Regular readers of our website know we are about saving employers money through reducing the cost of workers compensation. In this day of sound bites and short summaries, we offer easy ways to reduce the cost of workers compensation.
1. Report All Injuries Immediately
One of the biggest mistakes an employer can make is to delay the reporting of a workers compensation claim. The employee, whether suffering a major or minor injury, is going to understand very quickly that the employer is unconcerned about his well being when the injury is ignored. Also, the sooner the claims adjuster is aware of the injury, the sooner the adjuster can start the claims handling process moving the claim forward. The sooner the employee is treated, the sooner the healing process can start, and the sooner the employee will be able to return to work. (WCxKit)
2. Document the Details of All Injuries
The memory of the injured employee, the supervisor, and any co-workers who witnessed the accident begins to fade with the passing of time. To have the most accurate record of the claim, all witnesses and the employee's supervisor must be promptly interviewed. Write down what is said. If there are any tools, equipment or machinery involved in the accident, inspect it and document any failure of the tools, equipment or machinery. Do not dispose of anything involved in the injury until the claims adjuster has had an opportunity to inspect it or to have it inspected by an expert.
3. Keep in Contact with the Employee
Following an injury the employee is going to be concerned about: 1) obtaining the needed future medical care 2) how they are going to replace the lost income 3) losing the job if they are unable to work 4) the prospect of possibly being disabled and unable to ever return to the job.
While the adjuster can explain the workers compensation claim benefits, the adjuster does not replace the employer in the claimant's mind. The claimant is feeling vulnerable after an injury. Contact from the employer helps to reassure the claimant that the employer cares about their well being and returning them to work.
4. Keep in Contact with the Medical Provider
This is one area where most employers fall short. Even if the employer has kept in contact with the employee, the employer still needs to be in contact with the medical provider. Often the medical provider will be very cautious with the injured employee and will keep them off work the maximum time needed for full recovery if their only input is from the employee. For example, if the employee is asked by the doctor what is the maximum weight of lifting at work, the employee may honestly say 100 pounds, but that may happen only once per month. If the employer has advised the medical provider to modify the employee's position to not lift over 20 pounds, the employee will be returned to work much sooner.
5. Have an Established Return to Work Program
The easiest way to accommodate an injured employee's work restrictions is to have an established modified duty return to work program in place. If all employees know before an accident they are considered a valuable part of the company with an established return to work program, they will be more compliant with both the employer and the medical provider about working a light duty job until they are able to return to work full duty.
6. Have an Established Safety Program
This is a no-brainer. The accident that never happens does not incur any claim cost. Set up a safety program to identify those aspects of the work that potentially can cause an injury. Analyze what can be done to reduce or eliminate the risk of injury, and then do it. Establish the proper methods of doing the day-to-day task so that the potential for injuries is removed. Be sure the employees have everything they need to do their job in a safe manner. Arrange for on-going safety inspections to identify and correct any hazard.
7.Train the Employees to Work Safely
It is not enough for the employer to know the potential hazards of the job. The employees must know too. The employees must be trained to do the job correctly, including complying with all safety measures. Whether it is the safe operation of machinery, or the proper lifting techniques, the employer can reduce workers comp cost by training the employees to work safely.
8. Reward Employees for Promoting Safety
When employees think safety is “management's thing”, they are not considering themselves in the safety quotient. Involve the employees in the safe operation of the company by providing small monetary rewards to employees of a department that avoid injuries over a given period of time. The cost of the 'reward' will be far cheaper than the cost of workers compensation claims and the resulting insurance premium increase.
9. Have Your Insurance Premium Audited
Underwriters make mistakes. They can have your business improperly classified. They may also have employees misclassified or they may have the payroll information wrong for one or more categories. If the workers compensation insurance premium has risen lately and you do not know why, arrange for an independent premium audit. As the premium auditor works for a percentage of the premium reduction, it makes good sense to have your premium audited every couple of years or when there has been an increase in premiums. (WCxKit)
10. Have Your Claim Files Audited
The last thing the insurance company is going to admit is that the workers comp claims were poorly handled. When work comp claims are poorly handled, they cost more. The carelessness or oversights in claims handling comes back to the employer in the form of higher insurance premiums. If the results on the claims are not expected, hire an independent claims file auditor to review the files for proper handling, proper reserving and proper settlement.
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 website 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. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Average claim life continues to increase due to the injury severity and increasing medical treatment costs. While employers continue their involvement in processing claims to reduce costs, insurance companies/TPAs also must do all they can to save on the costs of handling and controlling
claims. Here are five ways to reduce WC costs.
1- Do not sign a contract for services with one national company/vendor
In an effort to control cost, insurance companies go to independent medical examinations (IME) or medial case management vendors for bids. The low bidder receives a non-compete contract from the insurance company/TPA for the life of the contract.
Good idea? Unfortunately low service costs are not the only criterion helping to resolve claims. These companies must proactively provide services in handling claims to resolution based on the TPA/insurance company’s criteria. If the vendor has no competition, how hard will they work in assisting you to resolve issues given they have a contract for a year – bought and paid for? (WCxKit)
2- Be aggressive with medical bill cost containment (per jurisdiction)
Bigger TPAs/insurance companies have internal
cost containment departments, otherwise known as “medical bill review” or “medical fee reduction.” Smaller places use an outside vendor for these services. There are a number of good vendors who do utilization review/cost containment at a reasonable cost. Whatever the name, their role is to reduce the costs of medical bills — procedure code by procedure code, depending on the TPA/insurance company’s participating medical network(s).
Often what is missed is some providers/clinics are open to agreeing to a lower fee. If a popular physical therapy clinic in your area nets many of your claimants, it is worth a phone call to negotiate a 10 percent under fee-reduction price in exchange for “preferred provider” status. (Check jurisdiction and legal counsel.) Think long-term. Any reduction is worthwhile especially for the price of a phone call.
3- Stay on top of your claims by being proactive
Some claims remain open due to adjuster laziness. This is especially true when the case is in litigation. By proactively handling the file and using negotiation skills, claims may be resolved months earlier instead of lingering from litigation date to litigation date without any aggressive attempts at resolution. Become involved and stay involved until the case is resolved. Prioritize your files and stay on top of them and before you know it the claim is ready to be closed.
4- Use telephonic nurse case management
When a worker is off work, every day of lost wage is an expense. You want to do everything possible to bring the worker back to the job as quickly as possible. Telephonic nurse case management (TNCM), as opposed to on-site nurse case management (NCM), gets the same result, for a quarter of the price. Cases needing a nurse usually demand more follow-up, easily done by phone. The nurse calls the employer, the claimant, talks to the treating doctor’s nurse, gets hospital records, etc. A TNCM frees the adjuster to work on other tasks the file needs, such as background checks, ISO searches, vendor assignments, etc. (WCxKit)
NOTE: The Utilization Review Accreditation Commission (URAC) is an umbrella organization responsible for certifying Nurse Case Managers (NCM); Triage Nurses (TN); Telephonic Case Management (TCM); Field Case Management (FCM); Utilization Management/Utilization Review (UM/UR); and Peer-to-Peer Review. To maintain quality control all these entities need URAC certification. URAC has stringent protocols for education, credentials, and training for these services.
5- Watch your Leakage
Leakage is the biggest animal in the “reducing claim cost” jungle. Unnecessary costs, expenses, and errors in payments add up to astronomical amounts of money — often unrecoupable. Audit your files, do file reviews, and make sure to resolve leakage when found and stop it from happening.
Summary
Claims costs are up across the board. By implementing a few proactive steps at a time, an employer working with the TPA/insurance company can stop the bleeding and keep costs as low as possible.
Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website 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. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com .
Our WC Cost Reduction Guidebook: www.WCMANUAL.com
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Should we use legal expense review companies? An attorney I know posted a joke on a Facebook page that is fairly accurate these days. An adjuster hands a new file to her counsel and tells him, “I do not want to pay anything on this file, including legal expenses.” Upon hearing this, the attorney asks why he should be expected to review, handle, and get rid of a new case for free? The adjuster advises, “That is not my problem it is yours. If you want the business, do as I ask.”
This is a current trend within the insurance business. Insurance companies have long used outside Medical Bill Review (MBR) companies, or they have internal review departments, to review procedure codes in medical bills and reduce charges per jurisdiction guidelines.
Legal expense review companies have popped up and are growing rapidly. Their purpose is to do the same bill review on legal fees for cases and reduce charges accordingly. This has led to some aggravation on the part of legal firms, who feel their bills are being reduced more and more. It seems like the carriers want more services for less cost. This can be achieved properly, however, if we use a lot of common sense here. Using the most experienced and attentive attorney on files, not the least expensive, is sometimes the best way to go, because one has to take a "TOTAL cost" approach, not a "short term cost reduction" approach. Sometimes it is better to spend more now to reduce overall expenses in the longer term.
5 Ways to Reduce your Legal Costs OR Prevent Your Charges from Being Reduced
1. Firms should use paralegals or legal assistants to review medical notes and establish a file timeline from start to current.
Certain adjusters have always used dedicated counsel — specific attorneys — to handle their cases. Sometimes the dedicated attorney is advised to handle the case from start to finish. The legal firm will use this as a chance to bill the insurance companies for all activity, including file review and setup.
The hourly charge between the actual attorney doing all tasks, and what they charge for their assistant doing the same tasks, can be very large. Attorney fees can range up to $300+ an hour, whereas legal assistants doing the same work can be billed up to one quarter of that, if not less, depending on the firm and what the insurance company has negotiated for a rate. These are called "negotiated rates."
The initial legal file setup, timeline construction, and medical records review are usually the most time-consuming tasks, depending on the size of the file and how complex it is. In one million dollar claim and the medical records took up an entire side of the office. The utilization review expert was reviewing each document, finding inaccuracies and reducing the medical expenses accordingly. An RN with 20 years surgical experience was doing this review. There can be significant cost-savings by making sure the assistant does this task, and not the actual attorney. An RN can be quite helpful on these tasks, and many paralegals are excellent.
2. Paralegals can attend mediations and initial negotiations.
The first meetings between plaintiff attorney and defense counsel are usually uneventful. Both sides review the case and offer their stance on the file. They point out differences in the case and why there is a difference in opinion. Legal expense reduction companies state the actual attorney should not be present at these hearings, since nothing of significance happens. This way you do not have to pay larger travel costs, and time charges while waiting for plaintiff counsel to show up. This can be a nice savings in your legal budget.
CAVEAT: While this is the advice proffered by legal cost reductions companies, some adjusters prefer to use the more expensive upfront strategy, which is to use the MOST qualified person on the team – usually an experienced defense attorney.
3. Legal firms should not have large charges for emails and quick phone discussions.
One thing the legal expense review companies see a lot of is overcharging for simple communication with the adjuster. A quick email response or phone call does not need to cost a quarter-hour fee, even though some firms try to sneak in such charges.
Granted, if discussion is part of a conference on an action plan or overall case review, the attorney can justify charges, and if it is a detailed discussion important to the case, the adjuster should be charged for that time. But, if the question is a simple issue, there is no need to overcharge for the service. Legal firms will often say simple communication is included in their negotiated cost for the opportunity to handle the case, and if such charges are included in their bill the legal expense company will cut the charge down or eliminate it totally.
4. Travel time to court should not be billed separately.
If your attorney goes to local court to handle most of their clients’ cases, they should not be able to bill each carrier separately at maximum rate if they were going to travel there anyway on cases for other carriers. Or, if they do, you should be aware of this practice. Most legal firms will bill separately for this reason, but there are some that will isolate each case and bill accordingly at the maximum rate.
Legal expense review will often ask, if counsel was heading to court to handle a day’s worth of case negotiations for various clients, why should each carrier have to pay a large charge for this travel? Granted, if this is a special trip, or a trip to another jurisdiction especially for your case, then the charge may be justified. But it is the job of the legal firm to handle their bills accordingly for each carrier or the charge will be reduced by the legal expense firm.
5. Law firms should be able to justify ALL billing charges on each bill, and they have the obligation to keep proper records for each case and each task they do for each carrier.
There has been a lot of backlash from legal firms about the billing reductions. One attorney said he had to “fire” his client, because their legal bills were getting reduced so much the firm was losing money by handling the case. Obviously, that is counter productive and not in the best interests of the employer, so make sure to rein in the legal bill reviewers so they do not go overboard.
Due to carrier demands, and the abundance of files for firms to handle, negotiating power is in the carrier's hands. The consensus is, if a firm does not want to reduce fees to what the carrier wants, the carrier will find a firm who will do what they want. This is creating a bad environment for attorneys since most of them have longstanding relationships with certain carriers and adjusters. They do not want to lose the business, but they have no choice.
Of course there are some carriers who are trying to cut down legal expense as much as possible, sometimes unfairly. By doing this they are trying to take advantage of legal firms to get as much out of them for as little cost as possible. Larger firms can sometimes absorb this possible loss just to keep the carrier’s business. But smaller firms that cannot compete are losing a lot of business.
In most cases, the relationship between carrier and legal firm can work if they negotiate an hourly rate, and the associated tasks that go along with it. Tasks need to be clearly defined so no confusion comes when the bill arrives. The legal expense review company should also be informed of certain fees and tasks as negotiated between the carrier and firm so no issues arise. The goal should be to maintain that solid relationship between counsel and carrier, and the associated fees that go along with the handling of a litigated case to overall settlement.(WCxKit)
Legal expense review companies can be a great asset in reducing your overall legal costs when handling litigated files. But the hourly rates and the tasks that go along with it need to be clearly defined between the carrier and the legal firm. Any confusion on any of these issues can lead to a breakdown of the relationship, which benefits no one. By being proactive and establishing clear expectations at the beginning of the lawsuit, both parties can deal fairly with each other. To get good service, you have to pay a fair price.
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 website 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. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
The majority of quarter-million dollar and half-million dollar workers compensation claims have a secondary medical issue that complicates recovery and extends the length of time the employee is disabled. Personal medical problems such as
obesity, smoking, poor physical condition and diabetes often complicate severe injuries, especially those involving surgical repair, making recovery more difficult, longer and expensive.
A 300-plus-pound employee who must lose 50 pounds before surgical repair of a herniated disc can easily add six
months of temporary total disability benefits and six months of doctor visit to overall claim costs. In most jurisdictions, state workers compensation laws take the employee the way you hired them; often referred to as, “You touch it, you bought it.” That the employee has a
pre-existing medical issue does not excuse the employer from having to pay all medical care for injury and indemnity benefits until the employee can return to work (or until indemnity benefits reaches the state maximum time limit for draw.)(WCxKit)
Obese employees with medical problems are not the only ones who increase workers compensation claim cost. A 6-foot-tall, 140-pound man smoking a pack of cigarettes each day will find a fractured ankle (or any other bone) takes much longer to heal in a smoker than in a non-smoker. Cervical and lumbar fusions often fail in the heavy smoker as the two bones do not grow together. A failed fusion in a person who smokes can add from months to a year to the life of the workers compensation claim, and increase the employee’s permanent impairment rating.
Most employers totally separate their health insurance program from their workers compensation insurance program with the human resources/benefits department handling the health insurance program and the risk management department dealing with the workers comp insurance program. If your health insurance and workers comp programs are handled separately, we recommend the two departments work together to institute a wellness program, or to improve the existing wellness program, for the simple reason that healthier employees have fewer insurance and workers compensation claims.
If you are thinking, “Okay, I understand that unhealthy employees take longer to recover from their work comp injuries, but how does a wellness program create fewer workers comp claims?” the answer is employees who are not in good physical condition are much more prone to strains and sprains than employees who are physically fit. For example, picking up and moving a 50-pound object does not create a problem for the physically fit employee who has muscles that are properly toned. The same 50-pound object creates a herniated disc in the employee who does not have developed back muscles to support the spine.
A study completed by the John Hopkins University Medical Center of employees at eight aluminum plants found that 85 percent of those injured were overweight or
obese. There is also the often-cited Duke University study that documented obese employees have twice the number of injury claims per 100 employees as non-obese employees, lose 13 times as many work days, with indemnity cost being 11 times higher, and medical cost being seven times higher.
(For more detail look
http://www.dukehealth.org/health_library/news/10044.The savings in this one area of wellness will greatly exceed the cost of the wellness program.)
One study showed that for every $1 spent on wellness programs, there was an overall reduction in medical care cost of $3 to $4. That is a return on investment that can not be ignored. By eliminating employee’s unhealthy habits, both parties benefit. Not only does the employer benefit by lower insurance cost, but the employer also benefits from higher productivity, as the employee is on the job working, not at home recovering from an illness or an injury.
By having an integrated, comprehensive wellness program you are taking a holistic approach to the employee's health and the impact it has on the employer. With the ever-rising cost of medical care, whether for health insurance claims or workers compensation claims, the need for a strong wellness program in your company will continue to grow.(WCxKit)
We recommend you do your employees and your company a big favor by starting or by improving your wellness program. There are a tremendous amount of resources on the Internet on wellness programs. We are also here to assist you in any way we can, so please contact us in regard to your questions about wellness programs.
Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website 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. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Errors in payments, usually referred to as "leakage," are a major issue for any insurance company involved in workers compensation claims. Generally “leakage” is classified into two types: hard and soft.
Hard leakage refers to erroneous payments made on claims without coverage, e.g., a claim is paid when no policy coverage or compensability exists.
Soft Leakage refers to overpayments to claimants in wage compensation, errors in medical payments, and errors in payments to medical providers after a claim is denied or disputed.
There is an area not often mentioned, however: vendor leakage.
Vendor leakage involves payments to various outside vendors used in investigation and claims handling such as nurse case management, surveillance, independent medical evaluation (
IME) companies, and vocational assessments. (WCxKit)
1. Nurse Case Management Leakage
Many companies use outside vendors for nurse case management (NCM). Adjusters use these nurses to assist in gathering medical records, to talk over medical issues with physicians either onsite or telephonically, and to meet with claimants to get another view of the ongoing medical complaints a claimant may have.
Leakage can occur when NCM is used on claims where it is not necessary. Too often adjusters have a high claim volume and, to save time, they assign an outside NCM to assist on uncomplicated medical claims. This is not only expensive, but also not needed.
For example, if a claimant has a typical back strain with no internal structural damage and no pending surgery, there is no need to involve a NCM. But in order to keep an eye on the claimant’s medical treatment, an adjuster assigns a NCM to oversee the medical portion of the file.
Adjusters are known to assign NCM from time to time solely to gather medical records so they do not have to call the provider and request records. This is both a waste of claim expense and a sign of a lazy adjuster.
NCM should only be used when there is a complicated surgical case, when congenital medical issues could complicate healing after injury (e.g., a case with a claimant with severe diabetes or morbid
obesity), or in scenarios when the same claimant has a number of similar complaints/injuries throughout years in the workforce, indicating the presence of a repetitive injury that could lead to a severe injury if the work duties are not corrected. Any other use of outside NCM is a waste of claims dollars and a waste of the nurse’s time and effort.
2. Surveillance Leakage
First of all, surveillance does have its place in certain claims and secondly, not all
surveillance is a waste of time. However, in most cases surveillance does not greatly impact the outcome of the claim. Depending on the jurisdiction, videotape of a claimant walking around outside or running various mundane simple errands will not impact the compensability of the claim. A workers compensation claim does not disable someone from performing most general activities of daily living.
Keep in mind though that even though it does not influence the outcome of the claim, it may be very useful to build internal management commitment for your program or be a deterrant to fraud when others in the facility become aware that extent of injuries is verified via surveillance. In fact, we at Workers Comp Resource Center are huge proponents of using surveillance to verify the extent of any injury before a settlement is offered. When one member of our staff was a litigation manager, he wanted to see with his own eyes that a claimant was really disabled before authorizing payment of a settlement. LowerWC.com is a stickler for detail.
Surveillance is typically costly, and unless an employers has an inside tip that the claimant has other employment, or is routinely breaking medical restrictions, it may not be useful. Surveillance without a purpose is considered leakage.
3. IME Leakage
Independent medical examinations (IME) are probably the most commonly used tool for adjusters. IMEs are used to make a medical correlation between the objective injuries a claimant may have, and how they relate back to the workplace injury. Inexperienced adjusters will send a claimant for an IME too soon, or too often. The results will shoot their defense of the claim in the foot because, depending on the scenario, the IME physician does not have a reason to terminate ongoing medical benefits. A typical strain can last up to eight weeks, and if the company does an IME at three weeks, the claimant is still in the healing stages and the company will either have to wait for the treating doctor to release the patient from care or perform another IME later and incur extra expenses. So, untimely IMEs are leakage. Using an M.D. to review timing of an IME can eliminate this type of leakage.
Depending on the jurisdiction, an IME may cost anywhere from $575 and $3,000, which often does not include medical record review, adding hundreds of dollars to the total bill. Plus, costs can vary on the specialty of the physician and the location of the IME. In our experience, which includes many claim audits by an M.D., about one-third of IMEs are unnecessary.
Often the treating physician can address any concerns an adjuster has regarding injury causation, and correlation of symptoms to the injury. This is usually free, and it only takes the time of the adjuster to draft a good letter to the treating doctor outlining the concerns. If the treating doctor will not respond, or it appears a claimant is over-treating for the injury, then an IME is warranted.
IME physician reputations are sometimes a greater factor than their actual report. There is a physician in Wisconsin who writes a good IME report, but when judges see his name, they disregard his opinions. Plaintiff attorneys and administrative law judges often see the same IME physicians again and again, and if these physicians have given poor depositions in the past or write overly-aggressive reports failing to support objective medical diagnoses, the IME report is not worth the paper it is printed on.
An IME is a fantastic tool when used properly, with the appropriate physician, with a cover letter written by an M.D. requesting specific medical information, at the correct time it is needed. Any overuse or improper use just leads to more expense sunk into the claim for no strategic benefit.
4. Vocational Assessment Leakage
When a claimant can no longer perform their pre-injury job, adjusters sometimes bring in a vocational expert to comb the job market for potential work based on the claimant’s experience and medical restrictions.
Similar to IME reports, the reputation of the vocational counselor is very important. In most litigated cases, a voc expert is used to show the injury and subsequent permanent medical restrictions the worker has doesn’t deter him or her from any future employment. But, this argument must be made correctly. Plenty of outside factors are taken into account, including geographical location, the current job market, the claimant’s transferable skills, and the overall chance that the injured worker will have gainful, long-term, satisfying employment within these restrictions. You usually can’t take a man who was a welder his whole life and turn him into a greeter at a grocery store, and expect a judge to be satisfied with that. This can be avoided by selecting a vendor that searches for jobs in the open market, sets up interviews, and follows up after the interview to make sure the employee attended the interview appropriately dressed, for example — making a real effort to get hired.
Adjusters know when a claimant sustains an injury resulting in the injured worker having permanent medical restrictions, the claim can go down several routes. First, the adjuster should go to the employer where the claimant was injured to try to either create a job within the restrictions and pay range, or to attempt to modify the worker’s position to accommodate medical restrictions. If this can be achieved a voc expert is not needed. Otherwise, vendor’s fees are spent on countless hours looking for jobs outside of the employer's facility.
In summary, leakage affects all insurance companies, third-party administrators (TPAs), self-insured employers, etc. Unnecessary outside vendor usage contributes to excessive claim costs and is known to be used more often than needed in day-to-day claims' practices. (WCxKit)
Consider on a larger scale the costs going into a basic, lost time claim. It is a good bet some of these costs can be eliminated with a more proactive adjuster who is open to getting the injured worker back to the employer by strengthening the adjuster/employer/worker relationship. Knowing your vendors, selecting your own vendors or becoming VERY WELL acquainted with TPA vendors, and specifying the triggers for use in your account instructions, can go a long way toward making your program more efficient.
Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website 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. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
We are very fortunate to be associated with some very fine, knowledgeable persons who provide excellent insight into the various topics we constantly highlight in bringing our readers and clients cost effective ways of reducing workers compensation costs.
On such person is Alice M Martinson, M.D., a board-certified orthopaedic surgeon and former Naval Medical Officer. I recently interviewed “Dr. Alice” on the topic of chronic soft tissue and its effects on workers compensation.
What is Chronic Soft Tissue Overload Syndrome?
This is a cluster of conditions that can develop in upper extremities which are used for rapidly-repetitive and/or forceful gripping activities.
Is there an abbreviation for Chronic Tissue Overload? Are there other names for this injury?
If you want to abbreviate it, it's most accurate to call it “chronic soft tissue overload syndrome" (CSTOS). Some people term it "repetitive stress syndrome,” but that seems a little vague to me. Repetitive stress of what? (WCxKit)
CSTOS is characterized by a group of separately-identifiable conditions, all of which have names and all of which are related to each other by the presence of tenosynovial irritation from rapid fingering activities. The commonest of the conditions are:
1. Carpal Tunnel Syndrome
2. De Quervain's "disease”
3. Trigger Fingers
4. Extensor Tenosynovitis on the dorsum of the wrist and forearm.
Conditions in the more proximal parts of the arms can appear in some employees as well. They are not related to tenosynovitis, but rather represent the consequences of prolonged periods of unrelieved fixed posture. The most common of these are:
1. Lateral Epicondylitis
2. Cubital Tunnel Syndrome (ulnar nerve compression at the elbow)
3. Postural Upper Backaches are the commonest examples of proximal problems.
In elbow problems, prolonged elbow flexion allows the extensor muscles to tighten and makes them more susceptible to strain ("lateral epicondylitis"). Prolonged elbow flexion keeps the ulnar nerve on stretch as it passes around the flexed elbow within the confines of the cubital tunnel. Sitting for a long time with shoulders hunched places the upper back muscles on stretch so that when there is concentration or tension, burning pain develops adjacent to the shoulder blades. Think accountants in the couple of months before tax time.
What industries does it typically occur in? Do federal agencies and private industry get this injury?
For many years it was the forceful-grip industries experiencing the condition the most – meat/ poultry processing and automobile or airplane assembly. When the objects gripped were vibrating tools, the problems arose faster than in other pure grip activities. Now that computer keyboarding and mouse use are so widespread, most of the problems seem to be arising in those jobs requiring constant activities of that sort in both Federal employment and private industry.
In Federal service I've seen it most in IRS customer service representatives, who spend their entire workday on the computer. Certain kinds of postal work can be highly repetitive as well. Customer service representatives in
telecommunications and other similar private industries seem to be quite commonly affected. The common denominator is rapidly-repetitive use of the hands for extended periods, and/or in fixed postures. That means the condition is also very common in professional musicians as well – particularly violinists and woodwind players.
Chronic illnesses also can have a major impact on these conditions. Diabetes, thyroid disease, gout, and rheumatoid arthritis are good examples. The fluid accumulation during pregnancy is well-known to precipitate carpal tunnel syndrome, even in non-repetitive situations. These non-work related conditions do NOT cause CSTOS, but they do influence the progression and severity or the conditions once they develop.
In your years in the Navy were there some departments in which it was most common?
My active duty career ended just as computers were starting to become ubiquitous. My recollection is that the heavy-duty specialties such as machinists' mate, boiler tender, and other similar ratings were the ones most commonly affected most commonly. Now, in the computer era, I would expect any of the ratings using computers extensively will see it. Fortunately the individuals in highly-stressful jobs such as radar, sonar, and fire-control technicians typically serve for only several hours at a time. That protects the soft tissues as well as ensuring fatigue doesn't degrade critical performance.
What type of specialist treats this type of injury? What type of treatment do they receive? Is it permanently disabling or can an employee recover 100%?
Orthopaedic surgeons primarily treat these conditions, although plastic surgeons specializing in hand surgery treat them as well. Ideally early appreciation and insightful intervention will allow these conditions to be treated non-surgically. Carpal or cubital tunnel problems, triggering fingers, and tenosynovitis of the thumb abductors can sometimes be settled down with corticosteroid injections, but if they cannot, there are simple and safe surgical procedures available to treat these conditions.
What should employers know about prevention?
Repetitive hand use jobs can't really be changed that much. Employers can, however, ensure that their employees have proper ergonomic environments. In the meat packing industries, this means keeping knives and scissors very sharp so that the force of grip can be diminished.
In keyboarding jobs, it means keyboards and screens are at proper height to allow proper employee posture. Taking frequent "mini-breaks" is a strategy used by musicians with great success, and one that can be used successfully by keyboarders as well. Those breaks are built into most compositions but musicians get into trouble during intense unrelieved periods of hard practice.
Frequent stretching of the tendons of the forearm and hand is very useful, as is the practice of postural stretching exercises for the shoulder girdles. It doesn't have to be for long periods; typical minibreaks will be useful if they are no longer than about 30 seconds and are repeated every 15 minutes or so.
Carpal tunnel syndrome seems very common. What treatment do you recommend for CTS?
Splinting for carpal tunnel syndrome – particularly at night is very useful. It's next to impossible to work in a splint, however, if you ever need to try, go to the bowling alley, and get a bowler's brace. It's cut differently since it must be used to hold the ball hold, the beer, and the pencil for scoring. What splints do is keep the wrist out of prolonged flexion. That's the position that pulls the maximum volume of tissue into the carpal canal, and it's the position we all tend to assume during sleep. That's why waking up at night with burning paresthesias in the fingers is a very common – almost diagnostic – part of the patient's history in carpal tunnel syndrome.
Once an employee has CSTOS, will they be able to return to work?
Every individual's soft tissues have different tolerance for highly repetitious activities. This appears to be an inborn biologic characteristic. Some employees will tolerate rapidly repetitive jobs for a number of years, while others will develop progressive symptoms is as short a time as two weeks. Once one of the soft tissue overload conditions appears, it can be successfully treated; but if the individual returns to the same job with the same poor ergonomics, another of the constellation of conditions will develop – and in less time than it took for the first one to appear. The employer can make the necessary ergonomic and scheduling modifications, but motivation plays a major role in individuals’ ability to resume their repetitive jobs successfully.
What is the typical length of time an employee is out of work with CSTOS?
That's a hard question to answer, since it varies depending on the syndrome being treated and its severity. The diagnosis itself is NOT a good reason to take an individual off work. Minimizing time off keeps employees engaged with their employment and doesn't allow the secondary gain of "illness" to take root.
When surgery is involved, most employees should be able to return to some sort of modified work within three to four weeks of the procedure. Frankly, the lost time from work has a great deal to do with an employer's response to the employee's complaints. In highly repetitive and unskilled jobs, employers are much less motivated to make the necessary adjustments or modifications, since the position can be filled by a new hire without sacrificing any investment in employee training. (WCxKit)
Doctor, do you have any final thoughts for employers (federal or private) about CSTOS?
Much as employers would like not to believe it, the condition is real. It can be managed, but ignoring it will not make it go away. There is a lot of partial or misinformation circulating among employees in industry where the conditions are frequently seen.
The three most important things for prevention and control of the decreased productivity resulting from these conditions are: (1) A proactive program of employee and supervisor education; (2) attention to the ergonomics of the workspace; and (3) fostering a corporate environment where employees do not feel threatened when reporting a condition.
Author: Alice M Martinson, MD has practiced for 40 years as a board-certified orthopaedic surgeon, 25 of which were as a Naval Medical Officer. Relying on her extensive military experience with injury evaluation, she performs IMEs and consults on loss control issues. Contact: 870-480-7475 or
docalice@aol.com. To read more about "Doc Alice,” go to:
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
In-house counsel are often frustrated when claims they are working on are settled without their consent. Here's why …. most companies do not spend time negotating their account instructions. Most don't know what the account instructions are. They are a well-kept secret.
Prior to settlement of claims, the carrier should contact the company for settlement authority on all claims over a certain threshold of, for example, $5,000 or $10,000.(WCxKit)
The company should be “consulted” before any lump sum settlement is offered. The more input the company wants, the lower the settlement threshold should be. For example, if a company wants to be actively involved in decision-making they can state “the company retains settlement authority for all workers compensation claims over $5,000 and all products liability claims over $1.”
There is a world of difference between an insurer having to “consult” its insured and having to obtain its “consent” prior to settling a claim. You want the former. If the insurer agrees to “consult” its client prior to settlement, the client may not have the power to alter the course of the claim.
A very rude awakening is in store for the company with a $500,000 deductible when a claim is settled against the wishes of the litigation manager, particularly when the settlement amount is within the client’s retention level.
In one large auto case, a plaintiff who had been a meat cutter for 20 years alleged his carpel tunnel syndrome was from the impact of the auto accident. It's possible, but perhaps there is another cause – meatcutting. In-house counsel will surely look into this, but if the insurer has full authority they can settle the claim without your consent.
The defendant company's in-house attorney hired a medical expert to review medical causality. Yet, even though it knew of the company’s involvement and interest in the case, the insurer settled the case without the consent of its insured client. That was a rude awakening for counsel.
This occurred because the company had previously given the insurance carrier $100,000 of “field authority” even though the company had a $250,000 deductible on auto claims and the settlement was, essentially, all the companys money.
From a company's perspective, a settlement decision can impact well beyond bottom-line considerations. Injudicious settlements can affect a company’s labor policy, its workers compensation practices, the reputation of its products and its susceptibility to future claims. For instance, an insurers denial of a legitimate workers compensation claim can adversely affect the labor climate.
Managing claims and litigation is nearly impossible without complete and explicit account servicing instructions (ASI). Also known as account instructions, claim service instructions or account handling instructions, ASI represent the agreement or understanding between the insured and the field adjusters at the insurer’s branch offices that guides the handling of all suits and claims, both litigated and non-litigated. These instructions should be disseminated to all your branch offices across the country.
The ASI includes information about how claims are to be handled in every line of insurance including workers compensation, products liability and automobile insurance. (Third-party administrators who provide claims servicing without insurance also use ASI to guide their adjusters.)
After ASI are negotiated, the insured must familiarize all internal claims handling personnel with the provisions of the ASI and provide them with a written copy to ensure they understand the responsibilities for key areas of claims handling. In addition to containing policyholder information and details about coverage and dissemination of data (loss runs), ASI can also contain other lesser-known guidelines.
For example, the referral of medical reports to a physician consultant for preparation of a letter to set up an independent medical examination (IME), or a requirement saying subrogation can be waived only upon receipt of a written evaluation and agreement by the company. In implementing an aggressive claims and litigation management program, a company is, in effect, “taking control” of its claims, exerting more authority in the handling of claims and becoming much more involved in their claims management.
When a company chooses to become more involved in “managing” as distinguished from “monitoring,” the roles and responsibilities of all parties, including the company and the insurance carriers, must be clearly delineated to avoid overlaps as well as gaps. In as much as in-house counsel frequently manages litigation and claims, while the risk manager establishes the ASI, the two departments discuss in advance, what to include in the ASI.
In-house counsel makes a list of all claims handling problems, then reviews and discusses it with the risk managers for solutions to be incorporated into the ASI.
While a company can actively negotiate for items it believes to be of sufficient importance, the carrier’s approach will normally run counter to the company’s approach. The carrier may seek to define as few issues as possible in writing; sometimes reassuring the company certain key items will be done as a matter of course (i.e., as “standard operating practice”).
The company needs to be aware of this, realizing it is prudent to put as much as possible in writing to avoid future problems and misunderstandings. It is not uncommon for a litigation manager to encounter problems that would not have occurred if “it had been in writing.” For example, a company may be “assured” it can select the local counsel of its choice. This verbal assurance from the carrier may work adequately until those who made these agreements move to other employers or are no longer involved with the account.
In general, the more risk a company has retained, the more control the insurer will relinquish. In a guaranteed cost program, for example, the insurer will relinquish almost no control because the exposure and expense are borne by the insurer. In a loss sensitive program, the insurer will negotiate to give a company more control.(WCxKit) In a loss-sensitive program with a very large deductible (e.g., $500,000) most companies can negotiate for a very high level of control close to what they would have if they were self-insured.
Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website 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. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com or 860-553-6604.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
It’s easy to become trapped in assumptions. One such assumption is that predictive modeling is exclusively achieved by scouring data using advanced mathematical computations. While that is the generally accepted method, and a valid one, it need not be the only method. Extraordinary outcomes and substantial savings can also result from simpler initiatives.
While more commonly used in other industries, predictive modeling is gathering interest in workers compensation. Predictive modeling is a process used to create a statistical model of future behavior. It is the area of data mining and business intelligence concerned with forecasting probable outcomes or trends.Multiple methods of testing assumptions and uncertainty are involved while looking for patterns in the data. Statistical modeling uses advanced mathematics to find correlations, look for consistent causation, develop a theory — apply it, validate it, adjust the theory and continually retest it. (WCxKit)
Answers are sought for basic questions using predictive modeling. If X is true, then what is the probability Y will occur? Or when Y occurs, what are the factors that could have predicted it?
A familiar example of how predictive modeling is used is auto insurance companies taking into account potential driving safety predictors in the data such as age, gender, and driving record. The predictions are not guesses. Instead, indicators are found using huge amounts of data and are based on the idea that consistent historic behavior found in costly claims is a predictor of future claims with similar conditions. Auto insurance premium costs are rated by this actuarial intelligence applied to the data.
Similarly, when predictive modeling is applied to workers compensation, the objective is to identify claims likely to be complex and costly based on historical data. The goal is also to identify those claims early so damage control can be implemented such as focused claim and medical management or early settlement. Regression analysis and other advanced methods of statistical mathematics are applied to the data to find key indicator data in those claims.
Nevertheless, advanced statistical modeling is not for everyone. Studying the data in this way requires huge amounts of data to achieve statistically significant results. Experts must be contracted and financial investments made. Such efforts are well founded, encouraged and ultimately lead to refined intelligence in workers comp. Still, there are lesser, yet valid, achievements to be made.
Notably, most payer organizations have an untapped predictive resource: internal wisdom. Claims adjusters, nurse case managers, and medical directors all know their claimant population and instinctively know what claims are likely to be problematic. Moreover, many organizations utilize the three-point contact methodology where vital data are collected about the claim that can be predictive. All this information should be collected in data form and structured procedurally to strengthen claim management functions.
Another way to find predictors in data is to leverage workers comp medical research as a guide. Edward Bernacki, MD and his team at Johns Hopkins published a study in the Journal of Occupational and Environmental Medicine in January of this year describing Cost Intensive Physicians. (Bernacki, et.al. “Impact of Cost Intensive Physicians on Workers Compensation” JOEM. Vol. 52. No. 1. January, 2010) Using five years’ closed claim data from the Louisiana Workers Compensation Corporation, they studied claims that began with reserves less than $15,000, but migrated to reserves of +/-$50,000. Of those claims, 3.8% of physicians involved were responsible for 72% of the costs. Their information about cost intensive physicians can be applied to identify predictors.
Cost intensive physicians, as labeled in the study, were those who had higher medical costs, longer medical treatment duration, longer claim durations, and higher indemnity costs. Therefore, one can conclude that identifying, avoiding or managing the cost intensive physicians is one way to contain costs. Look for those features associated with specific physicians in the data along with other characteristics highlighted in the study.
The Bernacki study also named certain injury types and procedures high cost predictors. Those injury types or diagnoses that do not have clearly defined treatment pathways are often problematic. Whereas a fractured tibia has a predictable treatment path, injuries of joints and back strains do not, leaving a wide berth of treatment options and opportunities for abuse. Monitor the data proactively to isolate injury types and procedures identified in the study and manage them aggressively.
Another study, “Long-term Outcomes of Lumbar Fusion Among Workers Compensation Subjects: An Historical Cohort Study”, found at
http://www.ncbi.nlm.nih.gov/pubmed/20736894. This study concluded, “Lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a workers comp setting is associated with significant increase in disability, opiate use, prolonged work loss, and poor RTW status.” Clearly, these conditions, when spinal fusion is the selected option, are predictors of complexity and cost. (WC
xKit)
Identifying and naming predictors using the knowledge from professionals and from research is a simple, yet valid approach to cost control through predictive methods. Call it “predictive modeling-light.” Monitor the data concurrently and continually to identify claims containing combinations of data that portend risk and focus on those. While the process is not sophisticated or complex, it will structure claims and medical management procedures, making them more proactive, effective, and replicable.
Author Karen Wolfe, BSN, MA, MBA, President/CEO, MedMetrics®, LLC. Karen is founder and president of MedMetrics® LLC, an Internet-based Workers Compensation medical analytics company. She applies her medical knowledge to gathering, understanding and applying Workers Compensation data to the operational process. MedMetrics imports, integrates, and analyzes its clients’ medical billing and claims level data. MedMetrics uses several tools such as Predictive Intelligence Profiling and Medical Provider Performance Assessment to gather and analyze data. Contact: Phone: 541-390-1680;
Karenwolfe@medmetrics.org; www.medmetrics.org.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Amaxx’s Workers Comp Cost-Containment Resource Center for Employers now provides workers compensation insurance-related information twenty-nine industry groups.
The industries covered are:
agriculture,
amusement parks, banks,
casinos, construction,
commercial fishing, logging and sawmills, oil and gas exploration, longshore and harbor workers, industrial equipment manufacturers,
telecommunications, food and beverage manufacturers, restaurants, professional services, schools, state and local governments, insurance companies, temporary staffing agencies, hospitals and nursing homes, entertainers, sports teams, printers and publishers, janitorial services, hotels and motels, transportation companies, retail chain stores, and horseracing. (WCxKit)
The new material includes sample transitional duty jobs for each industry. Transitional duty reduces unnecessary employee time out of work, cutting costs dramatically and is also called modified duty, alternate duty or light duty. Over 40% of workers compensation costs are related to indemnity payments (lost wages) paid when employees lose time from work so controlling these costs is paramount when developing a work comp cost-containment program.
Companies with effective transitional duty programs have lower experience modification factors. Companies with the highest return to work ratios – 95% of injured employees returning to work within one to four days - have the lowest mods, according to the 2010 RIMS Benchmark Survey. The new information in the Resource Center can be used to start a return to work program for your company. (WCxKit)
The Resource Center is located at
http://www.LowerWC.com and focuses on helping employers get a grip on decreasing their workers compensation costs. It contains several free resources including the Work Comp IQ Test, Transitional Duty Cost Calculator and Work Comp Sales Calculator.
About Amaxx: Amaxx Risk Solutions publishes the website www.LowerWC.com an online publication which provides suggestions, articles and resources for managing workers compensation costs. Amaxx is the developer of The Workers Comp Kit®, a comprehensive workers comp cost-containment resource for employers sold by Advisen Ltd. The Workers Comp Kit is an easy-to-use assessment, benchmarking and improvement plan with all the tools to reduce your company’s workers comp costs. The application is a best-in-business process that is based on 20 years of experience lowering workers compensation costs while improving overall program efficiency.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Workshop topics may stand alone or be combined depending upon quantity of material and how long it takes to present the information. If the company can only devote a limited amount of time to training, use a gap analysis to decide your most important areas. Agap analysis tells what best practices are currently being used across your corporation, identifying gaps in best practice implementation. Workshops should address specific needs, and there should be written training objectives that address the question, "What do we want the attendees to do differently AFTER our workshop?"
Key Elements: Injury Management Introduction and Basic Workers' Compensation Issues
1. Identify basic resources – what do the participants need to learn about workers compensation cost containment.
2. List the direct costs – include all medical, indemnity and expenses.
3. List the indirect costs – make a complete list of the costs of investigation, overtime, training new employees, etc.
4. List benefit levels – for the states in which you have employees.
5. Describe the financial impact of workers' compensation and explain the ways losses are measured and types of reports which are measures of your performance – relate it to something that "clicks" with your management, that relates to YOUR business.
6. It will be helpful to have on hand the most recent workers compensation laws – these are available at State Laws. http://reduceyourworkerscomp.com/workers-compensation-state-laws-and-regulations.php#axzz11v2L8Plo
An "extra" that is key is to cover the roles and responsibilities of everyone in your company or organzation. There is often confusion of who has primary responsibility for the duties associated with work comp.
Key Elements: Roles and Responsibilities of everyone involved including:
- Risk Management (RM) Department best practices.
- The workers' compensation manager.
- Supervisor responsibilities.
- Employee best practices.
- Senior management responsibilities.
- Medical department and medical director responsibilities.
- Legal department responsibilities.
- General manager (GM) responsibilities.
- Safety manager responsibilities. (WCxKit)
The initial sessions are the hallmark for the rest of the workshops. Once these first two sessions are out of the way spoken (and unspoken) questions will be answered. No matter what the questions are: "Why do we have to do this anyway?" "Is the company just trying to get out of paying injured employees?" "What specific work will I need to do?" – answers put to rest any initial skepticism, because the bottom line is a workers' compensation program save's the company money, genuinely results in better injury resolution and makes for a healthier, happier workforce.
\Author Robert Elliott, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact: Robert_Elliott@ReduceYourWorkersComp.com .
FREE WC IQ Test: http://www.workerscompkit.com/intro/
WC Calculator: http://www.reduceyourworkerscomp.com/calculator.php
TD Calculator: http://www.reduceyourworkerscomp.com/transitional-duty-cost-calculator.php
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers' comp issues.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
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