Work Comp Roundup -

10 Helpful Tips For Managing Angry Workers’ Comp Claimants

March 14, 2019 by Michael B. Stack

Unfortunately, angry workers’ comp claimants are often part of the workers’ compensation business. As hard as you try, you are never going to please all people all of the time. Experienced professionals know how to properly diffuse a tense situation. But it is an asset that is learned over time.

Here are a few important tips to remember:

1. Stay Calm

Regardless of the negative attitudes or unpleasant tones an angry caller may have, it is essential that you do not get emotional as well. Using phrases such as “I hear what you are saying” or “I understand” can help to calm angry callers. Remember they usually have no idea what is going on or why these decisions are being made on their claims, so take the time to let them vent a bit then calmly explain to them the situation.

2. Listen & Be Patient

Do not attempt to interrupt angry callers. Be patient and let them finish speaking. Sometimes they just need to vent their frustrations. After that, they will relax a bit and work with you to resolve their issue. Explain to them what is going on, and what options they may have for moving forward.

3. Remain Professional

Above all remain professional. Remember you are in the customer service industry, and there is a lot of competition out there. Every phone call should be dealt with in a professional matter, no matter the conversation.

4. Do Not Raise Your Voice

Raising your voice or talking in a sarcastic tone is only going to irritate your angry workers’ comp claimant further, which will resolve nothing. If anything, you can get in trouble with your supervisor. Many carriers record telephone conversations, and if this discussion gets pulled for review you are going to look foolish.

5. Try Not to Argue

Your main goal in diffusing a heated conversation is to resolve the problem. But a direct argument will rarely resolve anything. Instead, explain to them what is going on, and what they can do to help themselves. It may be that getting medical records or a more detailed report from their doctor is the piece of evidence you need to complete your investigation. Remember the claimant does not have the experience that you do in handling claims day in and day out, so cut them some slack and try to help them instead of just arguing point/counterpoint.

6. Speak Slowly and Clearly

Nobody likes to have to repeat themselves, so speak in a clear voice. Also, try to avoid talking in legal terms or in claim shorthand. The angry workers’ comp claimant will probably have no idea what you are talking about, which will frustrate them. Pretend you are explaining the issue to someone who has zero experience in this situation, and you may end up with better results than you planned.

7. Empathize & Apologize

How would you feel if you are in the same situation? What would you want to be said to you to make you feel better about the call? Angry workers’ comp claimants want to know that you understand where they are coming from, and they want the reassurance that you can help them with whatever issue they may have. Even if you know the caller is wrong, take a moment and apologize for the confusion. Many callers simply want acknowledgment from the carrier that a mistake may have been made, if applicable to your scenario. An apology is the first step to overcoming their anger and opening a dialogue about resolving the issue.

8. Offer Solutions

People are coming to you with questions about their claim, or why a decision was made. But oftentimes these decisions are not written in stone. Denied claims can be accepted later, and vice versa. Maybe your claimant can file for mediation on their denied claim. Or maybe they did not submit enough information in the beginning for their claim to be accepted. Whatever the reason may be, explain to them what options they have for moving to the next level. If you cannot answer a question immediately, let them know that you will work on it and get back to them with some answers or options and go from there.

9. End the Call if the Person is Repeatedly Abusive

Your goal is to bring a successful closure to each phone call. However, you do not have to tolerate abuse. Kindly interject with an “Excuse me” if necessary and inform the caller that their language or behavior is not acceptable, and it will not help them resolve their conflict. It is well within your ability to end the call if the person continues to be belligerent and abusive if you have asked them to calm down several times beforehand.

10. Do Not Take It Personally

In the end, this is your job. A lot of claims adjusters have a lot of hours of work invested into each file, and sometimes they can wear their heart on their sleeves. But at the end of the day, you have to accept the decisions you made on a claim. I recall a young adjuster I knew that was first starting out in work comp, and he used to agonize over his decision about whether a claim was compensable or not, and if he was making the right call. This is a good asset to have, but only if it is a healthy concern. The process that is in place with supervisor reviews and audits is there to catch your errors, if you have any, and to help you make confident decisions on claim outcomes. Trust in the process in place, and believe in your decisions that you make. Sometimes you have to go with your gut decision.

Summary

An adjuster is on the phone for the majority of their day, every day. And in the field of claims, conflict will arise. There is often no way to avoid dealing with an angry workers’ comp claimant. But you have to be armed with the proper way to handle yourself on the phone–not just for certain calls but for every call. Implement the tips above, and hopefully, you will be known around the office as a person that can diffuse any tough situation that is thrown their way. Knowing how to work the phone is one of the best assets an adjuster can have.

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

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.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.

Filed Under: Claim Management

The Dangers of Under-Reserving

March 13, 2019 by Rebecca Shafer, J.D.

Under-reserving in workers’ compensation is a dangerous practice.

A basic principle of business solvency is to have an asset to offset each liability. A workers’ compensation claim is a legal obligation – a liability for the company, whether it is a contractually assumed liability through an insurance policy for an insurance company, or a retained liability through self-insurance. A claim reserve is an estimate of what the workers’ compensation claim will cost. When the adjuster handling the work comp claim establishes a reserve on the claim file, it is a definite amount of dollars that are being set aside to pay the future cost of the work comp claim.

Under-Funded Liability Will Eventually Experience Shortfall

From an accounting standpoint, a claim is an incurred liability, even though it will be paid in the future. When the reserve is established by the adjuster, the company loses the ability to use the amount of money that has been set aside to pay the work comp claim. Inaccurate reserving, whether the reserves are excessive or inadequate, distorts the company’s financial condition. When the reserves are too high, money the company could use in other aspects of the business is no longer available for use by the company. When the reserves are too low, the company has an underfunded liability. This creates a situation where the company will eventually experience a shortfall.

While both over-reserving and under-reserving present an inaccurate picture of the company’s financial health, most financial people will argue that under-reserving is worse for the company. The reason for this is simple – the self-insured employer or the insurance company must have adequate reserves to meet their obligations. If the reserves are inadequate, the self-insured employer or the insurance company runs the risk of insolvency.

When the self-insured employer or insurance company has understated their reserves, they have overstated their assets and have understated their liabilities. The difference between the amount of assets an insurance company has and the amount of liabilities an insurance company has is referred to as the insurance company’s surplus. An insurance company’s ability to pay claims is evaluated by measuring its surplus in comparison to their outstanding obligations.

Evaluated By Ability To Pay Claims

Insurance rating firms like A.M. Best measure the financial stability of an insurance company by evaluating their ability to pay their claims. If the insurance company has understated their reserves, they may temporarily increase their financial stability rating, but when the claims come due (are paid) and the available surplus drops, the financial stability rating of the company will be downgraded. A downgrade in an insurance company’s financial stability rating results in fewer potential buyers of their insurance products because doing business with the downgraded insurance company is considered riskier.

An example of how under-reserving of work comp claims can impact the surplus is as follows (to simplify, the insurer has no other liabilities except claims).

Total assets Total Claim Reserves Total surplus

$10,000,000 $8,000,000 (under reserved) $2,000,000

$10,000,000 $9,500,000 (properly reserved) $500,000

In this example, when the reserves are understated, it appears the insurance company has a surplus of 20% of assets, but in actuality, the surplus is only 5% of assets.

Reserving Practices Subject to Audits

All jurisdictions regulate the financial stability of self-insured employers and insurance companies. The reserving practices of the self-insured employers and insurance companies are subject to periodical audits by the state insurance department or other state regulatory agencies. When the self-insurer or the insurance company is audited, if the reserves are inadequate to pay all open claims (and technically, all claims that have been incurred but not yet reported), the state insurance department will require the self-insured employer or insurance company to increase the reserves to cover their obligations on their claims. If the self-insured employer or insurance company does not have the assets available to place in reserve for those claims, the state insurance department will shut the company down.

Another aspect of under-reserving is the impact on the calculation of future premiums. The reserves on the open claims are a part of the calculations in establishing the loss experience of the company. If the loss experience is understated because the reserves are understated, the insurance company will be charging inadequate premiums, resulting in lower profits for the company, or even pushing the company quicker to insolvency.

Proper Reserving Is Essential

To accurately reflect the self-insured employer’s financial position or the insurers financial position, proper reserving for the claims is essential. Under-reserving impacts the financial stability of the company, as the shortfall in reserving will eventually be corrected by taking the shortfall from the company’s surplus. If you have any doubts about the adequacy of the reserves on your workers’ compensation claims, please contact us as we can recommend claim auditors that will verify the adequacy of your claim file reserves.

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 co-author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:.

Contact: RShafer@ReduceYourWorkersComp.com.

Workers’ Comp Roundup Blog: https://blog.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.

Filed Under: Claim Management

Six Things that Drive Workers Compensation Adjusters Crazy

March 12, 2019 by Rebecca Shafer, J.D.

Being a workers’ compensation adjuster has a lot of demands. Every day you have to juggle multiple demands on many files, sometimes within several jurisdictions. A typical caseload for the lost-time adjuster is 150 active files. The adjuster tries to handle the demands of those files in addition to the phone calls, emails, and medical records, usually without any support staff.

Every workers’ compensation adjuster appreciates anything that helps make their job easier. Below we discuss six small items that can make a big difference to Joe (or Josephine) Claims Adjuster.

1. Please complete all fields on the injury form.

When an workers’ compensation adjuster first gets a new assignment, nothing makes them more frustrated than to see many fields missing information. This can include social security numbers, birth dates, the type of injury, the date the injury was reported to the supervisor, etc. All of these fields are equally important, and when any are empty it means another phone call to the contact at the insured to gather this information. Take the time to complete all fields, so the adjuster has the information needed to get started on the file investigation without delay.

NOTE TO EMPLOYERS: IF YOU LEAVE BLANK FIELDS, SOMEONE ELSE MAY FILL THEM IN – WITH ANSWERS THAT YOU WON’T LIKE. Attach information if there isn’t enough room for the complete answer. Staple it and mail a copy to the adjuster.

2. Report All Claims in a Timely Manner.

The next thing that annoys workers’ compensation adjusters are late claims. Depending on the jurisdiction, this can put the adjuster in a time crunch to gather as much claims information to complete the investigation, and the fact they are rushing can lead to errors, or even worse, leakage. The last thing anyone wants is money and time wasted on a claim that is not compensable. One of the best things you can do is to report a claim right away. Do not let it sit on your desk until the injured worker goes in for surgery the next day. The sooner you can get that injury report to your adjuster, the better chance they will have to do a proper, thorough investigation. This leads to correct, ethical decisions on your claims without delays, penalties, or leakage.

3. Let the adjuster know if there is lost time on a claim.

Claims that include lost wages carry a certain priority with the workers’ compensation adjuster, since every day that clicks by means another day of potential wage loss due to the employee. As mentioned above, injuries should be reported right away. This gives the adjuster time to gather medical records to see if the claim is compensable. It also gives the adjuster a chance to get work restrictions on your employee so they can be placed in your light-duty work program. This eliminates the need for lost wages paid to the employee and keeps your claim costs down. When injuries are reported right away, everyone wins. The employee gets prompt contact by the adjuster, the adjuster gets a jump on the claim, and the employer gets to keep their costs down as low as possible.

4. Don’t tell the adjuster if a claim is compensable or not. It bugs them.

As much as you think a claim is legit or not, the employer typically cannot make a decision on a claim’s compensability. This is the adjuster’s job — what they get paid to do. This is why they are licensed to be claims adjusters in your state. They have the training and certification to make the decision on compensability. It is really important to voice your opinion on the claim, and to be able to back up your assumptions with facts. This will greatly help the adjuster with their investigation, but the overall decision on if the claim is accepted or not should be left up to the adjuster. Plus some jurisdictions have steep fines if claims are denied in error, so why put yourself in that position? Leave it up to the claims professionals.

IF IT IS NOT A LEGITIMATE CLAIM – TELL THEM YOU SUSPECT FRAUD. PUSH IT- so you are taken seriously. I don’t always live by my own advise here, and I almost always give my opinion about what I think is compensable, or not…

5. Make yourself accessible to the adjuster and return calls as soon as possible.

Workers’ Compensation adjusters have to make many phone calls every day. They are constantly on the phone. If they are calling you to get facts on an injury, and they leave you a message to call them, please call them back as soon as you can. Employer input on claims is important. Bear in mind you see your employees every day. You know a lot about them that the claim adjusters do not. Your investigation is just as important to the adjuster as is theirs. They rely on you heavily to know about the injury, what happened, why it happened, and what happened after the worker left. Send them any medical information you have, as this also will give them the provider’s name, address, contact info, and initial diagnosis. If you get bills for the treatment from the provider send them to the adjuster so they can be processed for payment if the claim is compensable. Anything you get that involves the claim should be sent to the adjuster, no matter what it is. The adjuster would always rather have more information than not enough.

6. Know the details of the injury soon after it happened.

The first question the workers’ compensation adjuster will ask you when they call is, “What happened?” Adjusters hate to hear the answer, “I do not know.” Obviously, this does not help the adjuster. You should be heavily involved in any claim that occurs at your workplace, whether it is a work comp injury, a liability injury, or a property damage claim. Gather facts and witness statements to send to the adjuster. Comments the witnesses have can impact a claim because the adjuster will compare that to the history given to them by the injured worker, and what history the injured worker gave the doctor when they were first examined in a medical facility. Any facts that do not add up will raise the red flag that there may be something more to this claim than what is on the surface, and it could prevent a claim from being falsely accepted. This again will keep your costs down, since you will not incur the leakage associated with paying a claim in error.

Conclusion

In conclusion, these are 6 items that can greatly help the workers’ compensation adjuster, even though you as the employer may find them quite trivial. You would be surprised if you saw the amount of information adjusters have to process on their 150-200 claims each day. Every little bit of information to the adjuster helps them out and makes their job easier. It all leads to the same goal that we have in claims, which is to properly investigate every one so the appropriate decision can be made on the compensability.

Contact: RShafer@ReduceYourWorkersComp.com.

Workers’ Comp Roundup Blog: https://blog.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.

Filed Under: Claims Adjuster & Employer Relationship

21st Century Skepticism in Science and Effects on Medical Care

March 11, 2019 by Thomas Glimp, MD

Dr. Thomas Glimp, Medcor Chief Medical Officer

We live in an age of scientific enlightenment. Science, through technology, has made remarkable advances in the 20th and early 21st centuries.

Health advances over the same time include sanitation and hygiene with cleaner water and food, advanced imaging technologies using ionizing radiation and nuclear magnetic resonance, minimally invasive surgical techniques, organ transplantation, the discovery of DNA and sequencing of the human genome, the relationship of the genome to heritability and disease with great promise for future health, the discovery and mass production of antibiotics and widespread vaccination. Because of these and other health innovations, the average U.S. life expectancy increased from 47 years to 77 years in the 20th century.

Most bacteria are still susceptible to at least one or a few antibiotics, but we are getting uncomfortably close to the abyss.

In spite of these advancements, there is a skepticism of science in general and of medicine in particular. Skepticism can complicate daily medical management. Let’s look at an example:

Antibiotic Abuse

There, I’ve said it – abuse. Not overuse, but abuse. Antibiotics, one of the most important discoveries in the history of medicine are abused and, as a result, are losing their life-saving power.

Antibiotics are substances produced by microorganisms, including molds, that inhibit or kill competing microbes. Alexander Fleming accidentally discovered penicillin, the first antibiotic, in 1928. Fleming saw that staph bacteria growing in a petri dish were inhibited by a green mold (Penicillium notatum) contaminant. Through further testing, he found that “juice” produced by this mold inhibited or killed any number of pathogenic bacteria. Penicillium “mold juice” ultimately became the first antibiotic, penicillin. During World War II the U.S. War Production Board recognized the strategic value of penicillin and made its production a priority under the direction of Albert Elder, known as the “Penicillin Czar.” I mention Elder for this quote:

You are urged to impress upon every worker in your plant that penicillin produced today will be saving the life of someone in a few days or curing the disease of someone now incapacitated.[1]

While true then, we have squandered the value of penicillin and many more antibiotics today. How do bacteria become resistant to antibiotics? It’s all about selection pressure. The CDC explains it well:

Every time a person takes antibiotics, sensitive bacteria (bacteria that antibiotics can still attack) are killed, but resistant bacteria are left to grow and multiply. This is how repeated use of antibiotics can increase the number of drug-resistant bacteria.[2]

This is true whether the person given antibiotics has a bacterial or viral infection. The overuse of antibiotics promotes resistant bacteria, even if the infection is not bacterial. The “bathing” of our population in unnecessary antibiotics for medical illnesses that are not or only rarely bacterial – colds, bronchitis, sinusitis, etc. – has led to resistance and a tragic loss of antibiotic effectiveness. You have undoubtedly heard about “MRSA” – Methicillin Resistant Staph Aureus. You are just as likely to have not heard about VASA, VRE and the hundreds of other highly resistant bacteria for which there are few antibiotic choices. In just the past year, resistance was reported to the last remaining antibiotic, colistin, to which no resistance had previously been described. Fortunately, most bacteria are still susceptible to at least one or a few antibiotics, but we are getting uncomfortably close to the abyss.

There is a delicate balance between clinical need and preventing resistance. To prevent resistance, antibiotic use must be thoughtful and frugal. The world is lacking that balance.

There are three culprits:

agricultural use of antibiotics in livestock feed
overuse of antibiotics through free access in much of the world
over-prescription of antibiotics by medical providers.

Our focus at Medcor has been on appropriate antibiotic prescribing practices or “Antibiotic Stewardship.” Our perennial campaign is comprised of patient education materials, including handouts and posters, specific provider support through education, monitoring of prescription practices, and feedback.

A world with effective antibiotics sounds like a place we’d all like, but there are considerable obstacles to antibiotic stewardship, not the least of which is skepticism. When it comes to antibiotics, physicians and other medical providers seem to have little credibility with patients. Providers seem unable to convince patients that not every infection can be successfully treated with antibiotics and further that indiscriminate antibiotic use is unnecessary and unwise. In a study published in the British Journal of General Practice, antibiotic prescribing volume was a strong predictor of “doctor satisfaction” and “practice satisfaction.” In this study, 55% of physicians reported pressure to prescribe antibiotics, 45% had prescribed antibiotics for a viral Infection knowing that they would be ineffective, and 44% admitted that they had prescribed antibiotics in order to get a patient to leave. The authors calculated that a 25% reduction in antibiotic prescription would result in a 3-6 percentile decrease in national satisfaction ranking.[3]

There is a clash between what is right for patients and what is desired by patients. It is borne of the skepticism surrounding what is right.

The Point

So, what’s the point of this exercise? It’s to give you a better idea of the surprising pressures, born of skepticism, under which healthcare providers operate today and the complex realities of medical practice. Who would predict that dedication to evidence-based care would meet with patient resistance and poor impressions of provider performance? Overcoming skepticism is not easy, nor does the pressure relent. Toward the goal of better health for all, it is up to all involved in healthcare to show grit – passion plus perseverance wielding science as a weapon.

[1] Quoted In John Parascandola. “The Introduction of Antibiotics into Therapeutics in Sickness and Health in America: Readings in the History of Medicine and Public Health Third Edition Revised, ed. Judith Walzer Leavitt and Ronald L. Numbers (Madison University of Wisconsin Press 1997), 106

[2] Centers for Disease Control and Prevention, “Antibiotic Resistance Questions and Answers” last modified May 29, 2018. https://www.cdc.gov/antibiotic-use/community/about/antibiotic-resistance-faqs.html

[3] Mark Ashworth et al., “Antibiotic prescribing and patient satisfaction in primary care in England: Cross-sectional analysis of national patient survey data and prescribing data” The British Journal of General Practice: The Journal of the Royal College of General Practitioners 66, no 642 (2016 ): e40-e46. doi: 10.3399/bjgp15X688105.

Author Thomas Glimp, MD, Chief Medical Officer, Medcor. Dr. Glimp, MD joined Medcor in 1994. Tom is board certified in internal medicine and in emergency medicine. Dr. Glimp’s clinical affairs team provides standards, scope, guidelines and protocols, quality assurance, and other support for Medcor’s clinical services and staff. Medcor helps employers reduce the costs of workers’ compensation and general health care by providing injury triage services and operating worksite health and wellness clinics. Medcor’s services are available 24/7 nationwide for worksites of any size in any industry.

Filed Under: Wellness Programs and Workers Compensation

Over-Reserving and Your Bottom Line

March 7, 2019 by Rebecca Shafer, J.D.

Over-reserving of workers’ compensation claims can have a major financial impact.

To pay the cost of workers compensation claims, the insurer or the self-insured employer sets aside the amount of money the company anticipates as necessary to cover the cost of the claim. The process of placing money in a reserve – reserving – sounds simple, but it’s not. While most financial obligations of a company have a set price, workers comp claims do not come with a predetermined cost. The amount of money needed to pay the claim is an estimate based on the experience of the adjuster with previous similar injury claims. Even though the reserve is an estimate, it is a legal obligation and appears on the insurer’s balance sheet.

Under-Reserving & Over-Reserving Creates Issues

If the workers’ comp adjuster for the insurer underestimates the amount of money necessary to pay the claim, the claim is under-reserved. If the adjuster overestimates the amount of money needed for the claim, the claim is over-reserved. Both under-reserving and over reserving creates issues for the insurer.

When a claim file is over-reserved, the extra money placed in the insurance reserve to pay the claim is not available to the insurer for any other purpose. The growth of the business is reduced because the insurer has less money available for its financial operations – investing, supplies, salaries, etc. While the impact of one claim being over reserved may not be felt, the impact of many claims being over reserved significantly curtails the growth of the insurance company and can even strangle the potential of the insurance company by reducing the funds it has available for its business.

Over-Reserving Causes Side-Effects

Over-reserving also causes a serious side effect for the workers’ comp insurer because of the way the premiums are calculated. The two components of workers comp claims affecting insurance premiums are frequency and severity. Workers comp claims are often referred to as “long-tail” claims because they often remain open for years. Therefore, when the underwriter at the insurance company computes the insurance premium, both the closed claims – where the reserves reflect what was actually paid – and the open claims, are used to calculate the future premium.

When the claim files are over-reserved, the severity of the claims is overstated in the calculation of the insurance premiums. This has a detrimental impact on the cost of workers comp insurance. The extra money in the over reserved open claims results in the premium calculation being higher than it should be. The employer is penalized for over reserves by having to pay higher insurance premiums than should be charged. If the employer can obtain the same workers’ compensation insurance at another company, at a lower price, the insurer loses the employer’s business. If the over reserving is severe enough, it can cause the financial collapse of the workers’ comp insurer because the insurer is unable to sell any new business as the insurance premiums it charges employers are too high.

Adjuster May Over-Reserve Out of Caution

The workers comp adjuster may over reserve the claim out of an abundance of caution, or more often, because it is easier to put a high reserve on the file than it is to spend the necessary time evaluating the medical information, the extent of the impairment/disability, and the applicable workers comp statutes to determine the correct reserve amount. As claims management understands the impact of over-reserving, when they see a pattern of over-reserving, the usual conclusion is the adjuster is either inexperienced or incompetent. The insurer or self-insured employer needs to work with the adjuster who is over reserving to improve the adjuster’s reserving skills. When over reserving is corrected, the excess money being held in reserves is released and goes straight to the bottom line of the insurer’s financial report.

The financial security and well-being of the insurer or the self-insured employer is dependent upon the adequacy of the workers’ comp claim reserved. If the reserved is overstated, it will diminish the monetary funds the company has available for its other financial obligations and opportunities. It will also cause the necessary premiums to be overstated, resulting in a loss of business for the insurer.

If you are a self-insured employer and believe your workers’ comp claim reserves are set too high, please contact us and we will be glad to set you up with an independent claims auditor to verify the accuracy of your claim file reserves.

Contact: RShafer@ReduceYourWorkersComp.com.

Workers’ Comp Roundup Blog: https://blog.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.

Filed Under: Claim Management

Detecting Workers’ Compensation Fraud

March 6, 2019 by Senior Editor

Workers’ compensation fraud continues to be a problem. Members of the claim management team need to be aware of this problem and develop a plan for its prevention. They also need to create a plan to remedy the situation. By taking steps to stamp out workers’ compensation fraud, programs will become more efficient and ultimately reduce costs program-wide.

Defining the Issue – What is Workers’ Compensation Fraud?

Malingering or showing signs of pain magnification is not workers’ compensation fraud. Instead, it is defined by state law, and investigated and prosecuted by a state agency. Other civil ramifications can also apply.

According to Webster’s Dictionary, “fraud,” occurs “when a person knowingly or intentionally conceals, misrepresents, or makes a false statement to obtain” workers’ compensation benefits or coverage, “or otherwise profit from the deceit.”

Workers’ Compensation fraud is not limited to injured employees. Employers can commit acts of fraud by:

Misrepresenting company payroll on underwriting forms;

Paying an employee cash or not accurately reporting wages;

Not accurately reporting their payroll staff; and

Intentionally not reporting proper employee work classifications.

In sum, an employer commits fraud anytime it intentionally undertakes an action to reduce the cost of its workers’ compensation insurance premium.

Common Examples of Workers’ Compensation Fraud by Injured Employee’s

There are numerous examples of workers’ compensation fraud committed by an employee in the context of a claim. Some of the more common examples include:

Filing a claim for an injury that never occurred, or occurred outside the workplace;

Delays in reporting a work injury with no explanation;

Reporting an injury that occurred during another activity, such and an employee intentionally inflicting an injury and making a claim for benefits;

Misrepresenting the nature/extent of a work injury to a medical provider; and

Making a claim related to an injury that occurred following a job termination, layoff, or end of seasonal work.

Danger Ahead – Common Red Flags of Workers’ Compensation Fraud

There are numerous red flags members of the claim management team should look out for when investigating a claim. It is important to work as a team and share information to help less experienced claim handlers detect it and avoid paying unnecessarily on a claim.

Employment changes and terminations: Be mindful of claims that arise at the same time an employee changes positions within an employer or is terminated/seasonally laid off. A complete review of whether the injury/incident was reported prior to termination or whether the employee was near the end of their unemployment benefits prior to reporting a claim is key.

Beginning of week injuries: It is often not a coincidence an employee is injured first thing Monday morning after arriving at the workplace. This should make anyone scrutinize a claim to determine if it in fact occurred over the weekend.

Unwitnessed incidents: This should be an area of concern when the claim is made by someone who would typically not be working in a particular area or performing a certain activity. A review of security video should be a part of any investigation to monitor the activities of the employee immediately prior to the incident.

Experienced claimants: These are individuals with a long and well-documented history of work injuries and other insurance claims. A review of an insurance bureau index can track claims histories of a person and be a part of an investigation.

Other red flags include employee’s who give differing stories, work other side jobs (often as independent contractors), or may be experiencing financial difficulties. It is also important to understand what hobbies or recreational activities an injured employee partakes in away from the workplace. This can include someone playing in a sports league or enjoys “extreme sports.” Proactive claim teams should have a plan in place to identify potential fraud issues and undertake a more exacting investigation.

Conclusions

Members of the claim management team need to be mindful of workers’ compensation fraud in all claims. In addressing this issue, there are many red flags a claim handler must be aware of before accepting a claim and paying benefits. By doing this, one can ensure that all valid claims are paid in a timely and correct manner. It can also improve program performance and efficiency.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.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.

Filed Under: Fight Workers Comp Fraud & Abuse

You’re Fired! Using Employment Release and Resignations in Work Comp Cases

March 5, 2019 by Michael B. Stack

Running an effective workers’ compensation program revolves around managing risk and reducing it when necessary. In some workers’ compensation cases, this includes the demand the employee voluntarily resigns their employment from the employer and agree to never work for them again, also known as an employment release and resignation. Before making such demands, it is important to understand the numerous pitfalls associated with an employment release and resignation and how to use it in an effective manner.

Understanding an Employment Release

A voluntary resignation and release of any and all employment claims by the employee are outside the scope of the workers’ compensation insurance policy. It is important for all defense interests to coordinate via their defense counsel. The Release must be found in a document separate from the settlement of the workers’ compensation claim and the consideration (money paid to the employee) must be paid by the employer.

An effective Employment Release should be written with the interests of the employee and their employer in mind. Given the numerous legal issues, attorneys representing the employer/insurer are often hesitant to draft such a document as it is outside the scope of their representation. Retaining separate counsel who understands employment law issues may be something to consider.

It is also important that the employee understands what they are giving up under the terms of an Employment Release. Points of contention include:

The inability of the employee to make a claim against the employer for future unemployment compensation benefits;

The inability of the employee to make an application for employment with the employer at any point in the future; and

The inability of the employee to make any employment claims against the employer such as age, gender, and race discrimination, along with claims for interference with and/or retaliation for making a workers’ compensation claim.

Essential Terms to Include in an Employment Release

Any Employment Release that is included in a workers’ compensation claim should be either drafted by and/or reviewed by an attorney specializing in employment law matters. They should also know and understand all applicable state-specific and federal laws governing employment law matters.

Common terms found in such an Employment Release include the following:

Discrimination: Prominent federal laws in the area of employment prohibit employers from discriminating against employees on the basis of race, color, religion, sex, or national origin. These provisions are found under Title VII of the Civil Rights Act of 1964. Other important federal laws include the Americans with Disabilities Act and equal pay laws. State laws typically mirror federal standards, but can also exceed the minimum thresholds or include other classes (g. – sexual orientation, marital status, economic status/receipt of public assistance) of employees.

Retaliation: Most states have anti-retaliation provisions in their workers’ compensation laws that create a civil cause of action against employers who harass or intimate employees who file claims. Case law in many states has extended legal protections to all employees, including those not legally authorized to work inside the United States.

Sexual Harassment and Emotional Distress: The #MeToo Movement has given rise to a renewed national consciousness regarding sexual harassment and assault in the workplace. Claims can include the intentional or negligent infliction of emotional distress under tort law.

Contract Claims and Breach of Contract: Employees can also allege their employers violated the terms of a workplace contract. This is often the case in dealing with employee’s subject to a collective bargaining agreement. While employees are generally considered “at will,” claims can be made for implied or express contracts.

Payment of Wages: Wage disputes are common for employee’s subject to overtime pay. The non-payment of a bonus can also be an issue when an employee is subject to termination at the end of a quarter or year-end.

It is important to avoid using forms. Failure to fully understand the law may prove catastrophic for all defense interests involved in a workers’ compensation claim.

Conclusions

Members of the claim management team need to seek opportunities to reduce risk and maximize the effectiveness of a workers’ compensation settlement. One such option is to seek a global settlement where the employee agrees to voluntarily resign their employment from the employer. It is important that the claim management team, employer and defense counsel discuss these issues and coordinate in an effective manner.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.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.

Filed Under: Settling WC Claims

Marijuana: A Medical Perspective

March 4, 2019 by Marcos Iglesias, MD

We have a drug problem.

Americans consume more opioids than anyone else in the world. We are also among the highest consumers of marijuana. As a nation, we continue to rely on passive treatments for chronic conditions, instead of active management.

There is widespread acceptance of marijuana in the United States. A recent Quinnipiac University poll of US voters found that 63% of respondents believe that marijuana should be legalized and 93% support its use for adults with a medical prescription by a physician. The 2016 National Survey on Drug Use and Health estimates there are almost 38 million marijuana users in the United States. Thirty states and the District of Columbia currently have legalized marijuana in some form (most of these are so-called medical marijuana states). Eight states and the District of Columbia have legalized marijuana for recreational use.

Yet marijuana continues to be classified as Schedule I drugs under the Federal Controlled Substances Act and, therefore, illegal to manufacture, distribute, or dispense.

When it comes to the legality of medical efficacy of marijuana use, there are a number of factors at play. These include:

Pharmacology — how exactly do the relevant chemical compounds, THC and CBD, interact with the body? And, given the non-traditional routes of administration for marijuana (usually inhalation or ingestion), how can we anticipate or regulate what the response will be?
Adverse effects — we’ve all heard about the euphoria and impairment of memory, judgement, reaction, and other mainstream effects. But what about adverse physical effects? Or, the link to psychological disorders like depression, schizophrenia, or psychosis?
Efficacy — in some circles, marijuana is touted as a harmless cure with the ability to cure everything from cancer to chronic pain. The challenge with these claims is that there are few methodologically rigorous trials that can back the claims up. Is there something here for doctors to work with or should the claims be dismissed as nothing but rumors from idealistic hippies?
Workplace impact and safety — with additional increases in marijuana use, both recreational and otherwise, seeming inevitable, what is the link to workplace safety? And how can employers, insurers, and claims handlers respond?

As part of our dedication to staying at the forefront of medical advancements and opportunity, we have prepared a white paper and recorded webinar to dive deep into these questions. Using evidence-based research, we separate fact from fiction and seek to find out if there is legitimate use of marijuana in our industry’s future or if all the claims will go up in smoke.

Author: Dr. Marcos Iglesias is Broadspire’s senior vice president and chief medical officer with more than 25 years of experience in workers compensation, disability evaluation and treatment, and insurance leadership. Iglesias has a special interest in the prevention and mitigation of delayed recovery and disability. He is driven to help ill and injured workers live active, productive and fulfilling lives, which has led him to develop innovative, comprehensive disability management solutions that focus on returning workers to preinjury function. Iglesias is board certified in family medicine and utilization review and quality assurance. He is also a fellow of the American Academy of Family Physicians, American College of Occupational and Environmental Medicine and the American Institute of Healthcare Quality.

Filed Under: Medical Cost Containment

9 Spring Cleaning Tips for Your Workers’ Comp Program

February 28, 2019 by Michael B. Stack

Cold winter nights and non-stop snow storms across the country should not delay claim management teams from preparing for springtime. Now is the time to do some “spring cleaning” in your claims management program to make sure you are ready for summer. Part of this process includes a complete review of your program to ensure efficiency and effectiveness.

Know the Goals of Your Clients

Everyone talks about “meeting the goals” of your clients. Do you really know what those goals are? The process starts with meeting with your clients to better understand what they are trying to fix, accomplish or avoid. This will allow your team to concentrate their efforts on these areas to meet – and hopefully exceed their expectations. Common themes can include:

Complete Required Documents in a Timely Manner: Members of the claim management team are required to perform a number of functions in a timely manner. This includes the prevention of unnecessary costs associated with administrative penalties, excessive litigation costs, and delayed return-to-work.

Avoid Communication Breakdowns: Workers’ compensation claims are driven by information. Not having correct and accurate information results in time lost by individual claim handlers. Physical and psychological barriers need to be removed so all interested stakeholders can communicate in an effective manner.

Full Regulatory Compliance: The workers’ compensation system is driven by the details. This includes ever-changing requirements on when, how and where forms are to be filed.

Implementation of Claim Management Decisions

Proper execution of a client’s decisions is essential when running an effective claim management team.

Empower all team members to make decisions: Surround yourself with people who exercise good judgment and make informed decisions.

Keep the goals and objectives of the client, and keep them in mind at every decision. This includes using preferred service providers when necessary and a willingness to make recommendations.

Be a zealous advocate for the claim – integrity is key! Treat all injured employees with respect and dignity. This can be accomplished by returning calls in a timely manner and making all decisions in good faith. Never cut corners or try and save a buck by issuing frivolous denials.

Coordinate Efforts on Risk Assessment

There are numerous ways claim management teams can be involved in the risk management process. Key areas to focus on include the following:

Preparing effective job descriptions: There are a number of challenges employers face when engaging in the hiring process by the posting of an open position. Potential barriers include the American with Disabilities Act and other affirmative action considerations. A proper job description should be written in a comprehensive manner that includes the ability to accommodate all prospective employees.

Interviewing process: This part of the hiring process is fraught with dangers that lurk in every question asked of a candidate. During the interview process, it is important to focus on someone’s experience, training, and planning ability. It is also essential to set the right tone when it comes to workplace safety.

Global Settlement and Release of Employment Claims: Seeking a voluntary resignation and release of all employment claims is often a term of settlement employers request when settling a workers’ compensation claim. While employees are a valuable asset, seeking their resignation of employment can be a tool to reduce future exposure and limit liability. Consultation with an attorney who understands employment law issues is important when making these requests.

Review of Return-to-Work Policies and Procedures

Countless studies indicate that returning an employee back to work following an injury pays dividends. It is important for employers and other interested stakeholders to be fully invested in these measures as part of their workers’ compensation programs. This should not be limited to returning an employee to work with the date of injury employer. Other considerations should include the Ticket To Work program and “work to loan” efforts.

Conclusions

Spring is in the air – now is the time to review one’s workers’ compensation program. This includes a proactive claim management team meeting with their insureds and better understand their goals. Suggestions can also be made when it comes to assessing risk and getting injured employees back to work in a timely manner.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.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.

Filed Under: Implementation and Rolling Out Your Program

Paul H. Sighinolfi Joins Ametros as Senior Managing Director

February 27, 2019 by Senior Editor

Wilmington, Mass. (February 19, 2019) – Paul H. Sighinolfi has joined the Ametros Senior Leadership team as Senior Managing Director. Bringing with him a wealth of knowledge and experience, he will provide thought leadership and lead regulatory and policy initiatives, while providing meaningful strategic direction and insight.

“Paul and I have known each other for several years. He brings years of experience and a unique perspective,” says Marques Torbert, CEO of Ametros. “We are happy to have him on board to help Ametros continue to innovate and provide thought leadership in our industry.”

Ametros strives to enhance the lives of injured parties with innovative and affordable settlement solutions. Ametros focuses heavily on improving the health and well-being of injured workers ensuring that they live happier, healthier, and more productive lives post-settlement.

Sighinolfi is an attorney who brings over 30 years of experience in the workers’ compensation industry, most recently as executive director and chair of the Maine Workers’ Compensation Board. Previously, he was a partner at Rudman-Winchell, LLC., directing the workers’ compensation practice group. He also coauthored Maine Employment Guide: Workers’ Compensation and has been a frequent speaker throughout the country on various workers’ compensation topics.

“Paul’s experience as the head of the workers’ compensation system in Maine, in addition to previously serving as both a plaintiff and defense attorney gives him a complete view of all sides of our workers’ compensation system and makes him a wonderful fit for our company,” Torbert says.

The International Association of Industrial Accident Boards and Commissions (IAIABC) elected Sighinolfi to its Board of Directors in 2014, and he served as its Board Vice President until earlier this year. He is a fellow of the American Bar Association, College of Workers’ Compensation Lawyers, and was formerly on the Executive Committee of the Southern Association of Workers’ Compensation Administrators.

Additionally, Sighinolfi has served as a director on the boards of several non-profit organizations, including Ronald McDonald House Charities of Maine, the Bangor YMCA, and the Girl Scouts of Pioneer Valley.

Sighinolfi earned his master’s degree at Trinity College in Hartford, Connecticut and his law degree at the Columbus School of Law at Catholic University of America, in Washington, D. C.

“I’ve worked in many aspects of workers’ compensation, and I truly believe what Ametros is doing is on the cutting edge of the industry,” says Sighinolfi. “I’m thrilled to be joining the Ametros team.”

ABOUT AMETROS

Ametros is the industry leader in post-settlement medical administration and a trusted partner for thousands of members receiving funds from workers’ compensation and liability settlements. Founded in 2010, Ametros provides post-settlement medical management services with significant medical and pharmacy discounts along with automated payment technology and Medicare reporting tools. Headquartered just north of Boston in Wilmington, Massachusetts, Ametros may be reached at 877.275.7415 or via www.ametroscards.com

CONTACTS

Ametros
Melissa Wright, 978-381-4329
mwright@ametroscards.com

Filed Under: Professional Administration

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21st Century Skepticism in Science and Effects on Medical Care

Over-Reserving and Your Bottom Line

Detecting Workers’ Compensation Fraud

You’re Fired! Using Employment Release and Resignations in Work Comp Cases

Marijuana: A Medical Perspective

9 Spring Cleaning Tips for Your Workers’ Comp Program

Paul H. Sighinolfi Joins Ametros as Senior Managing Director

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