program costs.  The result for many programs are higher costs per claim, which are passed along to the insured.  This trickle-down effect ultimately hurts the employees, which are the people served by workers’ compensation insurance programs.  Now is the time for interested stakeholders to employ innovative and creative investigative techniques used advanced techniques in claims investigation based on easy to use technology.

 

 

Social Media: Going Beyond the Basics

 

Social media investigation continues to be an area of initial research in every workers’ compensation claims investigation.  This is based on the continued growth in it is use over the last decade.  It is also an important area to investigate given its use with all generations.  The use of Facebook is a common example:

 

  • There are currently over 1.5 billion users of Facebook worldwide. The United States contains some of the most active users on this social media platform;

 

  • Over 72% of people who use the Internet are connected on Facebook; and

 

  • Nearly 10% of Facebook users do not change the privacy settings on their account. This means there is still a significant portion of users who allow all posts and updates to be visible to the general public.

 

Pictures posted to Facebook and other social media often contain hidden metadata.  This is information stored in the background due to the user failing to adjust the settings on their smartphone or other cameras.  The result is a treasure trove of information for the taking.  This includes:

 

  • Date and time stamp information as to when the photograph was taken; and

 

  • Specific longitude/latitude information as to where the photograph was taken.

 

Using this data, someone creates a “geofence,” which tells the world when and where a specific event took place.  It also limits the ability of someone to testify otherwise.

 

 

Vehicle Tracking and Sightings

 

State and local governments have employed millions of public security cameras across the country to capture real time images of what is taking place in their communities.  Part of this technology includes the use of license plate tracking information, which records when and where a particular vehicle passes a certain location.

 

While accessing and searching this information may be time consuming, it can establish a number of items that can be useful in a claims investigation.

 

  • The location where a claimant’s vehicle has visited;

 

  • Establish a pattern of locations visited by an employee;

 

  • Verify the testimony of an employee concerning the route taken to a certain location, which is important in “traveling employee” cases; and

 

  • Accessibility of information nationwide—it is used in every major city in the United States.

 

 

Keyword Search Technology

 

Most social media platforms are driven by “keyword” search technology.  This allows all users to use various terms and locate posts and other information from all users on the platform.

 

In the context of a workers’ compensation claims investigation, any user can ethically search to find information on where someone has been.  This includes postings by organizations or events listed in the platform that tag or record the names of attendees.  Although a user has set their privacy to limit the information from strangers, the fact someone else has a posting that includes a specific person’s name allows the public to obtain information.

 

 

Conclusions

 

Members of the claims management team have lots of readily accessible information at their hands based on today’s technology.  Proactive members will learn how to harness this information to advance and coordinate surveillance on workers’ compensation claims in a cost-effective manner.  The ultimate result is lower program costs and quicker claims resolution on troublesome files.

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO 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/

 

©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.

Where to Start For Best In Class Workers’ Comp Claims Management

All workers’ compensation claims management teams should have an attitude that seeks best in class when it comes to claims management practices.  This includes a focus on injury prevention, investigation and seeking to settle cases in a timely manner.  By taking proactive steps in these areas, any claims team will be set up for success and improve processes for employers and employees suffering from work-related injuries.  It will also reduce costs in the long run.

 

 

Start with Injury Prevention and Investigation

 

Injury prevention and investigation requires members of the claims management team to be proactive.  This includes creating partnerships with their clients on all workplace safety matters.  They also must be involved on the investigation of an injury and to ensure the correct reports are made in a timely manner.

 

  • Safety Recommendations: Members of the claims management team must be able to identify safety hazards and make recommendations regarding workplace safety.  This includes a review of safety equipment being used in the workplace.  Examples of this can include a review of workplace ergonomics and the rotation of job duties in repetitive lines of work or those that require heavy lifting.  It can also include the use of forensic experts who can dissect the anatomy of an injury and suggest improvements.  Injury avoidance measures also promotes employee satisfaction and positive morale within any company.

 

  • Primary Liability Determination: Time is of the essence when it comes to the investigation of any injury.  Claim handlers must be proactive on this issue to encourage their clients to obtain an injury report immediately and assist in the identification and follow-up with witnesses.  It is also important to understand and correctly apply the law.  Failure to make accurate primary liability determinations is an unnecessary cost and increases work for all interested stakeholders.

 

  • OSHA and Other Safety Compliance: Compliance with government and industry safety standards is an important component of any workers’ compensation program.  Claim handlers can help educate their clients on the basics of OSHA reporting.  This also includes information on state safety organizations tasked with injury investigations.  Failure to report any work injury in a timely manner can result in fines and other adverse consequences.

 

 

Promotion of Settlement Practices

 

The only good file is a closed file!  This is the mantra used throughout the claims management industry.

 

If a case is investigated and handled properly, it can be positioned for timely resolution.  Failing to do so can result in extra costs to any workers’ compensation program.  There are other additional considerations to be mindful of to save a program money and earn the respect of employer stakeholders.

 

  • Subrogation: This is the practice of seeking reimbursement from another party who shares in the legal responsibility for a work injury.  In order for any subrogation action to be successful, it is important to preserve physical evidence.  Common instances where subrogation recovery comes into play includes products liability actions, motor vehicle accidents and premise liability claims (slips/falls).  Examples of this can include a power tool or piece of machinery in a work injury.  Photographs of surface conditions or accident scenes are other forms of evidence that required for successful third-party recovery.

 

  • Independent Medical Examinations: In many jurisdictions, the defense interests have one opportunity to have an injured employee be seen for purposes of an IME.  Failure to prepare for this by recovering the necessary medical documents and obtaining other background information on the claim can result in a waste of time and money.

 

  • Medicare Secondary Payer Compliance: This is an area that continues to dominate workers’ compensation claims management given the increasing number of Americans on Medicare and/or Social Security Disability.  Part of any effective workers’ compensation program includes working with legal experts or other service providers who understand these complex issues.

 

  • Structured Settlement: Structured settlements are a stream of tax-free (IRC 104(a)(2) of (a)(3)) secure periodic payments providing income to an injured worker to settle a workers’ compensation claim. In addition to providing income for an injured worker, a structured settlement can provide income and up-front cash for attorney fees, medical expenses, and related liens. A structured settlement is a valuable piece of a comprehensive claim settlement strategy and creates a ‘win’ for all parties to a workers’ compensation settlement; the employer, the payer, the injured worker, and the attorneys

 

 

Conclusions

 

Claims management teams need to focus on high standards when it comes to assisting employers and other interested stakeholders in workers’ compensation claims.  Best-in-class should be the goal when developing a workers’ comp management program.  This starts with proactive injury prevention and investigation, as well as a firm understanding of settlement tools.

 

Learn more: The Step by Step Process to Master Workers’ Comp in 90 Days

 

Michael Stack - AmaxxAuthor Michael Stack, CEO 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/

 

©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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