Work Comp Roundup -

The Work Comp Tool Box: Employing Creative Strategies to Settle Cases

July 16, 2019 by Michael B. Stack

Settling workers’ compensation cases is an important part of being a proactive and effective member of the claims management team. It also allows interested stakeholders to concentrate their efforts on other more burdensome cases. Most importantly, it reduces unnecessary costs to a program’s bottom line. Working with an experienced workers’ compensation attorney can ensure you get the best agreement for both the employer and the injured worker.

What is the Claims Management Toolbox?

Having a “toolbox” at one’s disposal is important to being a great claims handler. Like a toolbox a mechanic uses to practice their trade, claim handlers need one as well to fix, accomplish or avoid a number of issues. Caution – use these tools with care and only when necessary.

Limited Compromise Settlements

All members of the claims management team will agree, the only good file is a closed file. In some instances, this is not possible given the interests of the claimant or on advice of their attorney. In cases that cannot completely settle, a claims handler should examine whether the claim presents an opportunity for a limited compromise settlement.

Under this type of settlement, indemnity benefits such as TTD, TPD, PPD and PTD are closed out. The only benefits available to the employee include past and/or future medical benefits.

Limited Compromise Settlements have some advantages:

Reduces costly exposures that may be present on a claim. This is especially the case when an employee is not incurring much in terms of ongoing medical benefits, but is struggling with return to work issues; and

Studies indicate claimants in workers’ compensation claims tend to reduce the frequency of their medical care and treatment after closing out indemnity benefits. Limited compromise settlements that leave open future medical benefits can also be helpful in instances where the parties may want to consider a Medicare Set-aside, but the cost and/or future medicals that are reasonable is astronomical.

Effective use of Hold Harmless Agreements

A “hold harmless” agreement is another tool members of the claims management team can use to settle cases. When using such agreements, the parties to a settlement are creating a contract where one party agrees to release another from all legal claims. In the context of workers’ compensation claims, this is mainly used when it comes to the reimbursement of past or future medical expenses and liens.

Such agreements can be used in many instances to expatiate settlements. This includes:

Delay in the receipt of medical bills related to a claim where the amount is either known, or reasonably expected to be known; and

One party to a claim has the ability to extinguish the interests or potential intervention rights of a known third-party.

Hold harmless agreements should be used with caution. While such agreements “require” cooperation from the party receiving protection, it might not necessarily be the case if litigation occurs. In fact, the indemnified party (the party receiving protection) may need to engage in litigation in order to secure cooperation.

Hold harmless agreements should also be avoided in instances where Medicare and Medicaid have an interest in a claim. The statutory framework establishing these federal programs does not prevent the applicable government agency from enforcing their rights against any party to a workers’ compensation claim. This rationale has been affirmed by a long line of case law interpretations.

Other Tools for Effective Claim Resolution

Settling workers’ compensation claims requires members of the claims management team to take affirmative steps to remove barriers to settlement by using their toolbox.

Develop strategies on their teams to identify cases ripe for settlement and take steps to close files. This sometimes includes picking up the telephone and making a settlement inquiry or offer. Once identified, these cases can be submitted to a competent structured settlement consultant who may be in the best position to determine the likelihood and course for settlement;

Using mediation and promoting the use of settlement conferences to move claims toward a timely resolution. Be prepared for these events. One may also want to consider bringing a laptop computer and printer to these sessions. This allows for the drafting of the settlement agreement on the spot and avoid delays in final execution; and

Implement effective medical management programs to lower prescription drug costs on all files.

Conclusions

The development of a claims “toolbox” is one step interested stakeholders can use to reduce workers’ compensation costs. This is accomplished by promoting the closure of files, or at a minimum resolving some issues on a file to narrow the issues in dispute.

Michael Stack - Amaxx 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 the founder & lead trainer of Amaxx Workers’ Comp Training Center.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://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

Sit Up and Take Note: The Truth about Ergonomics

July 15, 2019 by Ashley Clay

Article originally published on Medcor Health Blog

Does your back hurt? Are you experiencing neck pain? Do you find yourself complaining of hand, arm, knee, or muscle aches? If so, you may be suffering from a musculoskeletal disorder (MSD). Discomfort/pain, numbness, tingling, stiffness, burning, cramping, and swelling of bones, joints, muscles, tendons, and ligaments can be symptoms of MSDs. If work or leisure activities are causing discomfort – it is time to become more ergonomically aware.

MSDs are conditions of muscles (sprains/strains), tendons (inflammation), ligaments, joints (arthritis), and nerves that are often associated with exposures to ergonomic risk factors, including: awkward postures, repetition, force, contact stress, and vibration.1 Age, sex, obesity, and health conditions (i.e., diabetes, rheumatoid arthritis, and hypothyroidism) can also play a factor.

Truth: Being Aware Of Ergonomic Risk Factors Can Significantly Reduce Your Chance Of Developing MSDs

Being aware of ergonomic risk factors can significantly reduce your chance of developing MSDs which have costly and disabling effects for many Americans. An estimated 126.6 million Americans aged 18 and older suffer from MSDs – that is one in two adults.2 Costs related to MSDs involve treatment (medical visits, prescriptions), lost wages, and work-related injuries, estimated to exceed $200 billion annually.3

MSDs often result in chronic complaints, disability, issues with mobility and decreased quality of life and are the second largest contributor to disability worldwide. Frequently, MSDs result in work-related injuries impacting worker’s compensation costs, absenteeism, and productivity.

Truth: One-Third Of Million Nonfatal Workplace Injuries/Illnesses Result In Days Away From Work

The U.S. Bureau of Labor Statistics reported that approximately 2.8 million nonfatal workplace injuries/illnesses occurred in 2017, one third of those resulted in days away from work. MSDs represented 32% of those injuries.4

Employers and workers share in the responsibility to help reduce risk factors by understanding ergonomics, taking actions to decrease those risks, and promoting best work practices throughout the organization. Ergonomics involves everyone.

Truth: Ergonomics Help The Job Fit The Worker

Ergonomics includes engineering, administrative, and personal controls to help the job fit the worker, rather than trying to have the worker fit the job.5

Engineering controls include: workspace design, reducing the weight of loads or applying lift-assist devices, automating processes, and re-designing tools to promote neutral postures.6

Administrative controls focus on establishing work practices to reduce the risk of injury and encompass actions such as job rotation, managing over-time, providing adequate staffing, reviewing injury logs, performing accident investigations, promoting near-miss reporting, providing employee education on MSDs/risk factors, encouraging early reporting of work-related injuries/illnesses, implementing break and stretching schedules, discussing work load and job satisfaction with employees, and maintaining equipment and tools.7 Providing ergonomic friendly accessories, such as: adjustable table/chairs, lumbar supports, footrests, arm supports, document holders, sit/stand work stations can each promote the job fitting the worker.

Personal Controls

Lastly, personal controls include the appropriate use of personal protective equipment (PPE), being mindful of posturing, alternating between sitting and standing, reporting of work injuries at the first sign of discomfort, participating in ergonomic stretches/micro-breaks and safety committees.8 Everyone should be mindful of posturing (feet flat on the floor or footrest, back supported, elbows close to body, avoid slouching, keep neutral postures), avoid awkward positions (bending the neck, static postures, placing wrists at extreme angles, working above shoulder height, stooping/crouching), reduce unnecessary movements, limit carrying heavy loads, avoid excessive bending and twisting, avoid over reaching, and keep frequently used items within a safe reach zone.9

Implementing ergonomic awareness and promoting a culture of safety and overall total worker health will reduce the risk of work-related injuries, increase productivity and job satisfaction, decrease costs associated with worker’s compensation and health premiums. The truth is, awareness goes a long way in preventing injury.

This article is not meant to diagnose or treat any condition. Always consult your primary care provider for healthcare instructions.

Author Ashley Clay, MSPAS, PA-C, Medcor Provider. 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. Headquartered in McHenry, Illinois, the company operates 174 clinics and provides triage services to over 90,000 worksites across all 50 states and US territories. Medcor’s triage methods are covered by U.S. & foreign patents, including U.S. No. 7,668,733; 7,716,070; & 7,720,692; other patents pending. Medcor is privately held. Learn more at www.medcor.com.

Occupational Safety and Health Administration, “Ergonomics: Overview,” accessed March 15, 2019, https://www.osha.gov/SLTC/ergonomics/index.html.
Bone and Joint Initiative USA, “The Impact of Musculoskeletal Disorders on Americans—Opportunities for Action,” Executive Summary of The Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal and Economic Cost, third edition.
Ibid.
United States Bureau of Labor Statistics, “2017 Survey of Occupational Injuries and Illnesses Charts Package,” https://www.bls.gov/iif/osch0062.pdf.
Occupational Safety and Health Administration, “Ergonomics: Overview,” accessed March 15, 2019, https://www.osha.gov/SLTC/ergonomics/index.html.
Occupational Safety and Health Administration, “Ergonomics: Solutions to Control Hazards,” accessed March 15, 2019, https://www.osha.gov/SLTC/ergonomics/controlhazards.html.
Ibid.
Ibid.
Washington State Department of Labor and Industries, “Ergonomics Principles for Reducing Awkward Postures,” accessed March 15, 2019, http://www.lni.wa.gov/Safety/SprainsStrains/AwkwardPostures/ReducingAwkwardPostures.pdf.

Filed Under: Wellness Programs and Workers Compensation

Watch Chiropractic Care for Excessive Medical Bills

July 11, 2019 by Michael B. Stack

The use of chiropractic care is a recognized way to treat many workers’ compensation injuries. This includes injuries to joints, the back, and neck. If an injured employee is receiving medical care and treatment through a chiropractor, it is important to take note of several issues that will save money in a workers’ compensation program. It is also essential to develop effective claim handling techniques to get the employee back to work promptly.

Areas of Concern with Chiropractors

By definition, chiropractors are considered “doctors” who are capable of providing medical care and treatment in workers’ compensation cases. They are sometimes suspect as they do not have a formal medical education that an “MD” obtains through an accredited medical school. The focus of their medical education is concentrated on the diagnosis, treatment, and prevention of disorders of the neuromusculoskeletal system. There is also an emphasis on a holistic approach to health care that includes an understanding of the central nervous system plays.

Factors to Consider When Evaluating Chiropractic Care

There are various areas where members of the claim management team should focus their review of billing and provider issues related to chiropractors. These areas should include the following:

Evidence of a reasonable treatment plan: This plan should be reasonable based on the nature and extent of the work injury. It should include information on the duration of care and its frequency.

Documentation of the details of the treatment: A common complaint of chiropractors is their treatment notes outline the same complaints and care provided with every visit – it is almost as if the provider was using the “copy/paste” function on a word processor.

The degree and duration of relief resulting from the treatment: A review of what is stated in chiropractic medical records should always be reviewed for consistency. This includes whether the care being provided is advancing the patient’s care and consistent with their deposition testimony, and findings at an independent medical examination.

The frequency of treatment: This element evaluates how often the injured employee is treating and how they are scheduling appointments. Initial care with a chiropractor is typically set at certain intervals. After a period of time, that care should diminish, or be on an as-needed basis.

The relationship of the treatment to the goal of returning the employee to suitable employment: A successful return to work should be the goal of any medical care and treatment provided to an injured employee. This becomes paramount when dealing with chiropractic care as frequent, ongoing care can leave someone at their baseline with no improvement in pain relief or functional ability; and

Cost of Chiropractic care: This is an important factor to consider, especially when an injured employee is seeking approval for care after 10-12 weeks of care.

Issues to Review When More Care is “Required”

When it comes to chiropractic care, it is important to obtain detailed information from the injured employee on how they were referred to the chiropractor. Closer scrutiny should take place when this is someone the employee has seen in the past or based on a family member referral. A claim should be heavily scrutinized if the chiropractor shares a building with, or located in close proximity to a physical therapist also treating the injured employee.

Other issues to consider when challenging excessive care, or approving additional chiropractic care should include:

The injured employee’s opinion as to relief obtained;

The duration of relief from symptoms;

Whether symptoms return once care stops;

The use of other “alternative” medical care;

Whether the injured employee is psychologically dependent on chiropractic treatment;

Whether the frequency of treatment is warranted;

The cost/benefits analysis regarding treatment provided compared to the relief obtained;

The employee’s overall activities and the extent of the employee’s ability to work; and

The potential for aggravation of an underlying condition.

Conclusions

The goal when approving medical care and treatment should always concern the nature and extent of the injury and getting the employee back to their pre-injury condition. This can be obtained through chiropractic care. When handling a claim involving this treatment modality, it is important to be vigilant and ensure it is effective in providing lasting relief.

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: http://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: Medical Cost Containment

Ensure Your Workers’ Comp Files Are Properly Documented

July 10, 2019 by Michael B. Stack

It is important for members of the workers’ compensation claim management team to document their files properly. If you do not have access to the electronic claims file, now is the time to ask. If not, it should be a condition of claim handling agreement with your third-party administrator (TPA) or insurer.

What is in a Properly Documented File?

Several items need to be in a properly documented claim file. Important issues concerning coverage should be addressed at every step of the claim. This should include:

The policy number;

The policy coverage period;

The states or jurisdictions covered by the policy;

Endorsements to the policy; and

Exclusions from the policy coverage.

If you have questions, be sure to ask – and demand prompt answers before the adjuster proceeds with the contacts and with the investigation.

Points of Contact Following a Work Injury

Prompt contact with all parties should be initiated immediately after the report of the claim. Demand action is being taken on the same day a claim is received, or within 24 hours of the loss. Points of contact should include, but not be limited to the following:

The employee;

The employer;

Any witnesses to the injury. All contact information for witnesses should be included as people change jobs over time; and

The medical provider(s), including ambulance services and law enforcement responding to a work injury.

The clock is ticking. Steps taken during the initial phase of a claim are important. Other important notes from a claim handler should be noted. Important information to obtain should include:

Accident details as stated by the employee in the recorded statement, the employer’s version of the accident, and any witnesses’ version of the accident;

Index Bureau information and any history of prior insurance claims;

Analysis regarding the potential for subrogation;

The current disability status of the employee, and projected return to work date;

The employee’s job description, including title, duties, equipment utilized, etc.;

Length of time the employee has worked for the employer;

The availability of modified duty for the employee not yet back to work;

Information on the nature of the injury, the treatment plan, diagnosis, and the prognosis;

Subjective information such as the employee’s attitude toward the employer, returning to work, and the quality of the medical treatment;

The explanation of benefits provided to the employee and the action plan information provided to the employee;

If there is an attorney representing the employee, if so, obtain the representation agreement.

Moving the Work Comp Claim Toward Settlement

Any time is the right time to move a workers’ compensation claim toward settlement. Steps toward resolving the claim can also be taken after a work injury. Part of this process includes obtaining documentation that is required to evaluate the claim and set reserves. Documentation the claim handler needs can include:

First Report of Injury;

Recorded statements of the employee, the employer, and any witnesses;

Medical authorizations. These will be needed to obtain a complete set of medical records regarding other conditions possibility contributing to the employee’s disability;

Wage records from the employer to calculating the average weekly wage;

Complete set of medical records. This may include past records, records related to the work injury, and for other records created in the future;

Other required state workers; compensation forms;

Police reports, EMS reports, OSHA reports, other governmental reports on an accident;

Independent medical evaluations (IME) or peer review;

Vocational and rehabilitation reports;

Subrogation documentation;

Second injury fund correspondence and/or documentation;

Correspondence to/from employee’s attorney;

Correspondence to/from defense counsel;

Workers’ Compensation Board/Industrial Commission correspondence and records; and

File notes on every telephone call, e-mail, or any other activity related to the file.

The claim file may also contain other important information on the claim handler’s efforts to resolve the claim, including:

Case evaluations and status reports regarding causation, legal defenses, and settlement;

Exposure analysis and case valuation;

A synopsis of any legal questions and the efforts to resolve those questions;

Information concerning the disability rating or the potential disability rating;

Legal analysis regarding a litigation strategy;

The “action plan” to bring the claim to a conclusion; and

A history of the settlement negotiations.

Conclusions

The claim handler’s file notes contain the main details of all file documentation received regarding a workers’ compensation claim. It is important for employers to play an active role in every workers’ compensation claim and be engaged. Failure to do so can prove to be costly and increase program costs. The file documentation itself, whether maintained in the computer or by paper, must be complete and answer any questions you have about the file.

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 the founder & lead trainer of Amaxx Workers’ Comp Training Center.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://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

Workplace Safety for Non-English Speaking Employees

July 9, 2019 by Michael B. Stack

The American workplace continues to evolve and workplace safety for non-English speaking employees is paramount. Stakeholders running an effective workers’ compensation program need to be aware of this issue and implement policy to ensure workplace safety.

The American Workforce – By the Numbers

America has always been a land of opportunity for people with many backgrounds. In the past, immigration was mainly driven by European populations seeking a fresh start. Times have changed. This now includes shifting immigration patterns with people from Africa, Asia, and Latin American countries coming to the United States in search of a dream.

Unlike immigration in the past, newer immigrants are not dropping their native language for English. This presents a challenge to employers as they seek to promote a workplace that reduces work injuries. Now is the time to act.

Workplace Injuries and Hispanic Populations

The American Society of Safety Professionals has paid particular attention to workplace safety for non-English speaking Hispanic employees who may generally speak Spanish as their primary language. Studies indicate the following characteristics:

Nearly 70% of Hispanic employees who died in the American workplace were born outside the United States;

Hispanic immigrants account for over 20% of the construction workforce in the United States. These are jobs that require employees to work at heights and use safety equipment to prevent falls. Impacted industries include roofing, ironworkers, and other physical labor positions. A common denominator in these fatal incidents is workers not using proper equipment, work practices used in their native country (or by custom), or not being trained in the use of required equipment; and

Employees identified as Hispanic account for 15% of all fatal injuries – a rate of 3.7 per 100,000 full-time equivalent (FTE) employee, compared to a rate of 3.5 per 100,000 FTE for workers as a whole.

Avoiding Workplace Stigmas

All interested stakeholders in the workers’ compensation system should ensure employees, especially those who do not speak English as a primary language, are treated with respect and dignity. This is an opportunity to put aside differences of opinion people have regarding immigration (legal and illegal) and make sure employers step up when it comes to making the workplace safe, and ensuring work injuries are reported in a timely manner. In sum, one’s immigration status should never serve as a barrier to denying workers’ compensation benefits. This is a policy decision best left to state legislatures, and not one’s personal preference.

Taking the Next Step – Creating a Positive Work Environment

The first step to ensure workplace safety for non-English speaking employees is making sure everyone is on the same page when it comes to employment practices, and safety education. Steps interested stakeholders should consider can including:

Hiring safety individuals that speak multiple languages. If an employer has a significant number of Spanish speakers on staff, efforts should be made to have a safety professional who is fluent in that language;

Educate non-English-speaking employees on proper safety standards and procedures. This includes creating materials in other languages and reinforcing these best practices in the field; and

Involve all interested stakeholders in the safety process. This includes management, and organized labor. It is important to lead by example!

Additional attention needs to be geared toward employees who generally work as day laborers. These are people who typically work for someone for a short period of time – sometimes only a few hours on occasion. People involved in the workers’ compensation system can also ensure these employees understand the system, know how to report a work injury, avoid common errors such as working for employers without insurance coverage, and engaging in safe work activities.

Conclusions

The changing American workforce places many demands on employers and employees. One such change is to ensure workplace safety for non-English-speaking employees in the workplace. Now is the time to get engage and ensure these workers understand the process, receive proper safety training, and have access to resources to promote a better work environment

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://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: Safety and Loss Control

Five Effective Ways to Communicate Safety Messages

July 8, 2019 by Michael B. Stack

Communicating safety messages needs to be communicated consistently and continually. It is something that needs to involve all interested stakeholders. Taking the following steps can ensure the workplace remains safe for all employees, and provide a consistent response once an injury occurs.

Five Suggested Ways to Communicate Safety Messages

A safe workplace starts with an employer dedicated to safety. There are countless opportunities to communicate safety messages and promote a safe work environment. It starts with a commitment by all interested stakeholders to be involved in the process and not putting profit ahead of safety.

Employee Safety Meetings (for all shifts): Taking this step reinforces the message that safety is important in the workplace. Anyone from the president to mailroom clerk can talk about safety and promote a better work environment, but it is important for those who are perceived as leaders to do the talking – job titles do not matter. These leaders should also practice what they preach to ensure follow-through.

Posters and Bulletins: This can go beyond posters required by law. Keeping safety reminders visible and in conspicuous places around the workplace reinforces important safety reminders. Dedicated employers can also have posters produced in different languages if any employee does not commonly use English as a primary language. Graphics can also reinforce the message of a safe workplace.

Newsletters: Every company newsletter should include a blurb about safety. It can highlight changes suggested by an employee on how the workplace became safer. It can also update employees on changes to protocols and procedures. Other common highlights can include information on how to report a work injury and where to receive medical care and treatment.

Safety Suggestion Box: People are sometimes afraid to make suggestions on how to improve workplace safety. Anonymous suggestion boxes can provide people the ability to make suggestions. It is important to follow-up and highlights how these suggestions improved a defective condition and how remediation was made.

“Toolbox” safety talks conducted informally by supervisors with their employees: Safety should be emphasized every workday. Supervisor and managers can play an important role in explaining to their direct reports on how work injuries impact company and program efficiency. Do not be afraid to go beyond the basics when it comes to safety.

Other Requirements: Beyond the Basics of Workplace Safety

Training records must be kept that refer to federal and state regulations related to workplace safety. It is important to offer safety training in languages that match the workplace demographics.

Employers should also consider the implementation of a Safety Recognition Program. Before developing a Safety Recognition Program, consider the following:

You cannot “buy” safety, but you can expect safe behavior and recognize employees who deliver.

Concentrate on results (i.e., fewer injuries) AND on behaviors (i.e., use of personal protective equipment, safety inspection scores).

Establish clear, measurable goals for both results and behaviors.

Employees should know that there will be serious consequences for not reporting accidents.

Awards should have true value and be more than just cash (something tangible to remind the employee why they won the award and presented by senior management during an employee celebration (pizza party, for example).

Senior management must completely support the Safety Recognition Program and be visible in the process.

Consider rewarding individuals for safe behaviors and groups for safety results.

Conclusions

Now is the time to communicate safety messages and promote safety in your workplace. This requires all parties to be fully engaged, and leadership in management to follow through on their commitments. This includes effective communication and engaging employees on all aspects of a safe work environment.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://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: Safety and Loss Control

The RED FLAGS of Workers Comp Fraud

June 19, 2019 by Michael B. Stack Leave a Comment

A critical part of controlling workers’ compensation costs is to put into place solid investigation techniques. No matter how severe or minor a workplace injury, each case needs to be reviewed to identify any fraudulent claims and take appropriate action.

When communicating with employees, make it clear that the company will:

Immediately investigate each accident when it occurs to determine the root cause

Identify corrective measures

Watch for minor extensions of days out of work and outright fraudulent claims.

Review these Red Flags of Fraud and request an investigation if you suspect a claim is illegitimate or exaggerated.

Injured Worker Red Flags:

Injury reported late, to an attorney or to the state commission before reporting it to the employer.

Fails to attend weekly meetings.

Is uncooperative, e.g., refuses to try a transitional duty job.

Is never home when you phone, especially during regular workday hours.

Has only a postal box rather than a home address.

Misses doctor appointments.

Is known to perform seasonal activities, hobbies, or work.

Has moved out of town or out of state.

Disputes average weekly wage due to additional income.

Files for benefits in a state other than the main location.

Disputes information supplied by the employer on “First Report of Injury” notice.

Refuses to cooperate in claim investigation.

Has an unstable work history.

Has recently been terminated, demoted, or passed over for promotion.

Has a prior history of injury management or liability claims.

Makes excessive demands or is pressing for a quick settlement.

Carries little or no health insurance.

Medical Flags:

Medical reports are repetitive, indicating continuing, constant pain with conservative medical treatment

The word “disproportionate” is used in medical reports

The doctor mentions there is “facial grimacing”

Positive “Waddell Tests” (test for low back pain) are mentioned

Workplace Flags:

Employer experiencing labor difficulties (i.e., layoffs, strikes, walkouts).

Tips from fellow workers, friends, or relatives.

The insurance company wants to settle the claim for a considerable amount of money.

“Things” just don’t ADD UP! Trust your gut, and if something seems off, be sure to check it out.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://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 Tagged With: Combating Fraud, Controlling Fraud, Fraud & Abuse, Lowering Work Comp Costs, Red Flags of Fraud, reduce workers comp, reduce your workers comp, Reduce/Lower WC Costs, Reducing Workers Compensation Costs, WC Fraud, workers comp, Workers Comp Fraud, Workers Compensation

Top 5 Misconceptions Surrounding Workers Compensation

June 18, 2019 by Rebecca Shafer, J.D.

Everyone has opinions on what workers comp is. Some are correct, but most are misconceptions. The commercials seen on TV about people collecting hundreds of thousands of dollars are not true for the average claim. When looking at the bottom of the screen it indicates that the people on the commercial are actors, not even the real claimants. Most of the marketing material surrounds auto and liability accidents, where pain and suffering are translated into a certain dollar amount. This is not exactly true in workers comp. There is no pain and suffering payment. Insurance companies/TPAs are there to provide reasonable and necessary medical treatment and wage loss. Some states even allow a permanent partial disability payment, or impairment rating, on top of wage loss, but that is it.

Below we discuss the top 5 misconceptions surrounding the mystery world of workers compensation. Not all of these will apply exactly to every jurisdiction but are general. Remember to discuss with the adjuster and counsel any exact questions surrounding certain details regarding.

Workers Compensation is not Welfare

Compensation is not a free payment a worker is entitled. Just because you are injured at work, it does not mean a guaranteed payment or coverage for medical/wage benefits. There are a lot of criteria to meet in order for a claim to be compensable. Even if the claim is compensable, it also does not mean anything can be done. Claimants have to play by the rules and do as they are told by the adjuster. The adjuster must make the effort and take the time to explain to each claimant what the rights are, and what they can and cannot do. The biggest issue is miscommunication between the carrier/TPA and the claimant, so having an open dialogue will end any misconceptions that a claimant may have in regards to what their rights are, and what is covered; if indeed the claim is determined to be compensable.

Nobody gets rich from Workers Compensation

Depending on the jurisdiction, employees give up the right to sue in civil court in exchange for what are essentially no-fault benefits. Workers compensation pays lost wages, medical care, and vocational rehabilitation. Pain and suffering as an additional payment is not available or applicable to a compensation claim. The amount of money a person receives is a percentage of average gross pay. There are typically no increases for inflation, and each state has a maximum limit that a person can get per week as workers comp payments.

Michigan, for example, has a maximum rate of $921 per week (as of 2019). So even grossing $2000 per week as an average weekly wage, that amounts to $921 per week in Michigan. High-wage employees that fall into these criteria are usually not very happy when they find this out, but the rules are the rules. These statutes are set up within the workers’ compensation system, and they have to be followed by all parties. Even if a claim is settled for a certain amount of dollars, it is typically not a retirement jackpot. It may end the exposure for the carrier/TPA, but these claims that settle for very high amounts of money are the result of a very serious, extremely disabling injury. And even those are few and far between.

Workers compensation benefits will be stopped if the worker declines reasonable employment.

If the employer offers up a light duty job, within the injured employee’s medical restrictions, a claimant cannot refuse it and still get paid wage loss benefits. This opens a Pandora ’s Box, because an issue will come up about whether this light duty job is something an injured worker is trained to do or is the job offer seen as an insult to their professional skills, etc. If there is a welder sitting in a chair staring at a clock for a job, then maybe a case could be made that this work is not a benefit to the company. For light-duty jobs, they have to be deemed something that the employer gets a “gain” from performing, and almost all jobs within an employment facility can fall within these parameters. Certainly, if you provide a degrading job that is of no benefit, then you may get into legal trouble. But in all reality, I do not think any employer would take a risk in stopping a compensable case by trying to make a person sit outside and stare into space.

The bottom line is any light duty job, that provides a service to the employer, must be performed if it is offered to the injured worker. If the worker declines, then wage benefits will cease.

Workers comp fraud is extremely low

Actual workers comp fraud is less than 10% of all claims. And that number may even be high; I would go as low as 5% or less. For a case to be deemed as fraudulent, it must meet certain criteria within whatever state statutes are in the jurisdiction. That is hard to meet, and most cases will not even come close to being worth the pursuit of fraud in a legal court case. If a certain worker is claiming to be out of work, and you get surveillance of them outside roofing their house, this may not make the case actual “fraud,” it falls more within the injured worker not following their medical restrictions and going outside of their treatment plan as deemed appropriate by their treating doctor. This will provide the adjuster with the ammo to dispute ongoing benefits, but not exactly to pursue the case as overall fraud.

Workers comp fraud, as a whole, is not a major problem within the worker comp system. Sure there are a lot of people that do not follow their medical restrictions, or they may miss doctor appointments, or ignore physical therapy demands, but this provides only a dispute for ongoing medical benefits, not fraud. There is a difference between the two. If you think you have an actual fraud case, you need to discuss it right away with the carrier/TPA and counsel before taking any such action to pursue official fraud in a legal venue.

The vast majority of workers comp claims are paid and do not go to court

Generally, most comp cases are accepted, the injured worker gets treatment, and eventually goes back to work. The idea that someone stays home and avoids work when they are able to actually work is not the norm. Sure, there are those people out there who try to do what they can to avoid going back to work, but after an independent medical exam (IME) is performed, or after some surveillance discovers them being active out and about running errands, they are quickly flushed out and denied ongoing benefits.

Typically after a denial, and wage loss payments stop, these workers get on the wagon and get their treatment, so they can return to work and have their comp case end. Some will run to plaintiff counsel and try to get what they feel they are entitled to, and they will file for mediations and hearings, but the litigation usually is settled before a case is tried in front of a judge. Doctors can disagree on the causal relation of an injury, and this can speed up the case to go into litigation, but these cases are typically settled within 2-6 months. A low percentage of claims will stay in the litigation system, and go on for months or years, but these cases are usually quite complex and can involve several defendants and several employers, and that contributes to the complexity and the duration of the litigation. For the most part, on the normal workers’ comp claim that gets disputed and goes into litigation, these cases resolve themselves in the early stages of litigation and the files eventually close. But even those cases are not the common ones. The common claims are legit injuries, where benefits are paid and the worker returns back to work at full duty within whatever timeframe is needed depending upon the severity of the injury.

Summary

Everyone may have heard of someone that tried to get away with milking the comp system. Most of these people are caught through a good investigation, and their cases get resolved. The stereotype of work comp being a total pain can be true in some cases, but for the most part, work comp claims are legit, paid, and the worker returns back to work. There are always some exceptions, but if all parties communicate, know what their rights are, and know what they can and cannot do, their claims are resolved as quickly as possible and everyone can move on with their respective lives.

Rebecca Shafer 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: http://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: WC 101 Tagged With: WC 101, Workers Compensation

Protecting the Injured Employee in Workers’ Compensation is Paramount

June 17, 2019 by Senior Editor

The injured employee is the reason workers’ compensation laws exist. Without employees and their sacrifice, businesses would not accomplish their goal. Now is the time for every member of the claim management team to approach claims with this critical mindset.

Forget the Golden Rule – Follow the Platinum Rule!

The “Golden Rule” taught us to “treating others as one’s self would wish to be treated.” This is a common denominator handed down in both secular and religious societies. The problem with this Rule when applied to workers’ compensation claims is it view things from the perspective of the claim handler. Now is the time for members of the claim management team to put themselves in the shoes of the injured employee, and follow the Platinum Rule – To treat others as you would want to be treated!

By adopting this mindset, one will realize the following:

Being a true professional in every sense of the word is essential;

Treating all employees – regardless of ability with the respect and dignity they deserve is essential; and

Engaging every claim with good faith, fair dealing, and placing ethics at the pinnacle of every decision is essential.

Protecting the Injured Employee Through Injury Prevention

Members of the claim management team can be proactive when it comes to preventing injuries in the workplace. This can include educating their insureds on best safety practices. Their obligations also extend to their post-injury response. Here are some important steps include in every workers’ compensation claim:

Avoid unfair claims practices and bad faith denials;

Complete a timely and thorough investigation of all injuries;

Not exploited the financial vulnerabilities of policyholders;

Not make unreasonable demands on the policyholder during the claim process; and

Take all reasonable steps to preserve evidence.

Employers also play a role in this process. It must include promoting a culture of safety. Steps should include:

Evaluate workplace ergonomics continually;

Allow regular breaks for employee – especially those performing repetitive tasks;

Ensure the proper use of machinery, tools, and safety equipment – never cut corners; and

Lead by example!

Getting the Injured Employee Back to Work

Interested stakeholders need to take the lead on return-to-work issues and dispel the common myths that prevent employers from protecting their MVPs. Common misconceptions of injured employees include:

Injured employees are lazy – they sit around all day and do nothing;

Injured employees would rather stay at home;

Injured employees will only get re-injured – we need to get a voluntary resignation on every workers’ compensation claim; and

Injured workers receiving Social Security Disability are not allowed to return-to-work.

FACT: A vast majority of injured employees would rather get back to work. Getting them back to work can reduce program costs.

The challenge of effective return-to-work requires all interested stakeholders to move past the physical, educational, medical, and emotional barriers inherent in the workers; compensation system. Important steps to consider include:

Communication with the injured worker. This can include having a dedicated liaison for any employee off work. Employers can buy goodwill by returning phone calls from an employee not able to work due to restriction. They should also be proactive in initiating contact with an employee.

Communication with treating doctor. A return-to-work liaison can also serve as a point of contact with the employee’s treating physician. This can also include making certain communications between the physician and workers’ compensation insurer is taking place.

Providing legitimate written job offers. The requirements of job offers vary in each jurisdiction. It is important specific elements are satisfied. There are other legal requirements where consultation with an attorney may help facilitate this objective.

Interested stakeholders should also consider learning more about, and implementing a “Work on Loan” program, or hiring an injured employee through the Social Security Administration’s “Ticket to Work” program.

Conclusions

Employees are of paramount importance to every workers’ compensation program. Treat them respect and dignity. To run an effective and efficient program, interested stakeholders need to understand their claims, assess and evaluate risks, and look for opportunities to engage all parties in the process.

Michael Stack - Amaxx 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: http://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: Management's Role in Workers Comp

ADA – Is it against the law not to hire a person with a disability for a physical position?

June 13, 2019 by Attorney Aaron Konopasky

We had very successful wc mastery training recently on How to Coordinate Return to Work with ADA Compliance. There were many questions from the audience. Find below the responses to the questions related to the Interactive Process given by Aaron Konopasky, Senior Attorney Advisor, US Equal Employment Opportunity Commission, and Michael Stack, Risk Consultant, Co-Author Your Ultimate Guide to Mastering Workers Comp Costs

This post is one of a series as a follow up to training:

A prior training on Return to Work and the ADA initiated the following questions:

If a person with a disability applies for a physical position, is it against the law not to hire them?

Additional information: I work at a pharmaceutical packaging plant. The line operator job tasks are physically demanding, they have to lift, bend, squat, etc.

The answer to this question depends on several factors. Some disabilities will not affect the ability to do these things (e.g., someone with a psychiatric disability may be perfectly able to do this). Some people with disabilities might be affected, but because their condition is under control it wouldn’t actually interfere (e.g., epilepsy). In some cases, it will affect the ability to do the job, but a reasonable accommodation would overcome the difficulty. (Without knowing the details, it’s hard to come up with a realistic example of this. But perhaps a modified workstation would be an example.)

The employer must consider the possibility of reasonable accommodation before rejecting the individual. However, if the individual could not accomplish what he or she is required to accomplish even with a reasonable accommodation (or if all effective reasonable accommodations would cause undue hardship) then he or she is not qualified and may be rejected.

When we do the interactive process, when and how do we coordinate the workers’ compensation carrier/administrator?

Both the ADA law and workers’ compensation best practices run concurrently, and it is recommended to do everything required under both systems. Following workers comp cost containment best practices, good communication systems with your claims handler are an effective solution. Working with the adjuster in the ‘team approach’ to claims handling early in the process is recommended.

I encounter employers delaying the interactive process due to being afraid of a 132A violation.

Labor Code §132a states in pertinent part: “(1) Any employer who discharges, or threatens to discharge, or in any manner discriminates against any employee because he or she has filed or made known his or her intention to file a claim for compensation with his or her employer or an application for adjudication, or …Oct 23, 2016

It doesn’t make sense that a conflict would exist between Labor Code §132a and the interactive process. Labor Code §132a appears to be a state workers’ compensation law that states the employer is prohibited from discriminating on the basis of intent to file a workers’ comp claim. Engaging in the interactive process (e.g., asking whether the person could do the job with a reasonable accommodation) shouldn’t constitute discrimination. It’s not a threat to discharge or other form of discrimination. Also, the ADA is a federal law; doing what you are required to do under federal law can’t constitute a violation of state law.

How to Coordinate RTW with ADA Compliance

Author:

aaron konopasky Aaron Konopasky is a Senior Attorney Advisor in the ADA/GINA Policy Division at the U.S. Equal Employment Opportunity Commission (EEOC) headquarters in Washington, D.C. He assists the Commission in interpreting and applying the statutes it enforces, and participates in drafting regulations, policy guidance, and other publications.

Dr. Konopasky joined EEOC after receiving his J.D. from Stanford Law School. Prior to law school, he received his Ph.D. in philosophy from Princeton University, and served as an adjunct professor of philosophy at Rutgers University, Tulane University, and the University of New Orleans.

Author:

Michael Stack - Amaxx 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: http://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: ADA (Americans with Disabilities Act)