Improving Communication with Your Adjuster Can Save You Big Money

 

Communication Can Be Significant Problem
 
Self-insured employers unintentionally, but routinely, sabotage the results they get on their workers’ compensation claims from their third party administrator (TPA) adjusters.  Of course self-insured employers do not set out to get sub-par results from the adjusters.  And, it should be understood that most TPA adjusters want to provide quality claims handling.
 
The reasons for less than expected claim handling results vary greatly from one adjuster to another, but there are some common threads in the employer—TPA relationship that create poor claims handling. A significant portion of the claim handling problems lies in the communications between the self-insured employer and the TPA adjuster. Often an employer will assume the adjuster knows what to do (and the adjuster does), but then the employer will be dissatisfied with the claims handling results because the adjuster handled the workers’ compensation claim differently from what the employer expected. 
 
 
Improve Communications With These Recommendations:
 
·         Talk to your adjuster regularly to understand what is being done, and what needs to be done, on the larger work comp claims they are handling for you
 
·         Be ready to offer input, but don’t try to micromanage the claim handling
 
·         Provide all necessary supporting documentation as quickly as possible including Employer’s First Report of Injury, payroll records, pre-employment physicals and health questionnaires, personnel file, etc. 
 
·         Don’t surprise the adjuster with critical information that you have, or become aware of, by not providing it to the adjuster timely.
 
·         If you become aware of any new information on the claim, share it immediately with the adjuster.  If you do not, the adjuster will more than likely spend time acquiring the information you already have
 
·         Let the adjuster(s) know how you prefer to communicate – whether you prefer emails over phone calls, or phone calls rather than e-mails
 
·         Strive for timely response to all e-mails and to timely return all missed phone calls
 
·         Let your adjusters know you expect a team approach to the claims handling and show respect for the work the adjuster does to create mutual respect
 
·         Be consistent in your communications of your claims handling philosophy in regards to claims handling.  Don’t take a hard nose, defend at all cost approach to one claim and on the next nearly identical claim, overpay the claim to get rid of it.
 
·         Be consistent in your claims handling philosophy or the adjuster will quickly decide you ‘don’t know what you want’
 
·         Never let your personal like or dislike of a particular employee influence your guidance to the adjuster on a claim
 
·         Discuss with your adjuster how much a particular claim is worth and what you will be willing to pay to settle the claim.  If you withhold what you are really willing to pay on the claim, then at time of the mediation or hearing, up the ante significantly, the adjuster is going to wonder why you had both the defense attorney and him/herself spend needless hours working on the claim that could have been settled much earlier
 
·         Don’t change your evaluation of a claim unless new, pertinent information that was not previously known comes to light
 
·         With an eye toward improving your relationship with the adjuster(s) ask your adjuster(s) what can be done to improve the communications between your company and them.  Then, be willing to listen to constructive criticism and act on what is said. If you are not self-critical and not willing to acknowledge the adjuster’s input, then asking them how to improve communications will not benefit either of you
 
·         If you see an adjuster making the same mistake over and over, communicate with the adjuster about the problem, ask the adjuster how the problem can be corrected, agreed on how the issue will be handled in the future, and then follow up to be sure the adjuster makes the necessary correction(s)
 
 
Be aware that every adjuster works differently, and every adjuster is under organizational pressure to accomplish as much as possible on many other claims.  Show your willingness to work with and to assist the adjuster in getting the work comp claim resolved.  Treat the adjuster will respect and communicate your desires to get the best possible claims handling.
 
 
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com
 
Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com
 
©2012 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

The Best Tidbits of News From the Workers Comp Community

 

 
Deborah Pfeifle, CEO of Gould & Lamb, and Rafael Gonzalez, Director of Medicare Compliance and Post-Settlement Administration, are featured speakers at the upcoming PARMA conference next week in Rancho Mirage, California.  Ms. Pfeifle's presentation, "Taming the Prescription Drug Beast in Workers' Compensation", will focus on managing prescription drug programs, cost and mitigating the risk of prescription drug abuse. Mr. Gonzalez will present "An Update on Medicare Secondary Payer Compliance", which will focus on strategies for when and how to take Medicare's interests into account. Read more…
 
 
 
 
As policymakers and other system stakeholders wrestle with the rapid growth of health care costs, the debate about unnecessary medical care in the U.S. and in workers' compensation is taking on a new urgency.  Due to the importance of this topic, WCRI has dedicated a whole section of the conference on it.  Join Dr. Rebecca Yang, WCRI, and Professor Thomas Wickizer, Ohio State University, for a discussion about Unnecessary Care and the Impact of Treatment Guidelines.  Read more…
 
 
 
 
CID Review is pleased to see a report in the Wall Street Journal about the NFL and work-related injuries. After all of the media attention to chronic traumatic encephalopathy (CTE) that appears to happen after concussions, the WSJ story features a picture ofRobert Griffin III (RG III). He suffered a knee injury during a game recently. Instead of sitting out the next game (a playoff), as he undoubtedly should have, he played with a knee brace. He had his knee re-injured towards the end of the game and had surgery the following week. Apparently, he had torn the lateral collateral ligament (LCL) and the anterior cruciate ligament (ACL). He had also had an injury to the ACL during his college career.  Read more…
 
 
 
 
The percentage of older workers planning to hold off on retiring has increased 20 points within the past two years, according to a business research association analysis released Friday.
 
The Conference Board Inc. report titled “Trapped on the Worker Treadmill?” found that despite improvements in the U.S. economy over the past two years, 62% of workers were delaying their retirement plans due to financial considerations in 2012 vs. 42% in 2010.  Read more…
 
 
 
 
Effective today, the Centers for Medicare/Medicaid Services (CMS) has commenced the annual Responsible Reporting Entity (RRE) re-certification process for 2013. This process requires that the Authorized Representative at the RRE send an email to the Coordination of Benefits Contractor (COBC) EDI Representative confirming the contents of the four page Profile Report.The ProfileReport is included as an attachment to the Re-certification Email Notice and summarizes the information on file at CMS for the RRE. The email will come from 'cobva@ghmedicare.com'. Read more..
 
 
 
News From Lexis Nexis
 
Workplace Wellness Programs Return on Investment and Implementation Tips by Rebecca A. Shafer, J.D., Michael Stack, Robin E. Kobayashi, J.D.
 
“Of the many workers' compensation cost reduction initiatives available to employers today, wellness programs are by far the one of greatest interest. Employers seek statistics on ROI (return on investment), as well as costs of implementation of such programs, they hunt for information on how to implement such programs and which vendors provide them. How much can we save? What is the ROI? How quickly will I see the savings? Those are the primary concerns of employers today. Of all the articles I have written in the last 25 years, those on wellness programs have by far been most widely read and most requested for reprints.” Read more
 
 
 
 
“The Supreme Court of Kansas recently affirmed an award of work disability benefits to an undocumented worker who was ineligible for gainful employment under the Federal immigration laws. The employer contended that under Federal law, it was illegal for McDonald's (or any other employer) to reemploy the worker and that any wage loss she suffered was unrelated to the work injury but rather to her legal inability to return to work. McDonald's further contended that the award of work disability contravened public policy. The high court indicated resolution of the issue was a matter of statutory construction…” Read more…
 
 
Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.
 
©2012 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

Common Mistakes That Get Employers In Trouble on Questionable Claims

 

Employers Should Take the High Road

 

Every self-insured employer has to contend with the occasional workers’ compensation claim the employer feels is of questionable validity.  The urge is often to ‘fight fire with fire’.  However great the urge is to give the employee ‘a taste of his own medicine’, the employer must hold itself above taking the low road taken by the employee.  Just as there are laws in every state against insurance fraud, there are also laws in every state that have names such as “unfair claim settlement practices”.

 

Unfair claim practices are any action taken by the self-insured employer that are unfair, discriminatory, deceptive or misrepresent the facts.  Any inappropriate conduct by the self-insured employer can land the employer in legal trouble.  In addition, if a particular unfair practice is shown to occur with any frequency, the insurance regulatory authority will review their approval of your self-insurance status.

 

 

Common Mistakes That Get Employers In Trouble

 

While there is a wide array of inappropriate actions a self-insured employer can get into trouble for, we will discuss only the most common mistakes an employer might make that would be classified as an unfair claims practice.

 

  • Delaying the processing of a claim – the self-insured employer cannot refuse to process the Employer’s First Report of Injury form or delay sending the required forms to the employee or the required forms to the state agency that oversees workers’ compensation.

 

  • Delaying the necessary investigation of the claim – most states require the claims office to accept or deny the claim within a specific period of time.  If the claim is not accepted or denied timely, in most states the lack of a timely decision is acceptance of the claim.  Worst yet, if the employer does not investigate the claim within the frame specified by the state, the employee’s version of the claim facts is accepted without any rebuttal by the employer.

 

  • Misrepresentation of coverage – the self-insured employer handling its own claims must provide the employee making an injury claim full information on available medical care and indemnity benefits, if indemnity benefits apply.  For example:  you cannot tell the employee there is a 30 day waiting period for indemnity benefits.  Or, you cannot tell the employee that required medical services are not covered.

 

  • Withholding payment of benefits – the self-insured employer which has accepted a claim, or has received an adverse ruling on a claim, cannot withhold payment of temporary total disability benefits or the payment of medical bills in an effort to coerce a quick settlement with the employee.
  • Needless duplications – the self-insured employer cannot bombard the injured employee with extra or duplicate claim forms, or have the employee repeat medical procedures that were completed properly.

 

  • Withholding an equitable settlement – if the workers’ compensation regulatory authority has ruled that workers’ compensation coverage must be provided, the employer cannot refuse to make a good faith effort to reach a prompt and fair settlement of the claim, regardless of how the employer views the validity of the claim.

 

  • Appealing all awards – the self-insured employer cannot make it a standard business practice to appeal all awards of workers’ compensation coverage in an effort to compel employees to settle for less than they would otherwise be entitled to.

 

  • Putting forth an unreasonable settlement offer – the employer cannot offer to settle a workers’ compensation claim for permanent partial disability or permanent total disability for less than the requirements of the state statutes.  The settlement offer must be based on the requirements of the law.

 

 

 

Unfair Claims Practices Acts Designed to Protect Employer & Employee

 

The unfair claims practices acts are not designed to compel a self-insured employer to pay fraudulent workers’ compensation claims.  The unfair claims practices act statutes are structured to compel the self-insured employer to investigate thoroughly all claims. These statutes mandate the employer to either accept an employee’s work comp claim or to provide the reasons and the documentation as to why the work comp claim is not owed.

 

When the self-insured employer is confronted with the questionable claim, the employer should investigate the claim completely gathering all information from the employee, the co-workers, witnesses, medical providers, past employers, past medical providers, state agencies, the Insurance Services Office, and all other sources.  A decision on the claim should be made timely and the decision should be conveyed to the employee and to the state agency.

 

By acting in an unbiased and factual manner, the self-insured employer will avoid any violation of the unfair claim settlement practices acts.

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com.

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.

 

©2012 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

The Workers Comp Insurance Broker – Employer Relationship

 

The relationship between the insurance broker and the employer is often overlooked in the management of a workers’ compensation program.  (Employer as used in this article is any business that has employees subject to the workers’ compensation statutes of their state).  An understanding of the role and responsibilities of your insurance broker will make your interactions more productive and will strengthen your workers’ compensation insurance program.

 

The insurance broker acts in a fiduciary role for the employer.  The employer is entrusting the broker with protection of the financial assets of the employer, through the selection and obtainment of the workers’ compensation insurance.  While the broker is acting on the behalf of the employer, the broker’s actions are subject to the control and consent of the employer.

 

The broker is acting as an agent of the employer.  [The technical differences between an insurance broker and an insurance agent would be a separate blog, but for simplicity of this blog, an insurance broker is an insurance agent, but also performs a broader range of services for the clients than an insurance agent only would provide].  The agency relationship of the insurance broker from a textbook analysis includes:

 

  • Acting on behalf of the employer
  • Acting with the consent of the employer
  • Acting under the guidance and control of the employer
  • Acting as the fiduciary of the employer

 

 

Acting on Behalf of the Employer:

 

The insurance broker’s primary duty is acting in the best interest of the employer.  In most situations the broker’s and the employer’s interest align and this is simple for the broker to do.  However, there are situations where what is in the best interest of the employer does not benefit the broker as much as a conflicting interest.  For example, Insurance Company A has lower insurance rates but also pay only a 10% commission to the insurance broker.  Insurance Company B has insurance rates that are only 5% higher than Insurance Company A, but Insurance Company pays a 15% commission to the insurance broker.  The ethical broker will act on what is in the best interest of the employer, even if it is not the most beneficial approach for the broker.

 

 

Acting with the Consent of the Employer:

 

The insurance broker’s primary purpose is to represent the employer to the insurer(s).  In order to do this, the broker must have the consent and authority given by the employer.  Without the employer’s consent to act on the employer’s behalf, the broker is powerless to provide any services or benefits to the employer.  In several jurisdictions, insurance brokers require a written authorization from the employer to act as their agent/insurance broker.

 

 

Acting Under the Guidance and Control of the Employer:

 

The employer is responsible for guiding and controlling the actions of the insurance broker.  By this, we mean the employer instructs the insurance broker on the type of coverage (workers’ compensation) that is needed, the date the insurance coverage is needed, the type and number of employees to be insured, and the amount of payroll on which to base the workers’ compensation premium.  The broker has the duty to obey the instructions of the employer in obtaining insurance within the perimeters of the instructions provided by the employer.

 

The professional insurance broker will carefully follow the instructions of the employer, but will also provide assistance and guidance to the employer when the employer’s directions to the broker are not in the employer’s best interest.

 

 

Acting as the Fiduciary of the Employer:

 

The broker, acting as a fiduciary of the employer, is responsible for protecting the financial well-being of the employer.  Often employers think this means only finding the best price for insurance coverage.  This can be short sighted.  The fiduciary responsibility of the broker is to recommend the best financial protection of the employer assets both for the short term and for the long term.

 

If Insurance Company X has a lower initial price, but the broker knows Company X provides horrible claim service which results in employees being off work longer than necessary, causing more administrative headaches for the employer, and resulting in higher than normal claim cost, Insurance Company X would be a bad recommendation by the broker.  If Insurance Company Y has a slightly higher price, but provides excellent service and lower than average claim cost, the insurance broker would be violating his/her fiduciary responsibility to the employer if he/she recommends Insurance Company X without fully explaining and discussing his/her knowledge of both Company X and Y.

 

 

A Degree of Care:

 

The insurance broker has the duty and obligation to put the best interest of the employer first and should demonstrate a standard of care that shows the employer that the broker puts the customer first.  This does not mean the broker should do what is impractical or impossible.  If the broker sees that an instruction of the employer cannot be met, the broker should advise the employer of the reason(s) the instruction is not followed.

 

It should be noted that the broker often will act in what he/she believes is in the employer’s best interest in areas that have not been discussed with the employer.  When an employer finds a broker who takes the initiative to act and provide a benefit to the employer without the employer having requested it, the employer should recognize the broker is a good bet for a long-term relationship.

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com.

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.

 

©2012 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

Failure To Implement Safety Procedure Costs Employer a Bundle

 

Fell Almost 13 Feet and Sustained Serious Injuries

 

An Australian construction company was recently fined $50,000 and ordered to pay WorkCover’s legal costs after a 54-year-old man sustained serious injuries from falling almost 13 feet at a building site in Western Sydney, according to a report from the WorkCover Authority of New South Wales.

 

In August of 2009, a laborer was moving building materials at a construction site in Auburn as part of the 22-unit residential development.

 

The laborer was moving materials between the ground and second floors when he fell almost 13 feet through an exhaust hole in the ground floor onto the concrete floor below.

 

The man suffered severe head injuries, tissue damage and bruising and required emergency surgery at Westmead Hospital to relieve pressure on the brain caused by a brain hemorrhage.

 

 

Failed to Implement & Maintain Safety Procedures

 

WorkCover’s investigation found the failure to implement and maintain safety procedures, such as covering or sectioning off the exhaust hole with barricades, resulted in the serious injuries.

 

In particular the company:

 

  • Failed to ensure that the exhaust hole was securely covered;
  • Failed to conduct an inspection of the hole to ensure that it was securely covered;
  • Failed to warn persons about the risk of falling through the exhaust hole when working in the immediate vicinity;
  • Failed to conduct a risk assessment regarding working in the vicinity of an open unsecured hole and failed to implement appropriate control measures to address these risks.

 

Austar Constructions Pty Ltd was charged with breaching the Occupational Health & Safety Act 2000. The company pleaded guilty and was fined $50,000 by the Industrial Court of NSW.

 

Prosecutions Following This Incident

 

WorkCover is carrying out prosecutions against a number of companies and individuals following this incident:

 

  • Aleksic Carpentry Pty Ltd, a carpentry company that does timber door frames, window frames and other work in the construction industry and its director have been fined a total of $125,000
  • Multiplus Group Pty Ltd has entered a guilty plea with sentencing planned for the end of this year.
  • Two site managers have also pleaded guilty, judgements have been reserved.

 

This prosecution is one of a number in relation to this matter. Judgment has been made against one company and another individual. The six remaining matters are still before the court.

 

 

Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.

 

©2012 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

Employer Lucky Poor Safety Did Not Lead to Employee Death

 

13 Safety and Health Violations, 11 Are Serious
 
The U.S. Department of Labor's Occupational Safety and Health Administration (OSHA) recently cited Lapmaster Precision Finishing Services LLC in Dayton with 13 safety and health violations. Proposed fines total $65,500 following an inspection that OSHA initiated upon receiving a complaint alleging hazards.
 
"Lapmaster Precision Finishing Services is compromising its workers by failing to evaluate their exposure to and correct hazardous conditions," said Bill Wilkerson, OSHA's area director in Cincinnati. "Training workers is vital to their long-term safety and health. OSHA is committed to protecting workers."
 
Eleven serious violations include failing to develop energy control and hazard communication programs, train employees on the programs' requirements, provide machine guarding on belts and grinding machines, lock out the energy sources of machinery prior to servicing, require the use of safety glasses, ensure that workers are not exposed to live electrical parts, provide workers with personal protective equipment and training to minimize electrical exposure, train and certify employees who operate powered industrial vehicles, and properly store materials that can cause "struck-by" hazards.
 
 
Serious Violation Carries Substantial Probability of Death
 
A serious violation occurs when there is substantial probability that death or serious physical harm could result from a hazard about which the employer knew or should have known.
 
Two other-than-serious violations involve a failure to maintain injury and illness forms and a lack of written certification of a hazard assessment. An other-than-serious violation is one that has a direct relationship to job safety and health, but probably would not cause death or serious physical harm.
 
Lapmaster Precision Finishing Services is a part of Mt. Prospect, Ill.-based Lapmaster International LLC. About 48 workers are employed at the Dayton facility, which processes cast iron, steel and several metal alloys as well as plastics, Teflon, ceramics and composite materials to finish tolerances for automotive and other manufacturing applications.
 
 
Company Has 15 Business Days to Comply
 
The company has 15 business days from receipt of its citations and penalties to comply, request an informal conference with OSHA's area director or contest the findings before the independent Occupational Safety and Health Review Commission.
 
 
Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com
 
©2012 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

Miners Speaking Up About Their Safety Are Unjustly Losing Their Jobs

 

More Discrimination Requests Than Any Other Year
 
The U.S. Department of Labor's Mine Safety and Health Administration (MSHA) recently reported that it had filed 39 requests during fiscal year 2012, more than in any other year, with the Federal Mine Safety and Health Review Commission for temporary reinstatements on behalf of miners who submitted complaints of discrimination in the form of a suspension, layoff, discharge or other adverse action.
 
From October 2009 through September 2012, the department filed 79 temporary reinstatement requests – an average of 26 per year – compared to an average of seven per year from October 1993 to September 2009. Additionally, the department filed a total of 84 discrimination complaints with the commission during the same period, compared to 28 during the three prior years combined.
 
 
Miner Can Not Be Dismissed for Safety
 
According to Section 105(c) of the Federal Mine Safety and Health Act of 1977, a miner cannot be discharged, discriminated against or interfered with in the exercise of statutory rights because he or she has engaged in a protected activity such as filing a complaint alleging a health or safety violation, or refusing to work under unsafe or unhealthy conditions.
 
"MSHA strongly encourages miners to exercise their rights under the Mine Act and maximize their involvement in monitoring safety and health conditions," said Joseph Main, assistant secretary of labor for mine safety and health. "In turn, we will vigorously investigate all discrimination complaints."
 
If MSHA finds that a miner's complaint is "not frivolously brought," the agency, at the request of the miner, will ask the commission to order immediate reinstatement for the miner.
 
 
Fears Came to Light In Wake of Upper Big Branch Mine Disaster
 
Issues relating to fears of discrimination and retaliation came to light during congressional hearings held in the wake of the Upper Big Branch Mine disaster. Statements from miners and family members of the miners who died indicated that mine employees had been reluctant to speak out about safety conditions in existence prior to the April 2010 explosion, fearing retaliation by management. Testimony from UBB employees presented during MSHA's investigation also supports those claims.
 
 
Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com
 
©2012 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

What the SMART Act Really Does

 

There has been a lot of discussion recently in the insurance world about the SMART Act (Saving Medicare and Repaying Taxpayers Act) passed into law by Congress in December and signed by President Obama on January 10, 2013. 
 
Designed to Address Medicare Secondary Payer Statutes
 
The SMART Act came about due to the conflicts that occur between state workers’ compensation insurance laws and the federal laws overseen by the Centers for Medicare and Medicaid Services (CMS).  The largest area of conflict was the settlement of workers’ compensation claims that left Medicare paying for future medical treatment of injured employees. 
 
The main initiative to address this problem was the Medicare Secondary Payer (MSP) statutes.  The MSP Act requires insurance companies, including workers’ compensation insurers’ to be the primary source of payment for all injuries to people.  When a workers’ compensation insurer settles a workers’ compensation claim, MSP statutes require the insurer to either prepay the future cost of medical care, or to keep the medical portion of the claim open until the injured employee no longer needs medical care.  If the insurer failed to protect Medicare from payment of work-related, injury medical bills, Medicare can hold various parties responsible for reimbursement of the Medicare paid expense, including the insurer, employer, employee, attorneys who had represented one of these parties, and even the medical provider.
 
While the intent of MSP was proper, the MSP statutes created a whole new set of problems for insurers, employers and injured employees.  Different sections of the SMART Act are designed to eliminate some of those problems (but it is too early to determine what new problems will be created by the SMART Act).
 
 
Primary Changes in Act
 
Most risk managers and workers’ compensation managers know the SMART Act is about changes in Medicare Secondary Payer (MSP) statutes, but most don’t know the details of the changes in the law.  The primary changes brought about by the SMART Act include:
 
·       The SMART Act provides Medicare 9 months to create or to alter the operational guidelines to enforce the changes brought about by the SMART Act
 
·       A minor change is the alteration of the low dollar threshold exemption for MSP compliance. For example – the injured employee is 64 years old at the time of claim settlement (within 30 months of Medicare eligibility). Five years later the claimant incurs a single $250 medical bill.  Medicare will not pursue recovery of the low dollar claim.  The current low dollar threshold is $300.  The change in the law will allow annual adjustments in the low dollar threshold.
 
·       A major change is the mandatory $1,000 per day penalty for non-compliance with MSP is being changed to “up to $1,000 a day”.  The change was made to eliminate the fines being given to insurers, employers, employees, attorneys, etc. who had made a good faith effort to comply with the MSP law. The SMART Act gives Medicare 60 days to solicit suggestions on how the penalty provisions can be enforced while protecting those who have tried to comply with the law from being fined.
 
·       A change in the law that will probably have no impact on workers’ compensation insurers and employers is the change in the law that permits, but does not require, the use of social security numbers.  (The alternative is a Health Care Identification Number assigned to an individual).  Medicare currently uses social security numbers to track their payment history on each person.  As employers are required to use social security numbers for federal taxes, the continuation of using social security numbers in workers’ compensation claims is not expected to change.
 
·       A change for the better is the new 3 year statute of limitations on all legal complaints brought by Medicare and all actions seeking penalties. (Previously there was no statute of limitations and an insurer’s or employer’s exposure continued forever).  The statute of limitations is 3 years from the date Medicare is notified of a judgment, settlement, award or any other payment subject to their reporting guidelines. If an insurer fails to report to Medicare a judgment, settlement, award or any other payment subject to the Medicare reporting guidelines, the 3 year statute of limitations does not start to run until they are notified.
 
 
Hiccups Expected Along the Way
 
If it was only this simple.   As Medicare is a government agency which has been given the responsibility of modifying their own internal procedures to comply with the SMART Act, it is expected there will be hiccups along the way.  Also, prior changes in the MSP statutes have resulted in unintended consequences.  That could be the case with the SMART Act.  Employers, insurers, third party administrators and other parties responsible for reporting information to Medicare should continue to practice their own internal established procedures to insure compliance with MSP requirements.
 
 
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com
 
Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com
 
©2012 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

Differences between Physical Therapy and Occupational Therapy

 

Most Workers Comp Injuries Require Physical Therapy
 
To people who are not in the medical field, there is often confusion between physical therapy and occupational therapy.  People often think injured employees will have “occupational” therapy as the injury arose out of their occupation.  While there are some instances where an injured employee will need occupational therapy, in most workers’ compensation claims, the injured employee needs physical therapy, not occupational therapy.  While physical therapists and occupational therapists deal with many medical issues outside of workers’ compensation, this discussion will be limited to therapy treatment related to workers’ compensation.
 
 
Physical Therapy Restores Musculoskeletal System
 
Physical therapy is a medical service designed to develop, maintain or restore the injured employee’s musculoskeletal system.  When a treating physician refers an injured employee to a physical therapist, the physician will specify the anticipated number of physical therapy sessions needed to restore the employee to the maximum level of recovery. 
 
Upon the receipt of a new physical therapy prescription for the employee, the therapist will schedule the first visit.  At the first visit and in subsequent physical therapy sessions the therapist will:
 
·             Examine the employee’s body part needing therapy
·             Measure and test the employee’s
o   Strength
o   Range of motion
o   Balance, if applicable
o   Coordination
o   Muscle performance
o   Posture, if applicable
·             Develop a treatment plan to accomplish the physician’s goal in the allotted number of sessions
·             Provide exercises to improve muscle strength, range of motion and muscle performance
·             Provide traction and/or deep tissue massage, if needed
·             Provide cold compresses or hot packs, if needed
·             Provide ultrasound treatment or electrical stimulation, if needed
 
 
Goal to Improve Movement Dysfunctions
 
The overall goal of physical therapy is the improvement of an injured employee’s movement dysfunctions and returning the injured employee to the maximum level of musculoskeletal function.
 
 
Occupational Therapy Trains To Improve Functional Abilities
 
Occupational therapy is medical services designed to train and educate an injured person in how to modify their physical environment to improve their functional abilities. Often the occupational therapist will provide instruction on how to use durable medical equipment (prosthetics, crutches and wheelchairs) to increase the employee’s functioning.  The occupational therapist will evaluate the injured employee’s needs and will design a program to overcome the employee’s medical related deficiencies and improve the injured employee’s ability to perform the daily activities of their life.  The occupational therapist will teach the injured employee how to adapt to their physical limitations caused by the work injury.
 
 
Teaches to Adapt to Physical Limitations
 
In addition to teaching an injured employee how to adapt to their new physical limitations, an occupational therapist will often teach the employee on how to prevent and avoid injuries. The occupational therapist will recommend to the injured employee equipment, gadgets and devices that are designed to increase the employee’s safety and increase the employee’s functional ability.
 
 
Best Outcome When Physical and Occupational Therapist Work Together
 
While there can be overlap between the activities of a physical therapist and an occupational therapist, the best outcome for the injured employee is when the occupational therapist and the physical therapist work together.  For example:  An employee is involved in a horrific accident that leaves the employee a paraplegic. The physical therapist will work extensively with the employee to maximize the employee’s remaining functioning of their musculoskeletal system.  The occupational therapist will be brought in to train the employee in how to perform life functions from the confines of a wheelchair.
 
 
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com
 
Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com
 
©2012 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

How to Gather All Information Necessary for High Quality Claims Management

 

System Creates Repeatable, High Quality Results
A significant improvement in the world of claims management over the years is the implementation of an electronic system for entering and managing claims.  Used by employees of the Carrier/TPA, this is an automated system that assigns risk if certain conditions are present.  These systems allow the claims professional to gather more information in less time, follow up appropriately on responses to high-gain questions, and evaluate the information systematically. 

System Guides the Questions So Nothing is Missed
The person receiving the claim for the Carrier/TPA will have questions that need to be answered.  If the answers are positive for certain criteria, the system will assign the claim a risk number within certain values from the software. The higher the score, the more risk is assigned to the claim. The system will be used initially for 3-point contacts to the injured worker, the employer, and the medical provider.  Positive responses to certain criteria will pop up other questions to ask which ensures the adjuster does not forget anything that can be crucial to the claim.

When the claim arrives at the desk of the adjuster, they already have some risk areas highlighted that can negatively impact the claim.  This streamlines investigation and saves costs as the sooner a problem area can be addressed, the better.   

Adjusters are all under a heavy workload. Claims are in various stages of their lifespan, and some claims will get more attention than others.  This program presents a way for new claims to get the needed attention they require as early as possible.  Like any system, it also takes out a portion of the human factor.  After a while adjusters can get stuck in a rut and a question could be missed or skipped by accident.  The answer to that question could have a huge impact on the outcome of the claim.  This system can prevent those misses, which helps everyone in the end.  In no way does the system replace the need for a qualified adjuster, it does however, make every adjuster better.

Adjusters Can Receive Bonus for Following Best Practices

Bonus incentive can be another positive with the use of this program. Carriers/TPAs often use a bonus system to reward adjusters, and these bonuses revolve around timeliness of their contacts, resolution of their claims, and overall reserve savings by proactive claims handling.  A system that helps the adjuster hone in on what gets them salary bonuses is a nice incentive to ensure they are motivated to follow best practices.


Makes Process Efficient

Claims can also be classified based on their system score.  Medical only claims or minor lost time claims can be routed to the appropriate adjuster, instead of going initially to a senior level adjuster, only to be passed back to the medical only adjuster after contacts have been made.  Many Carrier/TPAs will assign the claim based on what information is listed in the injury report.  This process can be inefficient if the injury report was completed in error.  Time and money can be saved when each adjuster is making the highest and best use of their day.


Outside Vendor Usage Identified Right Away

Outside vendor usage can also be identified right away.  If the system has certain positives, it can trigger assignment to a field nurse case manager right away, instead of weeks after the claim process has begun.  This is another proactive benefit as the earlier a claim can be assigned to a vendor for help the better.  The outside case manager can get involved in the claim at the outset, instead of a month later.  This can equate to large cost savings as this month can include crucial moves within the claim, preventing missed work when a return to work could have been possible.  Another example is when the injured worker needs a medical referral to a specialist. Instead of waiting for the paperwork the case manager can get it at the appointment and send it to the adjuster the same day, instead of when the actual medical reports come in with the bill weeks later.


Summary

Several technological advancements are going on within the claim industry.  As an employer, you should be open to new technology, and trying new things in order to be more proactive in the claim process.  The same can be said for the adjuster.  Oftentimes the adjuster is very set in their ways, and there can be some resistance to the introduction to new techniques and new technology.  These advancements are made to help all parties involved to make the process more streamlined and more effective for the claims profession.


Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com.
 
Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact: mstack@reduceyourworkerscomp.com

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

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