Honesty In Work Comp Claim Reporting – A Claim Handler’s Point of View

Note: The following article was written by an experienced claim handler who wishes to remain anonymous. This will point out a disturbing issue in the world of insurance, where the employer is not being honest about injury.

 

 

Step into My World – The Life of a Claim Handler

 

Over the years, I have investigated workers’ compensation losses and have heard bizarre stories of personal injury and the circumstances surrounding accidents.  If someone asks me if I have seen everything in workers’ compensation, I have to answer an emphatic “NO!”  Chances are a bigger and more unbelievable instance has yet to cross my desk, and it will be my job as the claim handler to determine what happened. For those employers without the luxury of video surveillance, I go by witness accounts and attempt to piece the circumstances of the injury.

 

 

What do you know about the injury details?

 

Every employer has a designated person to report claims.  The first phone call I make after getting the claim is to this person. Today, we will call her Sally. I call Sally and ask her if this is all that is known about the injury.  She says, “yes,” and that all details are included in the injury report.

 

That may be correct, but I know the report is missing information.  I rephrase the question about the exact timeline of events:

 

  • Who was injured?

 

  • Did the worker tell someone?

 

  • Did the worker go to the clinic alone or did someone drive?

 

  • Do you know about any prior injuries to the claimant’s knee?

 

If you the employer, do not know the particulars about the injury, then be clear on that at the outset.

 

 

Just the Facts Ma’am

 

I can name countless times where an employer reports to me there are no witnesses to an injury. Then I interview the injured employee who provides several names as witnesses.  I then talk to those individuals and ask about their account of events, and more times than not they witnessed the incident or arrived shortly thereafter.

 

Perhaps the employer did not ask about witnesses at the time of reporting and was not aware of any. Maybe the internal injury questionnaire does not have the space to write witness names.  In some cases, the employer may intend for the claim to sound less substantial.

 

 

The Clock is Ticking – Failing to Make a Timely Injury Report

 

I sometimes get a claim with an injury date of a month earlier, or even a year.  Maybe this is an error, but if someone approaches you as an employer and reports being hurt, a claim should be filed immediately.  Do not wait and see if they are actually injured.

 

The employer needs to call it in because I will question the injured employee about dates.   Maybe the report was completed on the injury date and was sent to your agent or broker.  Agents receive a lot of paperwork from their clients.  Just call it in, and if it is sent to your agent, follow up with them.  The sooner the claim reaches the carrier, the better.

 

 

The Devil is in the Details

 

Do you know of any outside activities the claimant is involved in?  I like to ask employers this question to see how much they know about their employees. This kind of tip proves very helpful in a case and investigation.  However, if you as an employer cannot be sure about a tip, then tell us.

 

 

Avoiding Spoliation of Evidence – Saving Money through Subrogation

 

For those employers with moving machinery, admit if the safety guards were off at the time of injury.  The employee is going to tell us either way.  The guard is there to protect workers, so the worker is fully aware if it is missing.  Maybe this leads to a design flaw that our subrogation department can investigate so we can recoup claims dollars spent on this injury.  Modifying safety guards can lead to very serious injury, and the costs associated with that loss are far more than any profit you can attain by changing the functionality of machinery.

 

 

Conducting a Complete and Accurate Investigation

 

If you have internal reporting or accident investigations, then I commend you.  You are on the way to becoming more proactive at handling losses.  We frequently discuss reporting, trends, and identifying injury areas.  If you are not internally reporting, then that is okay also.

 

 

Conclusions

 

In the world of workplace injuries, a lot of people on the outside think that the carrier must worry only about the injured employee’s honesty, but the integrity of the employer is paramount.  In any case, the truth will prevail.  If all parties are honest in the beginning, it makes handling the claim that much easier for everyone involved.

 

 

 

Amaxx LLC is a workers’ comp educational company focusing on cost containment systems to help employers reduce their workers’ comp costs by 20% to 50%.  Amaxx offers 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 Certified Master of Workers’ Compensation designation through the Amaxx Workers’ Comp Training Center.

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

Amaxx WC Training Center: https://workerscomptraining.com

 

©2019 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Slips, Trips, and Falls Account for Up to 15% of Workers Comp Claims

workers comp safetyDid you know that slips, trips, and falls account for up to 15 percent of all workers’ compensation claims?  The average slip and fall workers’ compensation claim will cost on average $22,000.  It can also impact workplace productivity and add to programs costs as follows:

 

  • Sixty-five percent of lost workdays are due to slip and fall accidents;

 

  • Twenty-two percent of slip and fall incidents resulted in more than 31 days away from work; and

 

  • Twenty-four percent of workplace slip and falls can be directly attributed to footwear.

 

Now is the time for interested stakeholders to be on the look-out – literally – on how they can make their workplaces safer, and reduce workers’ compensation costs by preventing slips, trips, and falls.

 

 

How can I protect my employees from slip and falls?

 

A great way for an employer to reduce slip and fall accidents is with a company-wide slip-resistant shoe program.  This program should be a part of an overall safety plan and can be handled by the safety director, or loss prevention specialist in the organization.  A good slip-resistant shoe program can reduce slip and falls by 50 percent or more with little or no cost to the employer.

 

Implementation of this program starts with a mandate all employees wear appropriate footwear for their working environment.  It includes providing guidance to employees about where and how to purchase these slip-resistant shoes.  By taking this simple step, businesses can proactively reduce their accident rates and better protect their employees.

 

 

How do slip-resistant shoes prevent slip and falls?

 

Slip-resistant shoes have a specially made sole that offers increased resistance to sliding or skidding in wet, or greasy surface conditions.  Common places where this can be a benefit can include factories, industrial areas where employees are working inside, and outside.  It can also be beneficial in restaurants or other food service occupations where water and grease are usually found on the floor.

 

Slip-resistant shoes are made from a softer rubber compound that is designed to provide more traction.  When using this simple technology, the show can gripe the floor or another surface by creating a microscopic roughness of the walking surface.  Slip-resistant shoe soles typically feature a grid-like tread pattern that funnels liquid out from under the shoe.  This prevents the hydroplaning effect like what cars experience when driving on wet surfaces, or puddles at a higher speed.

 

 

How do I know my employees are wearing the right shoes?

 

Not all slip-resistant shoes perform equally.  Make sure that employees are only wearing shoes that have been tested and have a slip resistance rating.  Many of the shoes from retail shoe stores claim to be slip-resistant but do not offer any significant increase in protection for your employees.  A quality slip-resistant shoe vendor should be able to produce test results to verify the slip resistance of their shoes.

 

 

What styles of slip-resistant shoes are there?

 

Nearly any type of work shoe can be made with a slip-resistant sole.  Depending on your workplace, the shoe styles your employees wear will vary:

 

  • If you run a restaurant, your kitchen workers might be wearing waterproof clogs, while your servers could be wearing oxfords.

 

  • A hospital or long-term care facility will be a great setting for comfortable, supportive sneakers.

 

  • An industrial or manufacturing setting needs something tougher, such a steel toe or comp toe work boot.

 

Consider keeping a stock of various sized overshoes on hand for new hires to wear until they get proper footwear.  Having extra shoes on hand can also be used by visiting supervisors, or other guests on your premise.

 

Conclusions

 

Creating a safe workplace requires employers and other interested stakeholders use creative ideas to reduce injuries.  This includes reducing slip and falls, which can increase workers’ compensation program costs.  Requiring the use of slip-resistant shoes is one idea that can be implemented in an efficient and effective manner.

 

 

 

Michael Stack - AmaxxAuthor 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/

 

©2019 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Stop Making Excuses – Focus on Return to Work

return to workThe claim handler’s main role is to get an injured employee back to work.  The timeline on how this can happen depends on a multitude of factors, including the severity of injury, age of the patient, prior injuries to the same area, the diagnosis, and their occupation.  Employers and other interested stakeholders are sometimes afraid of returning an injured employee into their workplace.  This drives workers’ compensation costs and increases workplace anxiety among other employees.  Now is the time to focus on return-to-work efforts to reduce the cost of workers’ compensation, and increase morale.

 

 

It All Starts with the Employer

 

Employers need to take responsibility for return-to-work and make it a central part of their workers’ compensation program.  This is because the employer controls a lot of the future for the injured worker.  It is time for employers to stop making common excuses and get their injured workforce back into the work environment – even within their own organization.

 

 

Make Light Duty Work Available

 

This is always the easiest excuse to make.  Countless studies have shown that injured employees are willing to work and would prefer it to staying at home, watching TV, and doing other stereotypical things that come to mind when someone is off work.  The short-term impact is that individual lose confidence and self-worth, and becomes deconditioned.  Proactive employers can be creative when it comes to light-duty work.  This can include creating a job, which can include maintenance projects or other activities that advance the interests of the employer and keep the individual engaged.

 

 

Do Not Fear Work-Related Aggravations

 

Employers are often afraid of offering light-duty work to an injured employee given the possibility of an aggravation of the underlying work injury.  The argument is, “I am afraid my injured employee will aggravate the injury when returning to work.”  This is a valid concern.  However, these same aggravations could also occur when the employee is convulsing at home. Yes, the risk is there, but not if you as the employer plan accordingly, and be smart about putting the worker back on light duty.

 

 

Do Not Fear A New Work Injury

 

“What if the employee slips or falls?”  This is another common concern of employers.  Again, injuries can happen anywhere.  It all comes down to common sense.  Have the employee do something safe.  The point is not to have them riding the edge of risk every day until full duty resumes.

 

 

Don’t Be Afraid the Injured Employee Will Hurt Someone Else

 

President Franklin Roosevelt once proclaimed, “The only thing we have to fear, is fear itself.”  The modern workplace is filled with risk.  However, using common sense when it comes to post-injury employment pays dividends.  Return-to-work minimizes the exposure of wage loss being paid on a claim and also reduces medical care and treatment an injured employee may receive.

 

 

Injured Employees Are Productive

 

The productivity of an injured employee is subject to many urban myths and legends.  If the employee has a hand injury, it does not make sense to have them packing boxes, taping them, and carrying them out to the loading dock.  Everyone can be productive if the circumstances are favorable to their strong points.  Be creative!

 

 

No Job Description – No Problem

 

No job description provides an easy out for a claim handler not to seek return-to-work.  On the other hand, it is an opportunity for an employer to review all the positions in the company, and create them before injuries occur.  It all comes down to the employer’s commitment to saving money.

 

 

Don’t Ignore the Value Add

 

Employers generally have the option of paying an injured employee their full wage for doing something other than their pre-injury position.  While the employer does not receive the “full value” of the employee’s work, they do receive the benefit of lower workers’ compensation costs.

 

 

Conclusions

 

There are many excuses when it comes to returning an injured employee to work.  At the end of the day, it is your job as the employer to set the tone for being proactive.  Team up with your HR department and make those job descriptions.  Be creative about light-duty work and what a person can do.  It is still better than letting the injured worker control the claim since the only job would be to check the mail for a compensation check.

 

 

 

Michael Stack - AmaxxAuthor 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/

 

©2019 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Reduce Workplace Risk With a Solid Plan of Attack

workers comp plan of attackA lot of employers strive to maintain a safer, more productive workplace for their employees. Every business would love to reduce costs and increase profit margins.  The cost of claims can account for a big chunk of money losses, especially for the self-insured or self-administered employer.

 

So how do you get started? Where do you start, or better yet when do you start? The answer is RIGHT NOW, and here is how:

 

Step 1: Know Where Your Risk Lies

 

This process starts with a simple observation of your workplace.  Keep the following factors in mind:

 

  • Go through department statistics and see how they compare to each other regarding losses. Perhaps 75% of your injuries occur in the shipping department. Go down there and talk with the supervisor. Find out what the issues are and why they think injuries are happening. Then work together to solve the problem.

 

  • Examine your loss run. Talk to your workers’ compensation insurance carrier and see if they notice any trends. Which people are getting injured? Maybe newer hires account for a lot of injuries.  This may show that a focus needs to be directed toward training and safety.

 

  • Look at your business. What do you do?  What are the risks involved?  Identify issues. Work on ways you can reduce your injuries or occurrences from happening in the first place.

 

Step 2: Develop a Plan of Attack

 

Once you have identified a few areas where you could improve on reducing injuries, it is time to solve the problem.  What do you do to fix it?  Planning is important, but the most important thing is to start, even if that is with small steps.  The answer lies in the resources you have all around you:

 

  • Talk to your carrier. Chances are the carrier has loss prevention specialists ready to help you work with what needs to be fixed. Ergonomic professionals can be brought in to address workstations and to suggest solutions to reduce exposure.

 

 

  • Utilize legal counsel by having them come in to explain the risks and costs associated with potentially serious injuries, automotive accidents, or failure to drug test your employees. Any or all of these will help you reach your goal of reducing risk exposure.

 

Step 3: Implement Your Solution

 

Get rid of old equipment and bring in new equipment with better safety features.  Newer equipment costs less to maintain and repair and is quicker to operate. Most modern machines use less energy too.  Install padding on the floor for workers to stand on at their workstations.  This reduces strain on feet and legs, and reduces body fatigue.  Whatever the fix might be, get it done. Out with the old — in with the new!

 

Step 4: Measure Your Success Statistics

 

Now it is time to measure your reductions. Take a two, four, or six-month period of time to quantify your results. Did you see a drop in claim activity?  Did claims increase, meaning your plan backfired?  Be patient.  Change is disruptive to employees. Give it time, and measure your numbers post-change against the ones you first noticed back when you were figuring out where your risk was coming from.

 

Step 5: Get Feedback From Employees

 

Taking time to speak with your employees increases morale and makes them feel involved in the process.  Ask them the following questions:

 

  • How do they feel it impacted their workday?

 

  • Were the changes helpful, or did they hurt production?

 

  • How do they feel at the end of the day?

 

  • Do they feel less sore, or are the new workstations worse than the old ones?

 

Ask as many questions as you can. This makes your staff feel that their input is important, and taken into account.  A supervisor once said, “It is hard to fully embrace change. To make things easier, you have to ‘lean’ into it a bit at a time until you have accepted the entire package of change.”

 

This is true on many levels. Even though it is hard work to find out what your risks are, discover how to attack them, implement changes, measure success, and get worker feedback, in the end, it will be worth it.  Lean into the task.  Do not try to tackle it all at once.  As I have always said, “Don’t eat an elephant in one bite.”

 

Conclusions

 

Change is sometimes a difficult thing.  However, proactive employers need to drive change to reduce workers’ compensation program costs.  It not only can reduce injuries and their severity but increase company morale and make a workplace more efficient.

 

 

 

Michael Stack - AmaxxAuthor 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/

 

©2019 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Drive Buy-In With A Workers’ Comp Cost Allocation System

This is a 16 Minute preview of the complete course “How to Create and Implement a Workers’ Comp Cost Allocation System” Register for the complete on-demand course here: https://workerscomptraining.com/registration-cost-allocation/

 

Yeah. Hello everyone and welcome to workers’ comp mastery training. My name is Michael stack and I really couldn’t be happier than for you to be joining us for this training session today. What I think you’re going to find is you’re going to find some information and some contacts on a very important topic, which is how to motivate behavior, how to motivate behavior, which is the essence of what is the title of our training, which is how to create and implement a worker’s comp cost allocation system. Because if you think about it, it’s not a mystery of how to do it. It’s not a mystery of how to reduce workers’ compensation costs. We know what those fundamentals are. We know return to work. We know Andrew response, we know how to work with your adjusters. You can go to a bunch of our trainings to learn all those fundamentals in detail.

 

 

It’s Not A Question of HOW…It’s a Question of MOTIVATION

 

So it is not a question of how to do it. It’s been done successfully for years and decades by hundreds and thousands of companies. So then the question becomes if it’s not a question of how, how to add two plus two it’s a question of how to motivate engagement, how to get buy in from your senior managers, from your supervisors, from your employees and from your upper management at the organization. Because if you have that, if you have that vine, if you have that engagement then you will be successful period. If you have that buy in, if you have that engagement you will be successful period because we know how to do what the prep, the tactics are so well proven and documented for what [00:02:00] works. So we’re going to be talking about today is have you not get sort of caught up in sort of this minutia of the actual elements of cost allocation, which we will be talking about going over and examples we’re looking at numbers but going through all that in detail, what we’re gonna be talking about is the greater picture then of motivation.

 

So here’s what that looks like. Then as far as the three major points of how we’re going to kind of flow through today’s session. So the first major point is we’re going to be talking about these drivers of behavior. What are those drivers of behavior in sort of getting into that greater context as I was referencing of what actually motivates us to engage. Second piece then is these actual cost allocation systems. We’re going to go through the examples. We’re go through different methods. We’re going to be looking at numbers, what have you sort of going through how companies do this, how they set it up, actually, what does it look like from a setup and numbers standpoint and like I said, we were going through some examples of that and then the third piece then is then those steps to actually implement this cost allocation. What are those steps?

 

 

The Greater Picture of Motivation

 

Then once you know kind of these nuts and bolts, once you know the greater picture of motivation, how do you then implement this into your organization? A couple of quick administrative points before we get going. The outline for today’s session is in the GoTo webinar interface, so it’s a word document. You can download that, take some notes right along there. There’s also a lot of good examples in there, so if you’re not able to kind of follow along. If I write something on the board and I erase it and you meant to see it, that’s a great place to reference it. That’s the outline for this today’s session. That’s what I follow when we’re going through the session. It’s a great thing to reference. You can get it there. I know sometimes some people with firewalls and things have trouble downloading that. Another place to look at that is in the final email that I just sent you that said we are starting now.

 

There’s a link in there where you can download that as well. And then the other piece that I want to encourage you to do too is this is a live session. The greatest thing and one of the greatest things about this style is that we can work together. So I encourage your comments. I encourage your questions. I do have my big screen right behind the camera here, so when you type something in, I’ll be able to address that as best we can through the out today’s so get, let’s get right down then into this first major point, which I think is really the most interesting. You know it’s the most sort of theoretical, but it’s also the most interesting and also as we’re getting into this topic, the most important because if we look at it as I referenced earlier, we’re going to be talking about this in several different instances.

 

 

If You Are Only Looking At Numbers, You are Missing the Point

 

If you’re looking only at the numbers, then you’re missing the point of this entire training and you’re missing the effectiveness of what a cost allocation system can actually do. Okay, so I want to lay out the context of this sort of idea of motivating behavior. And I want to start with this research study that was done by MIT and what it was called. It was called large stakes and big mistakes. So large stakes and big mistakes was the name of the research study. And here’s what they did is they took a group of students and this study has been replicated many different times. They did in India, they did it at MIT, they did it out in California. They’ve done it many different times. So here’s what they did is they said, okay, we want you to do this set of tasks of what they were looking at and studying was this reward system.

 

So we always think, and sort of the typical thing that we always think because we think that results and rewards are perfectly correlated. So we always think if you give a bigger reward, then you can expect that to drive behavior. That should be a one to one symbiotic relationship. If we give you a bigger reward that’s going to drive your behavior, that should drive greater results. So that’s what they were testing. So they split the kids up into different groups and they asked them to do these tasks. So memorize digits, do word puzzles, shooting a ball through a hoop, very sort of rudimentary tasks, pounding in a nail, things like that. Things that don’t really require a huge amount of thought. It’s just kind of go, go, go, go, go, go, go, go, go, go, go, pound as many nails in as you possibly can.

 

 

The Bigger the Reward, The Greater the Result?

 

And the more nails you pound it in, the bigger the results, the bigger the rewards. Fantastic. And as they look at those results that held true. So that was that sort of one-to-one relationship that we kind of expect and that sort of made sense, make bigger reward, bigger results, fantastic. Then they asked them to do a little bit more difficult, a little more tasks that required a little bit more cognitive skill. So a little bit more thinking involved in regards to these tasks. And here’s what they found is they found actually the exact opposite of what we would expect. So what they found was the bigger the reward, I’ll, maybe I’ll do this in blue so we can differentiate. What they found is the bigger the reward. Then I just grabbed my black, all right, here we go. Bigger. The reward actually the worse the results.

 

So the bigger the reward, the worse the results. And that finding was, as I already mentioned, anytime the skill that they were testing required even a little bit, even just a little bit of cognitive skill, more than just palmed in the hammer and pounding the nail pounded them in as many as you can. Anytime they required a little bit more thinking involved. The reward system that we expect was the exact opposite of what actually happened. So I want you to kind of think on that sort of conclusion for a second because if you can grasp that conclusion of why that’s the case, you can grasp this entire essence of what I talked about in that opening statement there of cost allocation and how to do it most effectively. I’m going to say that again, think about this result, this sort of opposite result of what we would expect.

 

 

The Goal is to Motivate Behavior

 

If you can grasp that concept of why that’s true, which we’re gonna talk about here in a second, you can grasp the entire effectiveness of everything involved in success in setting up a successful cost allocation system. Cause remember as we said, all we’re trying to do here is motivate behavior. We’re trying to have those results be better. And we’re looking at this reward system. This is all we’re doing in a cost allocation system really at its core. So if you have that in your mind, I want to talk about this sort of next sort of description of it or why that’s the case and the little bit more data [00:08:30] that was gathered and studies that I’ve done research that I’ve done that has been done to prove why that’s the case and that a study and that sort of context comes from the book called drive.

 

So it’s a book called drive written by the author Daniel pink. So if you’re interested in sort of this motivation and motivating behavior concept, great book, I highly recommend checking out a lot of really interesting information that he talks about in the, in that drive. Okay, next piece here, and I want to talk about sort of the, the why that’s the case. So why was that opposite results and rewards came out when it causes a little bit of cognitive skill. And if you think about worker’s compensation and work comp management, it requires a little bit of cognitive skill. There’s some complexity, certainly involved. There’s some human emotion involved, there’s a lot of stakeholders involved. So we’re definitely falling into that requires cognitive skill category. So want to bring your attention now here and what this is is this is something that we all probably learned.

 

 

Hierarchy of Motivation at Work

 

I don’t know if you’d go over this in grade school or high school, but this is Maslow’s hierarchy of needs. And so on the bottom you have the physiological needs and then as you move up the pyramid here you’ve got security, you’ve got a belonging, love and belonging, you’ve got the next, you have self esteem, and then you have self actualization. And we’ve probably seen all this before. And then we can kind of understand this general concept of this is your, your basic needs, you need to get those squared away, food, water, shelter, et cetera. That’s at the bottom of that period pyramid. And as you move up this of what actually drives our motivation, what drives our behavior, what drives us as individuals to want to be better and want to do better and wants to pursue more. That’s as you move up this chain, there’s a great article written by Roosevelt moth Moss Kanter in the Harvard business review and here’s what Rosa Beth has to say about motivation and that reward results, rewards dichotomy that we were kind of just talking about.

 

Roosevelt says the key to motivation doesn’t depend on elaborate incentive schemes. What makes a good work environment is getting better at stuff or mastering a task. So the key to motivation doesn’t depend on elaborate incentive schemes. What makes a good work environment is getting better at stuff or mastering a task. As we now start to kind of internalize what that might mean in regards to this rewards and incentive schemes. I want to add one more layer to this to have you start to think about, so Roosevelt came up with what she calls the four M’s, so the four M’s and those four M’s are money. Next up then is membership. So money, membership mastering. And at the top there is meaning.

 

So her four M’s are money, membership, mastery and meaning. And if you lay these over Maslow’s hierarchy of needs, you can see quite a connection in what’s actually driving our behavior. And what I want you to pull out of this is what I talked about in my opening statement, because if you’re missing this point, you’re missing the real value of what a cost allocation system can do for an organization. The point of what she’s talking about and, and, and that sort of root rewards results scheme is they use something very basic such as money. And if you see here, when we, what we all sort of think about  when we think about a rewards or a bonus system is we think we always go here. We always go to money and we stop there. We always go to money. And that’s where we stopped. And so if you look at this, as far as we all need money, everyone needs money.

 

 

Money Is Not the Best Motivator

 

Of course you got to pay the bills, you got to pay your mortgage, you gotta pay every whatever you gotta pay. You gotta pay for school, you got to do this and that. Everybody needs money. That’s at the bottom of this pyramid and everybody has food, shelter, clothing, all that stuff costs money. So you need money in order to do all that. But if you look at actually what is really driving our behaviors, what is really motivating us to pursue more, what it’s really mourning of us to be fully, fully engaged, which is what we’re trying to do here with this cost allocation system, is get people engaged in what the heck it is that we’re doing here and work on management. You got to think further up this chain and as Roosevelt said, it’s not about incentive schemes. What’s comes down here. It’s not about coming up with these elaborate schemes that people can make more money as long as they have enough to buy the stuff that they need.

 

They’re in pretty good shape and that’s only gonna get them so far. As you move up here, particularly as we’re talking about division leaders and we’re talking about these operations managers, you’re talking about a store, a location owner, or you’re talking about someone that’s in a bit of a higher position within an organization. When you’re talking about these cost allocation systems, that’s the level that we’re really talking about here. You’ve got our supervisor training when you’re talking about the supervisors and really getting them involved, and that’s a little bit of a different conversation when you’re talking about our metrics and you’re trying to get the senior managers involved, the upper management at the organization. That’s a little bit of a different conversation to get them fully engaged. When you’re talking about these division leaders, these operational leaders, as you’re thinking about this cost allocation system specifically, you need to start thinking about these higher levels of engagement.

 

These individuals are have some responsibility at the organization and they’re going to be more engaged. The more they can want to get better at it, the more meaning that they can put within the work that they’re doing. Then they’re going to be fully engaged. If you just talk about them, about money that might move the needle just a little bit. But if you want it to go off the charts, you need to start thinking about some of these other items as far as what actually drives behavior. So [00:15:00] if you think about that, results in rewards study from MIT of the large mistakes and big stakes and large mistakes. The reason that that was different is because the rewards and results was different because they were strictly focusing down here. And oftentimes those people that are fully engaged in what they are doing, and you would do it anyway.

 

 

You’re Doing It Because You Want to Get Better

 

You know, think about if you’ve ever picked up a guitar and you’re like, Hey, I just love playing guitar. And every night you’re practicing the songs and you’re singing, you’re having a great time, you’re never going to be on the stage with the rolling stones, but you just really enjoy it. You’re doing it because you want to get better at something or you’re doing it because you’re doing it with your kids and you find a great amount of meaning in that. That’s how you get fully engaged. And so when you think about sort of those levels of engagement, that’s when you can really start to cook with gas in regards to bringing in that element or bringing in some of that element to this cost allocation system that we’re going to be talking about. Getting into kind of some of the nuts and bolts of it.

 

 

 

Michael Stack - AmaxxAuthor 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/

 

©2019 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Brand Name and Specialty Drugs Drive Up Workers’ Comp Pharmacy Costs

brand name and specialty drugsThere’s a lot of good news in the latest pharmaceutical reports for the workers’ compensation industry. Prescribing and spending on opioids is down, and compound medications are much less of a factor than they have been in the past.

 

Stakeholders that want to continue seeing positive trends need to keep their eyes on the ball with trends affecting the industry. Many are wondering what’s next? What will be the next development that could unexpectedly drive up pharmaceutical costs among injured workers?

 

“There’s significant concern over the rising cost of prescription drugs,” according to the Drug Trend Report released by myMatrixx earlier this year. And “there is a lack of understanding about the impact specialty medications may have on workers’ compensation insurance.”

 

Stakeholders who are aware of, and take steps to address these two issues will be ahead of the game in holding down pharmaceutical costs.

 

 

Brands vs. Generics

 

Substituting generics for brand-name drugs where possible is one of the most effective and easiest ways to reduce drug costs in the workers’ compensation system. And yet, there are still many providers who prescribe brand name drugs unnecessarily. These prescribers and their injured-worker patients may be unaware of the cost differences involved.

 

“Over the past five years, the most commonly used brand-name traditional drugs among injured workers experienced list price inflation of 65.5%, but prices for the most commonly used generic medications declined 35.0%,” according to the myMatrixx report. “In contrast, a market basket of commonly used goods (e.g., milk, bread, etc.) rose only 7.4%.”

 

As Phil Walls, chief Clinical Office of myMatrixx explained, a generic version of a drug may cost 20 percent of the price of the brand name drug, on average. Spending $100 for a drug that could be purchased for $20 can have a significant impact on costs. But cost is not the only issue.

 

Many providers and injured workers believe brand name drugs are inherently of better quality than the generic versions. However, they have the same active ingredients and work the same way as brand name drugs.

 

“A generic medicine is the same as a brand-name medicine in dosage, safety, effectiveness, strength, stability, and quality, as well as in the way it is taken and should be used,” per the Food and Drug Administration.

 

To gain FDA approval, a generic medication must be ‘bioequivalent’ to the brand name version. That means they are chemically nearly the same, although generic drug makers are allowed 20 percent variation in the active ingredient from the original formula. But according to Harvard researchers, “while the FDA does allow for up to 20 percent wiggle room, in reality, the observed variation is much smaller, 4 percent.”

 

Several brand name drugs that are widely used among injured workers have patents that have recently expired, such as Lyrica. That’s good news, in that less expensive generic versions will likely come on the market soon. However, stakeholders are advised to ask their pharmacists if the generic may be substituted for the form of a drug that their injured worker is receiving.

 

For example, some drug makers issue a long-acting version of a medication that is set to expire and set the cost at a lower amount than it would be for 2x the original drug. Providers and patients would be inclined to seek the long-acting version since it would essentially cost less than taking two pills of the original version. However, once the patent expires, patients who are taking the long-acting version won’t be eligible to receive the generic version, which would only be a substitute for the original version.

 

Some additional drugs with patents expiring this year are Amrix®, Fentora®, Flector®, and Vivlodex®.

 

 

Specialty Meds

 

The vast majority of workers’ compensation payers will likely never encounter a claim that involves specialty drugs. But for those that do, it can be a shock. These drugs comprise just 1.7 percent of claims, yet they drive 7.1 percent of spend. That number represents an increase of 18.5 percent over the prior year.

 

“On average, payers spent $5,130.57 per injured worker on a specialty medication,” according to the myMatrixx report. “Specialty medications cost four times as much, or more, as traditional medications for payers.”

 

While those numbers might cause payers to shy away from footing the bill for these medications, that strategy will drive up costs even more. “The maxim that the most expensive specialty drug is the one not taken means that poor adherence on the part of the patient may render even the best therapy ineffective,” the report said. “Compliance is vital; if the patient is not compliant, the course of therapy has to be repeated,” Walls added.

 

Paying for, and ensuring that injured workers take specialty medications when warranted is, therefore, imperative to achieving the best outcomes and containing costs.

 

Specialty medications are used for conditions that have not traditionally been associated with injured workers. However, that is changing.

 

The proliferation of new cancer-presumption laws for firefighters means more cancer drugs will be seen in workers’ compensation claims. Needlestick injuries to healthcare workers and first responders may warrant specialty drugs for HIV and Hepatitis. Specialty drugs for hepatitis C can cost $100,000 for a 90-day supply.

 

Workers most likely to receive a specialty drug include:

 

  • Emergency first responders
  • Public safety personnel
  • Law enforcement officers
  • Correctional officers
  • Healthcare workers
  • Certain defined workers in states with cancer presumption laws

 

 

Conclusion

 

Drug spend in the workers’ compensation system can be astronomical, but the costs can be controlled. Staying on top of issues such as generic vs. brand name drugs, and the increased use of specialty medications will help. Working closely with providers, pharmacists, and PBMs is the best way to ensure injured workers get the medications they need without payers spending unnecessarily.

 

 

 

Michael Stack - AmaxxAuthor 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/

 

©2019 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Terminate ‘Ongoing Responsibility for Medicare’ (ORM) or Invite Big Problems

terminate ORMThe famed University of Alabama head coach, Paul “Bear” Bryant said, “when you make a mistake, there are only three things you should ever do about it: admit it, learn from it, and don’t repeat it.”  These wise words are particularly applicable to termination of Ongoing Responsibility for Medicals (ORM) in the Medicare Section 111 Mandatory Insurer Reporting process.  Failure to properly report ORM termination can yield unnecessary Medicare conditional payment demands, costing time and expense to resolve.  When such an error is made, admit it to CMS, correct it, and learn from the experience so it is not repeated.

 

 

Background on ORM Reporting

 

Since October 5, 2015, the CRC has had responsibility for the recovery of conditional payments where the insurer or employer (including self-insured entities) is the identified debtor, known in CMS terms as the “applicable plan.” The CRC learns of opportunities to recover through the Section 111 Mandatory Insurer Reporting process. In other words, the applicable plan’s reporting is the catalyst for Medicare conditional payment recovery.

 

The mandatory reporting provisions of the Medicare Secondary Payer Act require the applicable plan to report to Medicare in three instances – the acceptance of ORM, the termination of ORM and issuance of a Total Payment Obligation to the Claimant (TPOC), settlement judgment, award or other payment.

 

 

ORM Termination Key to Cutting Off Liability to Medicare

 

Once ORM is accepted, CMS claims the right to recover against the applicable plan through the date of ORM termination. That means CRC’s recovery efforts may happen years after the ORM was first reported. Further, if the applicable plan fails to terminate ORM when appropriate, then the plan may receive CRC repayment demands for time periods in which it has no liability to pay for medical treatment.

 

Accordingly, terminating ORM when appropriate is vital to cutting off liability to Medicare.  An applicable plan may terminate ORM through the Section 111 Reporting process under the following situations:

 

  • Settlement with a release of medicals
  • No-fault policy limit reached
  • Complete denial of the claim
  • Statute of limitations has run, or medical benefits have otherwise been exhausted pursuant to state law
  • Judicial determination after a hearing on the merits finds no liability
  • Signed statement from the injured individual’s treating physician that the injured party will require no further medical items or services associated with the claim related injuries.

 

Providing CMS with the ORM termination date gives a bookend to recovery by the CRC. If no termination date is provided, then CRC assumes the applicable plan remains liable for injury-related payments indefinitely.

 

Unfortunately, workers’ compensation claims systems do not always prompt the submitter when a settlement amount is entered to confirm whether ORM is also being terminated.  As a result, the TPOC amount and date are reported to CMS, ORM remains at a “Y,” and the ORM termination date is left blank.  This not treated as an error when CMS processes the submission as CMS allows for multiple TPOC amounts.

 

Consequently, unreported ORM termination dates can continue for years, and the RRE may only become aware of the oversight only when a conditional payment notice is received for the previously settled claim.

 

 

Case Study (provided by Tower MSA)

 

Tower’s client received a Medicare Conditional Payment Notice and then a demand from the CRC in the amount of $125,554.  A review of the demand revealed many of the charges related to the injury which would typically present a challenge to requesting their removal from the demand.  However, all the dates of service itemized in the demand were after the settlement date of 8/5/2014.

 

Upon further investigation it was learned that while a TPOC or settlement date of 8/5/2014 had been reported, ORM termination had not (Tower was not the Section 111 reporting agent for this client).  Consequently, the CRC assumed that the primary plan was still accepting medical on the claim and asserted a demand for recovery of conditional payments.

 

Our client updated their Section 111 report with the correct termination date, and Tower was able to obtain CRC’s agreement to withdraw the demand.

 

In the end, our client was fortunately not held liable for repayment of $125,554 to Medicare. Nonetheless, the error of not reporting ORM termination concurrently with TPOC took several months to resolve.

 

 

Key Takeaway: Training, quality assurance and a reliable reporting agent are critical to avoiding ORM reporting errors.

 

  • Train Adjusters on ORM Reporting: If an adjuster is responsible for inserting the data required for ORM reporting, then they require training as to when ORM acceptance and termination should be reported and how to determine the appropriate diagnosis codes to report.  Significantly, anytime a TPOC (settlement) is reported, the adjuster should determine if medicals are closed as part of the settlement and whether the ORM termination date should also be reported.
  • Effective Quality Assurance of ORM Reporting: Even with training, errors will occur. Additional resources placed into quality assurance of ORM reporting, such as double checking claims for proper ORM termination and appropriate diagnosis code choices avoids the expenditure of additional resources at a later date to correct errors in reporting and address unnecessary recovery demands from the CRC. If you are an employer or carrier relying upon a TPA to report, it is especially important to have a QA process in place to check the data entered by the TPA.
  • Ensure Reporting Platform is Accurately Reporting: Section 111 Reporting is electronically based and requires a data exchange with Medicare. Errors can and will occur in this data exchange. Ensure you have a trusted and reliable reporting agent, like Tower, who will not only identify CMS submission errors, but also capture issues like a missing ORM termination date, and work with you to have them corrected prior to reporting to Medicare.

 

For more information on Medicare Set Asides (MSAs) and conditional payments, check out the webinar “Everything you ever wanted to know about conditional payments but were afraid to ask” on Wednesday, October 23rd at 2:00 pm ET. 

 

 

Author Dan Anders, Chief Compliance Officer, Tower MSA Partners. Dan oversees the Medicare Secondary Payer (MSP) compliance program. In this position, he is responsible for ensuring the integrity and quality of the MSA program and other MSP compliance services and products. Based upon his more than a decade of experience in working with employers, insurers, TPAs, attorneys and claimants, Dan provides education and consultation to Tower MSA clients on all aspects of MSP compliance. Contact: (888) 331-4941 or daniel.anders@towermsa.com

 

Using Results-Based Physical Therapy to Control Workers’ Comp Costs

results based physical therapyWhen an employee has a musculoskeletal injury keeping them from returning to work, it is routine practice for orthopedic doctors to recommend a physical therapy program. The purpose of the physical therapy program is to assist the injured employee in restoring function, regain a pre-injury level of mobility, control pain, and prevent permanent physical disability. This can be accomplished with physical therapy, providing both range of motion exercises and strengthening exercises.

 

Members of the claim management team and other interested stakeholders need to understand physical therapy and implement claim handling changes to control program costs.  This allows them to control workers’ compensation costs and return the injured employee back to work in a timely manner.

 

 

The Basics of Physical Therapy

 

The doctor treating the injured employee will prescribe the amount of physical therapy that is necessary to restore an injury.  Some doctors are very good at estimating the number of physical therapy sessions an injured employee will need, and hopefully, prescribe it accordingly. For instance, the doctor will prescribe physical therapy for the lumbar spine “3 x 4,” which tells the physical therapy facility to treat the injured employee three times per week, for four weeks. The return appointment with the doctor’s office is normally scheduled after the anticipated date of the last physical therapy treatment. This allows the doctor to assess the benefits of the physical therapy treatment program, but it is after the fact.

 

On the other hand, other medical professionals will prescribe the same amount of physical therapy for just about every patient they see.  If every patient is “3 x 4,” or “3 x 6,” some injured employees end up having excessive medical care and treatment.  This not only impacts the cost of workers’ compensation claims but does not resolve a work injury in a timely manner.  When the injured employee does not get enough physical therapy, they return to the doctor before they have not recovered from their injury. The doctor then prescribes more physical therapy and sets up another return visit to the doctor’s office.

 

 

Results Based” Physical Therapy

 

When the orthopedic describes physical therapy, the physical therapy facility wanting to ensure payment will normally call the workers’ compensation claim handler for approval. The claim handler may not know whether physical therapy is needed.  In many instances the claim handler will not question the need for physical therapy – use the thought process that if the doctor requested it, the care must be needed. This results in the injured employee receiving more physical therapy than needed.

 

One approach to this dilemma when reviewing a request for physical therapy is to refer the request for to utilization review. Utilization review can eliminate some excessive physical therapy treatment by allowing trained medical professionals to assist in the determination based on the information in the medical notes.  Utilization review will not know if the injured employee recovers faster than normal, resulting in the injured employee continuing to go to unreasonable and unnecessary medical care and treatment.

 

A recent innovation in managing the physical therapy treatment is the development of “results-based” treatment approach.  Instead of the injured employee going to the physical therapy office 15 times because the doctor wrote a “3 x 5” script, the injured employee goes to the physical therapy office for as many or as few times needed for the employee to make a proper recovery from their musculoskeletal injury.

 

In the traditional fee for services model of physical therapy treatment, it is in the financial best interest of the physical therapy facility to continue physical therapy treatment until the doctor sees the injured employee again. This often results in excessive treatment. The results-based approach to physical therapy aligns the interest of the employer and the insurer with the physical therapy facility.  A timely recovery and return to work benefits all parties including the employee.

 

 

Conclusions

 

A results-based approach to physical therapy allows a single flat fee for service. It reduces paperwork for the claim handler, by leaving them with only one bill to pay, rather than multiple forms related to ongoing medical care.  Results-based physical therapy treatment is also an innovative way for employers and insurers to manage the physical therapy treatment process, and to provide the injured employee with the treatment needed in a timely manner.

 

 

 

Michael Stack - AmaxxAuthor 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/

 

©2019 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Areas You Could Be Missing That Increase Work Comp Costs

workers comp savingsFor the majority of employers, the work comp process runs on its own. They are not really involved, and they just direct workers to their insurance carrier if they have any questions. Then the employers also blame disputes or other issues on the carrier, stating that it’s an “insurance thing” and they really “have no impact or ability to do anything in regards to their case.”

 

The fact is that almost all workers compensation costs are controllable. The more involved you are, the better-run your program is, the lower workers compensation costs you are going to see.

 

Even those are actively engaged in their workers’ compensation program will have some areas that could be improved. Every claim that has a reserve can increase your program and insurance policy costs. So what could you be doing wrong?

 

 

Claims That Do Not Need To Be Reported

 

Some claims are not workers’ comp claims. Just because you are at work and something happens, that does not mean that work directly caused or exacerbated or aggravated anything. But what happens is a claim is reported anyway, and maybe it is a medical-only file, and the adjuster is not going to even blink at it. The worker gets $1,000 in medical bill coverage under your comp policy, when in fact it should not have been a claim at all. You may have sufficient evidence to show a controversial work comp issue, but chose to just file it, and the adjuster then did not investigate because you failed to mention it was questionable. That is leakage, and that is money right down the drain.

 

 

Improper Claim Reporting

 

Regardless of an employer’s size, you must have some sort of process for a worker to report an injury. Usually, they go to a supervisor or manager, and then that person goes to the HR dept. As simple as this seems, this is always the hardest task to accomplish. It is essential for every worker to know what to do should an injury arise. We recommend Injury Triage to correct this problem.

 

 

Late Claim Reporting

 

Late claim reporting is an easy fix with Injury Triage. Employers love to hold on to claims for whatever reason. The longer it takes to reach an adjuster, the longer it takes to resolve the claim. Even worse, the carrier and the employer may be fined by the State for late reporting. This all adds up to more money down the drain.

 

 

 

Lack Of Employer Interaction With The Carrier

 

For any program to be successful and run efficiently, the employer has to be involved. The adjuster needs to have a contact person at the employer, and that person needs to know how to get a worker back to work, where to send wage histories, to provide job descriptions, etc. It can’t be 18 different people at the same location, but rather a few, or a small team at most. If the adjuster has no idea of whom to talk to at the employer, this program has no chance of success.

 

 

Failure To Monitor Claims

 

This goes back to interaction between the carrier and employer. If they are not working together as a team, the relationship is doomed. The claims are also doomed, and the money is going to go pouring out the window. Missed chances for light-duty work will probably be the biggest culprit. Having to pay wage loss on any claim that could have had the chance to be a medical-only is not only disappointing but costly. You must think on a cumulative scale, $100 here and there is nothing, but when you add it up after years and years, it can be significant.

 

 

3rd Party Audit Of Claims

 

This is one that we do not see much of. If you really want to see how great your adjuster or carrier is, have them audited by an outside vendor. This is where you are going to get the truth of if they are really an asset to your company, and if that carrier is really doing all that they say they are. It is one thing to say how much they are saving you, but it is a different thing to see how much they missed out on saving on the program as a whole.

 

 

 

Michael Stack - AmaxxAuthor 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/

 

©2019 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

How To Ensure Your Adjuster Is Being All They Can Be

Workers comp adjusterIf you have ever felt an adjuster assigned to one of your workers’ compensation claims was not making a proper effort to investigate a questionable injury claim, you are not alone. Every large claims office has some really good adjusters, some acceptable adjusters and some unmotivated adjusters who are just going through the motions to make it to the next weekend.

 

If you contact an unmotivated adjuster about the status of their claims handling, the adjuster will tell you, that she is doing everything she can on the claim. The reason the adjuster will say that is because the adjuster knows that the employer most often does not know what can be done on the claim. If you want to really shake up the unmotivated adjuster and to get the adjuster moving forward full speed on the investigation of the claim, review the following list of investigation suggestions with the adjuster.

 

Check List of Investigation Tools:

 

  • Employer’s First Report of Injury form
  • Employee’s written report of claim form (in states where it is required)
  • Insurance Services Office filing (formerly known as the Central Index Bureau)
  • Contact with claim adjuster(s) on claimant’s prior work comp claims
  • Contact with prior employer(s) on claimant’s prior work comp claims
  • Medical records from claim files of prior work comp claims
  • Contact with work comp board/industrial commission for their records on prior claims (some states will not cooperate, other states do cooperate)
  • Employee’s detailed recorded statement
  • Recorded statement of any witnesses to the accident
  • Supervisor’s recorded statement
  • Police report on vehicle accidents
  • OSHA reports, whether federal OSHA or a state OSHA
  • Any other government agency records
  • Discussion of the claim with the employee’s attorney, if the employee is represented
  • Contact with any third party involved in the claim – driver of other vehicle in auto accidents, manufacturer of machinery that injured employee, manufacturer of defective product that caused employee’s injury, etc
  • Telephone contact with each medical provider to have the most recent medical report(s) faxed to the adjuster
  • Medical records for all medical appointments
  • Photographs of the accident scene
  • Diagram of the accident scene
  • Having the claimant call the adjuster after each doctor’s appointment to report on medical progress
  • Nurse case manager’s input on serious injury claims
  • Field case manager to meet with the employee and doctor, and to attend medical appointments with the employee
  • Review of claimant’s social media sites – Facebook, Twitter, LinkedIn, etc.
  • Employer’s personnel file on the employee, including job application, new employee forms, disciplinary records, etc.
  • Employer’s safety records for the accident location
  • Employer’s public notice of plant location closing, lay-offs, union issues, etc.
  • Referral of the claim to the Special Investigation Unit (the unmotivated adjuster may be quick to do this, as this passes the buck to someone else to do a complete investigation).
  • Outside Vendor Services (Investigation steps that can be taken, but not normally performed by the adjuster, but overseen by the adjuster).
  • Surveillance
  • Activity check
  • Neighborhood canvass
  • Background check
  • Credit check
  • Public records review / civil records searched
  • Criminal records check
  • Skip tracing
  • Clinic records sweep (checking for medical treatment at all clinics in the area of the employee’s address)
  • Hospital records sweep (checking for medical treatment at all hospitals in the area of the employee’s address)
  • Pharmacy records sweep (checking for prescriptions filled at all drug stores in the area of the employee’s address)
  • Video re-enactments of the accident
  • Examination under oath

 

Unfortunately, there is no central system where an adjuster can check to see if the employee is currently working another job. The use of a private investigator for surveillance can fill this void, but without knowing where an employee might be working, this is often a hit-and/or-miss approach.

 

It would be a very rare claim where it is necessary for the adjuster to take all of the investigation steps listed above. The key to an investigation is for the adjuster to take as many of the investigative steps as needed to verify the validity of the claim, or to disprove the claim.

 

We realize this checklist of the investigation steps your adjuster can take is incomplete. We welcome our readers to contact us with additional investigation techniques they would add to our investigation checklist.

 

 

 

Rebecca ShaferAuthor 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/

 

©2019 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

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