Dealing with Idiopathic Injuries

Dealing with Idiopathic InjuriesMembers of the claim management team are called upon to make important decisions at the inception of a claim.  One of these decisions includes the investigation of idiopathic injuries and making determinations regarding primary liability.  While this may take more time, failure to understand the mechanism of injury can result in extra time and money being spent.

 

 

 

Idiopathic Injuries Result From Unknown Origins

 

Simply put, idiopathic injuries are those that result from unknown origins that more likely than not are the result of workplace exposure, or related to a workplace injury.  In its basic form, it is an injury resulting from a condition or disease an individual has that has nothing to do with their place of employment and is not easily explained.

 

A common example of an idiopathic injury includes an employee walking down a hallway free of imperfection – suddenly, their knee gives out.  Was it work-related?  Is it compensable under workers’ compensation?  These types of injuries present several challenges for all interested stakeholders in the workers’ compensation system.

 

  • Employee: Proving up their case – receiving compensation for their work injury;

 

  • Employer: Preserving evidence that will be used in determining primary liability, and zealous defense of the workers’ compensation claim; and

 

  • Insurer: Diligent and proper claim investigation, and if necessary, making a legally defensible determination regarding liability.

 

 

 

Investigating Idiopathic Work Injuries

 

Investigating idiopathic injuries starts with a timely and accurate report of the work injury.  For members of the claim management team, the following needs to occur to make the right decisions:

 

  • Encourage employers to have an open line of communication with their workforce. Make sure injuries are reported in a timely manner can help preserve evidence;

 

  • Accurate reporting is essential. Do not guess the weights of various objects or distances involved.  Make sure everything is documented correctly; and

 

  • Preserve all evidence. This includes taking a photograph of conditions as they excited at the time of the incident in case they could change.  Examples of this include a hallway that has carpeting, uneven surfaces, slippery surfaces that might be covered in ice; and stairwells.

 

 

 

Determine Exact Mechanism of Injury

 

The devil is in the details – attention to details is required.  It is important to determine the exact alleged mechanism of injury.  Document the best you can in terms of movements and motions made by the employee at the time of the injury.  When you are able, make a contemptuous recording to “lockdown” someone’s version of events.  Pre-existing conditions are also important to uncover.  Other important factors to consider include:

 

  • Did an injury occur because of a work activity?

 

  • Was the employee performing work activity consistent with the claimed injury?

 

  • If there was, in fact, a work injury, what body parts are involved? Defining an injury by ICD-10 codes may also be important given the reporting requirements for Medicare and Medicaid coordination of benefit issues.

 

  • How long did the employee engage in the work activity for it to result in a work injury? Was it a substantial contributing factor in the disability and/or need for medical care and treatment/disability?

 

  • If not a specific incident-type injury, when did the injury culminate?

 

It is essential to provide this information to an independent medical examiner.  Questions regarding these issues may involve a medical director, nurse case manager, or someone with an advanced understanding of medicine.

 

 

Other Considerations

 

Other idiopathic injuries in workers’ compensation can include workplace exposure to dusts, allergens, asbestos, and idiopathic pulmonary fibrosis.  These claims can be difficult to defend as some jurisdictions have a statutory presumption, albeit rebuttable, which puts insured on the defensive – literally.  These complex cases require the use of experts to successfully defend.

 

 

Conclusions

 

Idiopathic injuries create a series of challenges for members of the claim management team.  Defense of these claims involves proactive actions from the defense interests to preserve evidence, determine with accuracy the circumstances surrounding the events leading up to the injury, and the injury itself.  Failure to take these important steps can increase program costs and lead to excessive litigation.

 

 

 

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.

What To Do If You Have An OSHA Inspection

osha inspectionThe Occupational Safety and Health Administration (OSHA) is a creation of the federal government to ensure a “safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education, and assistance.”  It has a significant impact on workers’ compensation claims in terms of workplace safety and injury prevention.   Given its role, it is important for employers and other interested stakeholders to know how to respond to workplace safety inspections and post-injury response.

 

 

Understanding OSHA Basics

 

OSHA’s jurisdictions cover nearly every workplace and job site regardless of size or function.  In terms of safety, they have the ability to inspect the workplace randomly or following a complaint that merits action.  Common conditions that result in violation include the following:

 

  • Falls from heights and failure to implement requires fall protection systems;

 

  • Scaffolding and other elevated structures;

 

  • Use or manufacture of hazardous materials; and

 

  • Machinery and implementation or use of required safety guards.

 

The federal act also allows states to create their own OSHA programs.  This act allows states to develop their own standards, provided they meet the federal minimums required under the Act.  There are currently 22 OSHA approved programs that include: Alaska, Arizona, California, Hawaii, Indiana, Iowa, Kentucky, Maryland, Michigan, Minnesota, Nevada, New Mexico, North Carolina, Oregon, Puerto Rico, South Carolina, Tennessee, Utah, Vermont, Virginia, Washington, and Wyoming.

 

Given their role, OSHA can undertake programmed or unprogrammed inspections.  “Programmed inspections” are those that involve enforcement of rules and regulations and occur on a regular basis.  Inspections that are considered “unprogrammed,” are those that involved an employee complaint, identified imminent danger, or catastrophe.

 

Regardless of the type of inspection, it is important to prepare and know how to respond.

 

 

Knock, Knock – Who’s There? OSHA!

 

It is important to courteous and professional anytime you are working with someone from a government agency.  An OSHA inspector is required to provide you with their identification and state the reason for their inspection.  The nature of the visit should also be provided.  Make sure everyone knows the process and procedure when someone arrives.

 

A typical OSHA inspection follows the following process:

 

  • Opening Conference: The purpose of this conference is to review documentation related to the site visit and determine what areas are going to be inspected.  It is important to be professional and understand the basis for the site review.  Important trade secrets may be disclosed during this process.  Have the inspector sign a non-disclosure agreement, if applicable.

 

  • Walk-Around: This portion of the visit will include a review of the physical workplace, job site, or area of specified concern.  An employer representative should always be with the OSHA inspector.  Parameters of the inspection should be defined so interaction with employees can be limited.  If the inspector takes a sample or measurement of something, it is important to verify the accuracy of the process.  Document, document, document – and listen to what the inspector is saying.

 

  • Interview: A site inspection may also include an interview with employees.  These should be monitored.  Statements made by a supervisor or someone in authority are attributable to the employer.  Interviews with general employees can be done in private.  Always consult with an attorney if there is doubt.

 

  • Closing Conference: This will typically occur at the conclusion of the walk around and interview(s).  The inspector will discuss their findings and possible courses of action.  Listen to what is being said and do not argue.

 

  • Post-Closing/Penalties: Violations always require remedy and remediation.  It may also include a penalty assessment.  The consequences of a violation generally increase with the frequency and/or severity of the offense.  There is a legal process to challenges any penalty.

 

It is important to remember that penalties can create an opportunity to better workplace safety and morale.  Federal and state OSHA programs also provide employers with the chance to have inspectors to come in and review workplace conditions without the threat of penalty or sanction.  If utilizing this method of review, renumeration is compulsory, and failure to make proper changes with result in fines.

 

 

Conclusions

 

OSHA plays an important role in making our workplaces safe.  It is important for employers and other interested stakeholders to know how to respond to an inspection.  The net result is reduced chances of workplace injury, and a safer work environment.

 

 

 

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 long will my injured worker be out of work?

How long will my injured worker be out of work? How long will my injured worker be out of work? Hello, my name is Michael stack and I’m the CEO of AMAX and that’s a good question to ask and a common question to ask when one of your employees is hurt because you need to have that expectation for how long they’re going to be out and what their recovery time is. If you’re not a medical genius, it’s hard to know if someone hurts their shoulder and has a partial rotator cuff tear, what that actually means in terms of recovery time. I want to talk to with you today about how to know that information by using a really, really handy little tool to help you uncover some of these medical secrets to say, well I don’t really know how long it’s going to be out, but they’ve already figured it out.

 

 

Evidence-Based Medicine Injury Duration Guidelines

 

Other people have already figured it out and they tell it to you in a very simple and easy to use format in the form of evidence-based medicine, injury duration guidelines. And these are provided by two different companies or most commonly by two different companies. One’s called ODG guidelines provided by the work loss data Institute and then MD Guidelines provided by the Reed Group. So two great resources to tap into this and I want to cover very quickly, so take a look at the board here. So this is the evidence-based medicine injury duration guidelines for a partial rotator cuff tear. And you’ll see here there’s various categories and levels that you can look at. So whether the person’s in a sedentary job, medium, heavy, light, very heavy type of job, and then they give these guidelines as far as expected, physiological.

 

 

 

Look at Simple Chart To Find Your Answer

 

So how long should it take that person’s body to physically heal for them to be able to be back to work in these different categories of jobs. So pretty general categories, but you could know where your forklift driver fits versus where your office worker fits. If you know what I’m saying, so let’s take a look here. So you’ve got your minimum, your optimum, and then your maximum physiological time that will be required for that person to return to work and you’ve got zero and it goes up to 21,42, 85 etc. And you can just figure out on that little chart there of what that looks like for you. So if you asked yourself that question, how long will my injured worker be out of work? Go ahead and take a look at this chart and have that expectation. Here’s what I also want you to realize, and this is if you’re not familiar with some of this, it will kind of probably surprise you, is that when you look at this, you see these guidelines even for the very heaviest positions of the heaviest light do or heaviest job required here, the maximum out of work time physiologically is 85 days for the most physically demanding jobs that are available.

 

 

50%+ Employees are Not Back to Work Within Maximum Expected Recovery Time

 

If you look at what the actual data says in both ODG and MD guidelines provide this actual data, you will see that actually only 5% of people are back to work within 18 days, so 5% of people are back to work within 18 days and the median so meaning 50% more and 50% less are back to work in 95 days, so more than 50% of people aren’t back to work within the maximum amount of time required for physical healing. Now that should put you on edge to say, what are we doing wrong? Why are we missing this? Look at some of this data, leveraging some of this data and you’ll see that if you have this type of injury, almost all of your people should be back here in some sort of light-duty job within at most four days and that should be your goal.

 

Getting them in that transitional duty position to start healing. Then continuing to progress them back towards their medium heavy and light duty positions, evidence-based medicine injury degree. Injury duration guidelines are a very handy and useful tool for you to implement into your work comp management program. If you’re using them, use them more. Tap into them, leverage them more if you’re not using them. I recommend starting today.

 

Again, my name is Michael stack and CEO of AMAXX, and remember your work today in workers’ compensation will have a dramatic impact on your company’s bottom line, but it will have a dramatic impact on someone’s life. So be great.

 

 

 

 

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.

Radius Bank Partners with Professional Administrator Ametros to Offer Checking and Savings Accounts

BOSTON, /PRNewswire-PRWeb/ — Radius Bank, a forward-thinking digital bank, today announced their partnership with Ametros, the current leader in personal injury settlement solutions and post-settlement administration services. Through partnership with Radius, Ametros members can now have non-medical settlement funds automatically deposited into a white-labeled Ametros Checking or Savings account for easy account management.

 

Founded in 2010, Ametros provides individuals that settle their personal injury case with medical management services, medical and pharmacy discounts along with automated payment technology and Medicare reporting tools. Radius partnered with the settlement solutions company to power Ametros Banking, as they saw a strong cultural alignment between the two organizations, with both focused on transforming customer experiences by developing products for targeted client segments.

 

Ametros Banking is now available to Ametros members nationwide and offers the following benefits upon account approval:

 

  • Earn 0.10% APY on the entire balance(1)
  • No monthly service fees or minimum balance requirements
  • FDIC insurance
  • A debit card to make purchases, access ATMs, and use mobile wallets
  • Free ATMs worldwide and unlimited ATM fee rebates(2)
  • First order of checks is free
  • Eligible for early direct deposit where available(3)

 

Members may manage the funds they receive from their settlement through the Radius Bank online banking platform or through the Radius mobile app where they can also use the Radius personal financial management tools to create a budget, track their spending, use mobile check deposit, and pay bills online.

 

“We are inspired by Ametros’ mission to help people save money on their ongoing medical expenses, and we are excited to work with them to power Ametros Banking to help clients maximize the value of all of their settlement funds,” said Radius Bank Vice President of Strategic Partnerships and Technology, Huma Usmani.

 

“We are excited to announce our partnership with Radius Bank, furthering our goal of making life easier after settlement,” says Ametros’ Vice President of Product, Gal Zhovnirovsky. “Our members are now able to access award-winning checking and savings accounts at the time of settlement. Through our partnership, we look forward to providing more innovative solutions for our members.”

 

To learn more about Ametros, visit https://ametros.com.

 

Ametros Banking marks the seventh strategic partnership announcement for Radius this summer, and their fifteenth in the last four years. To learn more about partnership opportunities at Radius Bank, visit: https://radiusbank.com/company/partnerships/.

 

 

About Radius Bank

With assets of approximately $1.4 billion, Radius Bank is a forward-thinking digital bank committed to providing a full complement of accounts and services to meet the banking needs of consumers and businesses nationwide. Radius provides the product depth of a national brand, the technology of a fintech, and the personalized attention typically reserved for a local bank to consumers, small and middle market businesses, unions, government entities and non-profit organizations. The Bank’s award-winning digital banking platform allows consumer clients to bank from anywhere with a computer or mobile device and provides convenient features such as check deposit, bill pay, card management, and a personal financial management dashboard. Business clients enjoy a wide array of award-winning deposit products, advanced treasury management services, and loan and payment solutions. In addition, Radius’ suite of open APIs deliver a robust banking-as-a-service (Baas) platform for fintechs to quickly access core banking features and build best-in-class financial solutions. Radius specializes in partnering with forward-thinking fintechs to provide white-label deposit products, cards, digital onboarding, and account management. Radius Bank is a member of the Federal Deposit Insurance Corporation and is an Equal Housing/Equal Opportunity Lender. For further information, visit the Bank’s website at radiusbank.com, or follow the Bank on Twitter, LinkedIn, Facebook, and Instagram.

 

 

Ametros provides settlement solutions for personal injury settlements. Over the past nine years, Ametros has built, from scratch, the nation’s largest technology-enabled administrator in the country. The innovation team at Ametros has had the honor of partnering with almost all the workers compensation industry’s largest payers, vendors and attorneys to find new ways to bring ideas to the claim settlement space. Headquartered just north of Boston in Wilmington, Massachusetts, Ametros offers injured parties (its “members”) patented medical administration tools and reporting, automated payment technology, and access to significant healthcare discounts for pharmaceuticals, provider visits, and medical equipment, in addition to live phone/email/chat support from its dedicated care advocates teams. Ametros’ core products, CareGuard and Amethyst, enable members to approach settlement with confidence and security. Ametros’ services are frequently useful for settlement recipients needing help administering a Medicare Set-Aside, but can be used to help administer any allocation of self-pay medical funds. Learn more at ametros.com or by calling 877-275-7415.

 

(1) Ametros Banking is a free checking account with no monthly maintenance fee, no minimum balance requirement to open the account and is FDIC-insured up to the maximum allowed. Annual Percentage Yield (APY) accurate as of 08/27/2019. Minimum amount to open account is $0.00. Rate tiers are as follows: 0.10% APY applies to balances of $0.01 or more. Rates may be subject to change without notice after account is opened. Fees may reduce earnings.
(2) Get unlimited automatic ATM surcharge rebates for ATM fees other banks charge you. ATM surcharge rebates apply to cash withdrawals from an Ametros Banking account using the Ametros/Radius debit card wherever it is accepted. Radius Bank does not charge a fee for using another bank’s ATM. ATM fees will be rebated at the end of each statement cycle. Excludes international exchange fees. Radius Bank makes its best effort to identify those ATM fees eligible for rebate. In the event that you have not received a rebate for a fee you believe is eligible, please contact Customer Service at 800-242-0272. Radius Bank reserves the right to modify or discontinue the ATM surcharge rebate program at any time.
(3) Direct Deposit and earlier availability of funds is subject to payer’s support of the feature and timing of payer’s funding.

 

Vocational Rehabilitation Qualified Rehabilitation Consultant Misconduct

vocational rehabVocational rehabilitation and working with a Qualified Rehabilitation Consultation (QRC) can reduce workers’ compensation costs and get an injured employee back to work in a timely manner.  Problems can arise when the QRC starts acting like an advocate for the injured employee.  Members of the claim management team and other interested stakeholders need to be on the look-out for QRCs gone wild – and ensure they are working for the rehabilitation plan, and not the employee.

 

 

What are QRCs?

 

QRCs are trained vocational rehabilitation consultants than assist employees in post-injury return-to-work and medical management activities.  Requirements for QRC registration are typically governed by administrative rules established by an industrial commission.  They are appointed following a work injury where the employee’s injury is severe enough to require extended time off work.  They should have a solid medical background, and understanding of the labor market and empowering employees to return to suitable gainful employment.

 

 

Acting in the Best Interests of the Rehabilitation Plan

 

QRCs will meet with an injured employee at appointed times set forth in statute or rule and determine the vocational goals.  This includes an assessment of various factors, which can include:

 

  • The nature and extent of the employee’s injury;

 

  • Restrictions and other limitations placed on the employee post-injury;

 

 

  • Ability of the date of injury employer in returning the employee to work, including in a light-duty capacity.

 

QRCs are required to be neutral parties and not an advocate for the employee.  The best interests of all parties need to be carefully balanced and taken into consideration.

 

 

Qualified Rehab Consultant Misconduct

 

QRC misconduct is defined by statute or rule in each jurisdiction.  There are general principles that govern the conduct of a QRC.  Proactive members of the claim management team need to be on the look-out for these factors and take appropriate action against a QRC that steps outside their role.

 

  • Failure to perform rehabilitation services with reasonable skill because of negligence, habits, or other cause. This can include a number of different factors and behaviors.  It can be something as basic as missing meetings or appointments, and consistently not returning telephone calls in a timely manner.  It can also include failing to properly supervise QRC interns and support staff;

 

  • Engaging in conduct that is likely to deceive, defraud, or harm the public;

 

  • Fraudulent billing practices, or failing to properly bill for vocational rehabilitation services; and

 

  • Engaging in adversarial communication or activity. This can include behaviors such as offering opinions on the facts of the case, litigation strategy, requesting information not related to the rehabilitation plan, failing to report all relevant information, and not complying with authorized requests for information.

 

QRCs need to take their responsibilities seriously.  Let the attorneys advocate for their client(s).

 

 

Removing a QRC From the Rehabilitation Plan

 

Each jurisdiction has the mechanisms and standards for removing a QRC from the rehabilitation plan and installing a difference vocational assistant.  Most states look at the “best interests of the parties” when making such changes.  Factors for consideration include the following:

 

  • Loss of trust of the QRC. Claim handlers making this argument should provide concrete evidence on how the QRC has “picked sides” in a dispute – become an advocate for the inquired employee;

 

  • Duplicative time and costs that may be incurred as the result of the removal/change in QRC. This is an argument that can be made when the claim management team opposes the change in QRC;

 

  • Reputation and years of experience and complexity of assignments by the individual; and

 

  • Geographic location of the QRC. In some instances, one QRC may be better than another if the employee relocates.

 

 

Conclusions

 

QRCs play an essential role in vocational rehabilitation and getting an injured employee back to work.  Claim handlers need to be diligent in making sure the QRC is doing their job and being an advocate for the rehabilitation plan, and not a party.  Failure to do so will result in an employee being off work for a longer time, and more money spent on vocational rehabilitation costs.

 

 

 

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.

Closing Down Vocational Rehabilitation Workers’ Comp Cases

vocational rehabVocational rehabilitation is an essential workers’ compensation benefit for employees suffering from the effects of a work injury.  It not only helps the employee understand their medical care and treatment, but provides them with assistance in getting back to work.  This reduces the money spent on a workers’ compensation claim and improves program efficiency.  Members of the claim management team need to examine their files to ensure this benefit is being provided in a responsible manner.  When there is no longer a benefit to the employee, steps must be taken to discontinue services.

 

 

When is Vocational Rehabilitation Appropriate?

 

Vocational rehabilitation services are provided to employees who are qualified under a workers’ compensation law.  This is a benefit that did not come into acceptance in most jurisdictions until the 1970s.  It is generally not available to an employee unless they have been off work for an extended period of time.

 

In order to qualify, a consultation is usually performed by a Qualified Rehabilitation Consultant (QRC), and a recommendation is made regarding the employee’s status.  Factors generally considered include:

 

  • Whether the employee is permanently precluded or is likely to be permanently precluded from engaging in their usual and customary occupation or from engaging in their pre-injury job;

 

  • Whether the employee is reasonably expected to return to suitable gainful employment with the date of injury employer; and

 

  • Whether the employee can reasonably be expected to return to suitable gainful employment through vocational rehabilitation services by taking into consideration the treating physician’s opinion regarding the employee’s ability to work.

 

 

Vocational Rehabilitation is Being Provided – Now What?

 

During vocational rehabilitation, the QRC will issue regular progress reports.  It is essential that the claim handler monitors vocational rehabilitation once it has been approved.  These reports outline the services being provided and the progress the employee is making in recovering from the work injury.  Important issues to consider when reviewing periodic reports are as follows:

 

  • New or continuing physical limitation that significantly interferes with the completion of the rehabilitation plan;

 

  • Whether the employee is participating fully with the plan; and

 

  • Whether the goals of the plan should change, or be modified.

 

Steps should be taken to termination vocational rehabilitation services if it appears the employee will not benefit from ongoing assistance from the QRC.

 

 

Do Not Pass Go: Shutting Down Vocational Rehabilitation Services

 

Each jurisdiction has the prescribed method one must follow in order to terminate the rehabilitation plan, and discontinue ongoing services from the QRC.  While the process may differ, there are general requirements that are considered when putting an end to vocational rehabilitation serves.

 

  • A new or ongoing physical disability that significantly interferes with the completion of the rehabilitation plan. This is sometimes the case when the employee has a significant setback in their medical care or new injury or disability that is not related to their work injury;

 

  • The employee is not cooperating with the vocational rehabilitation being provided by the employee. Common examples include missing medical and physical therapy appointments, or failing to keep in contact with the employer and/or QRC; and

 

  • The employee is not participating effectively in the implementation of the rehabilitation plan.

 

The focus of the arguments made to terminate ongoing vocational rehabilitation services is whether the employee would benefit from additional vocational rehabilitation assistance.  The party seeking to cease these services has the ultimate burden of proof.  Grounds for stopping these services that are absolute usually include:

 

  • An employee who has returned to work with a negligible wage loss, or without a wage loss. Expectations of near-term future earnings can also be taken into consideration;

 

 

  • The employee is no longer making themselves available for services;

 

  • Death of the employee.

 

The closure of a rehabilitation plan generally requires a form to be filed with the industrial commission.

 

 

Conclusions

 

Members of the claim management team must closely monitor every workers’ compensation benefit being received by an employee.  This includes keeping abreast of the employee’s status and cooperation with vocational rehabilitation benefits.  While this is a useful benefit, steps should be taken to terminate it if evidence supports the conclusion the employee would not likely benefits from ongoing vocational rehabilitation services.

 

 

 

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.

 

 

 

 

 

 

 

 

 

Maximize ROI of Workers’ Comp Management Improvements with the Right Insurance Structure

 

TO LEARN MORE ON THIS SUBJECT:

 

Register for the full on-demand course:

 

  • HOW TO DETERMINE WHICH WORKERS’ COMP INSURANCE STRUCTURE IS RIGHT FOR YOU

Registration – How to Decide Which Insurance Structure is Right For You

 

 

How does a company maximize the return on investment of implementing work comp management best practices?

 

Hello, my name is Michael stack and I’m the CEO of AMAX and the short answer to that question of ‘how does this company maximize their ROI’ is to start with the right insurance structure, whether that be guaranteed cost, or a retro or a captive, high deductible program or self-insurance policy. But the question is how does a company then determine what is the right insurance structure for them? So often I see this done in the marketplace so incorrectly and only a small percentage of the time is this actually done right. Most of the time it’s just sort of done Willy Nilly and you’re just guessing or the insurance broker says, Hey, I’ve got this really awesome retro policy with this XYZ carrier and I think you’re perfect for that.

 

 

The Right Insurance Structure for the Right Employer

 

Or, Hey, I’ve got this really awesome captive because I know captives really well and I specialize in captives and I think everyone should be in a captive and you should be going to captive to. In short, what often happens is that if an insurance broker is a hammer, everyone looks like a nail and if that hammer is a captive program or if that hammer is a high deductible program or if that hammer is a retro program or even if the hammer is a guaranteed cost program, where all you know is guaranteed costs, every single company you look at looks like they should fit into that program, which is not the right way to do it at all. You need to raise yourself up and have a higher level of professionalism in the marketplace to analyze an employer’s needs or if you’re an employer yourself to analyze your own needs and be able to ask the right questions to your insurance broker and risk advisor team.

 

So I want to talk about today is these four cornerstones of risk financing, what they look like and how you start to go about making this decision because when we’re talking about maximizing the return on investment, why are we implementing from a senior management standpoint, why are we doing all this work with return to work? Why are we working and our injury response systems? Why are we working on building out our medical networks and building this adjuster team and building out this partnership with all our whole risk financing, our risk management team? Why are we doing all that stuff? Of course, it’s to impact those injured workers, but particularly from a senior manager standpoint, it’s all about that bottom line and that’s what’s going to fuel, if you hit that bottom line right, then you’ll really be able to fuel that injured worker being able to really take care of them as well.

 

 

4 Cornerstones of Risk Financing

 

Let’s talk about these four cornerstones and what they are, and again, this is how you’re going to go about really starting to make an analyze this decision. I’m going to write these out here first.

 

These four cornerstones are:

 

  • Risk tolerance
  • WC Management Best
  • Predictability of your risk
  • Financial Impact

 

So these are the four cornerstones and I’m just going to run through these again very quickly cause this is all about changing the mindset and if you can get out of this video to change your mindset of how you examine this from being a specialist in retro programs where everyone looks like they fit into a retro program, to now being a professional in the marketplace to now determine via these four cornerstones and asking these questions and having this perspective and how you look at this to change up that, how that looks like for you.

 

 

Determining Risk Tolerance

 

Okay, so risk tolerance, how comfortable is an organization with this variability of risk? Are they really risk-averse and they want to be very conservative, they want to be very predictable. We’re going to write a guarantee cost check and we’re going to know that in our budget and that’s going to be solid and we can predict that out and we’re in great shape or can they handle a little bit more variability as far as what’s going to happen with their losses? That’s sort of question number one. What helps you then be more comfortable taking on more risk is these two things right here. These two things are going to help you be more comfortable in taking on more risk. One is if you know, whoops, I wrote best twice there. If you know you’re doing really well in your return to work program, you know you’re doing really well in your injury prevention program, you’ve really cranked that up, you’ve dialed everybody in, you’ve gone through the supervisor training, your supervisors know how to respond to injuries appropriately.

 

You’ve built out your claims handling team with your adjusters and you’re just cooking with gas. You can take on a lot more risk because you know you that you’ve reduced it on your own side. Same thing with this predictability of risk number. This is a big, big factor in this decision-making process. If you’ve ever going retro or high deductible or kept over self-insured, you start to look at this law of large numbers to say, well, how likely are we to now incur these losses? How likely based on actuarial data, big numbers based on this predictability of losses, how comfortable are we in this section? You’re going to get some help. You’re going to get some help from an actuary most likely to help you have this predictability of risk and the more comfortably without that, the more risk you can take on. So big two pieces here.

And then, of course, the financial impact is understanding that financial impact, both tax implications from your different structures and then that risk-reward feature as well as the more risk that you take on. Obviously, the more reward and organization it’s going to take.

 

 

Change Perspective of Risk Financing Decision Making

 

This is a very complex topic as you start to unfold it. And as you start to dig deeper into this. But again, the point of this video today is to change your perspective on how you look at this, to raise up your level of professionalism. To say that this decision is it about the market. This decision is about what’s best for the client, and if you are the client, if you are the employer client to now have these four things, your risk tolerance, how well you’re doing it, management of work comp, the predictability of risks, and then the financial impact on your organization.

 

Those are the four cornerstones of now you how you start to go about making this right decision to maximize that return on investment and get, my name is Michael stack and the CEO of AMAXX, and remember your work today in workers’ compensation can have a dramatic impact, as we’ve talked about here on your company’s bottom line, but it will have a dramatic impact on someone’s life. So be great.

 

 

 

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.

 

Medcor Announces the Purchase of Proactive Occupational Medicine

Chicago-based Medcor, Inc., a leading health navigation firm, announces the expansion of its services through the purchase of clinic operations and other assets from Proactive Occupational Medicine, Inc., an Ohio-based health services company. Medcor already operates over 240 onsite and nearsite clinics providing both occupational and general healthcare across North America.

 

Medcor Chief Operating Officer Ben Petersen said, “This acquisition complements and strengthens Medcor’s onsite clinical and safety staffing relationships. I’m excited to welcome Proactive’s talented staff into our team and to equip them with Medcor’s state-of-the-art systems.”

 

With this horizontal acquisition, Medcor expands its Construction Health and Safety business in the power and general construction industries. It also enters the steel industry, bringing to that sector Medcor’s evidence-based medicine and proprietary clinical systems.

 

Medcor Chief Financial Officer Mark Smolenski said, “This purchase demonstrates Medcor’s commitment to continue growing our construction practice and to deliver health navigation to new customers and new industries.”

 

Medcor Divisional Vice President of Construction Health and Safety Kevin Kelley said, “The addition of Proactive Occupational Medicine also enhances our service offerings by expanding our mobile audiometric and X-ray capabilities.”

 

Terms of the transaction were not disclosed.

 

About Medcor

 

Medcor provides health navigation through integrated services that include onsite and mobile clinics, injury triage, telemedicine, and safety staffing and training. Medcor serves clients throughout the United States and Canada across a wide range of industries. Medcor helps employers and their employees navigate the complexities of healthcare to achieve better clinical and financial outcomes. Learn more at www.medcor.com.

 

About Proactive Occupational Medicine

 

Proactive Occupational Medicine is an occupational health services company that has served clients in the power, construction, pipeline, steel, coal, automotive, manufacturing, chemical and lumber industries. Learn more at www.pominc.com.

How to Control the 5 Variables that Impact MSA Amounts and Approvals

How to Control the 5 Variables that Impact MSA Amounts and ApprovalsWhen is the right time to get a Medicare Set-Aside? What medical information is needed? And what can you do to expedite the CMS approval process?

 

These questions plague any organization trying to settle workers’ compensation claims with injured workers who are or soon will be eligible for Medicare. But understanding when, how and why MSAs are most appropriate allows payers to work proactively with an MSA vendor to reach settlements that are in the best interests of all parties involved.

 

Anne Alabach, the Workers’ Compensation Department Manager of CPC Logistics, joins Daniel Anders, Chief Compliance Officer at Tower MSA Partners to discuss Achieving Great Outcomes with Your MSA Vendor during the National Workers’ Compensation and Disability Conference® & Expo next month at Mandalay Bay Resort in Las Vegas.

 

The session will focus on the key indicators to determine success or need for improvement, ways to leverage partner relationships to drive down unneeded MSA costs, and variables that can significantly affect the amounts of MSAs as well as approval times from the Centers for Medicare and Medicare Services (CMS).

 

 

Prime Variables

 

There are a variety of factors that go into developing an MSA. There is not necessarily a ‘right’ or ‘wrong’ amount. What’s important is that the injured worker has enough money to pay for his injury-related medical expenses throughout his life, and the payer is not incurring irrelevant and/or unnecessary costs.

 

In addition to meeting the threshold for needing an MSA, injured workers should be at maximum medical improvement before one is even considered. An employee who’s about to undergo surgery or a change in medications is not at the point where an MSA should be developed.

 

Instead, it is most appropriate when the worker’s condition has stabilized.

 

The variables that should be considered to achieve the most suitable MSA include:

 

  1. Time
  2. Documentation
  3. Legal
  4. Medical
  5. CMS MSA Review

 

 

Timing of the MSA

 

Time is of the essence — unless it’s not the right time for an MSA. As described above, prior to MMI is the wrong time to establish an MSA. Changes in treatment or services will undoubtedly mean new medications or procedures will be needed, at least in the short term. The MSA should, instead, be developed when there is a reasonably strong chance the person’s medical requirements won’t vary much going forward. CMS’ MSA review program is actually designed for the injured worker who is already at MMI.

 

However, MMI does not necessarily indicate all medications and other medical needs are appropriate; far from it. For example, medical records for the injured worker may include a medication that was prescribed just one time, months or years ago. It is not uncommon to see medications included in the MSA that the injured worker doesn’t even remember taking.

 

Uncovering those types of issues is invaluable in reducing unnecessary costs from the MSA. Talking with the MSA vendor about the injured worker’s current situation may reveal clinical interventions that place the case in a more favorable position.

 

Also, there may be case-specific recommendations based on jurisdictional issues and opportunities that would change the MSA amount. Working with a qualified MSA vendor can lead to major changes in MSA costs.

 

 

The Right Documents

 

Workers’ compensation stakeholders are often frustrated by delays in the CMS approval process. While some of the blame may fall on the agency, it is often the result of insufficient or inconsistent information provided. “An MSA is only as good as the information it is based upon,” according to Anders. Failing to give accurate and complete information may result in letters from CMS and errors in the MSA amount.

 

“Put yourself in CMS’ shoes,” Anders advised. That means to obtain and provide recent treatment records, or an explanation as to why those documents do not exist. Also, contradictory recommendations need to be corrected. The MSA vendor can ensure the right documentation is provided and is properly filled out.

 

 

Legal & Medical Issues

 

There may be legal justification to exclude or limit medical care in the MSA. Working closely with the MSA vendor can identify those issues.

 

Physician peer review, clinical oversight, and physician follow-up are the types of interventions that are critical in creating MSAs. Every aspect of the injured worker’s future medical needs must be explored, by obtaining and analyzing his past medical care. Inappropriate care that may be huge cost drivers should be singled out and eliminated where possible, while still ensuring the injured worker’s care is optimized.

 

Date of injury, accepted and denied dates of injury and body parts, compensable injuries, & diagnosis codes are just a few of the many things that must be considered.

 

 

CMS Review

 

Gaining CMS approval for the MSA, while not required by law, is often a best practice. The outcomes of these reviews are largely predictable — once the process is well understood.

 

Correctly following the guidelines in the CMS WCMSA Reference Guide, using the correct pricing in fee schedules and recognizing statutory limitations are a few of the factors that can lead to CMS approval.

 

Certain metrics identified in the MSA preparation and submission process can allow reverse engineering to correctly allocate the MSA and identify obstacles to settlement. An experienced MSA vendor can help pinpoint and analyze metrics to get CMS approval as quickly as possible.

 

 

Conclusion

 

Creating an MSA can be tedious, painstaking work, especially for those whose jobs are not solely focused on them. Those MSAs that gain quicker approval from CMS and are properly funded are developed by payers working in conjunction with MSA vendor partners who have the skills to carefully look at a myriad of factors that impact the injured worker and his medical needs.

 

 

 

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 the 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.

5 Criteria to Choose the Right Professional Administrator

professional administratorIt’s not often you hear of the government endorsing a particular service in the private sector. That’s what made it so unusual when the Centers for Medicare and Medicaid Services in 2017 “highly recommended that settlement recipients consider the use of a professional administrator for their funds.”

 

The 2017 statement spoke volumes about the need for injured workers and others to get help managing their money and lives post-settlement. The concept of professional administration is, unfortunately, highly misunderstood by many workers’ compensation professionals. But once stakeholders are exposed to the ins and outs of this unique benefit, they realize how it can easily be a win-win for all parties to a claim – and why CMS encourages the idea.

 

 

What is Professional Administration?

 

The vast majority of workers’ compensation stakeholders are keenly aware and focused on injury prevention and claim management. What few stakeholders address, however, is that life after a claim is settled. Employers, payers, and injured workers alike usually want claims settled as soon as possible. It gets these cases off the books and allows the injured party to move on with his life.

 

The problem is the logistics of actually getting to claim closure. The biggest question for everyone involved is often, how much money will it take? The employer/payer wants an amount that will cover the injured worker’s needs, but that is also fair and accurate. The injured worker, understandably, may be extremely fearful that he will run out of money too soon.

 

In many cases, the claim has been open for months, if not years. While the workers’ compensation system may be seen as adversarial to the injured worker, it at least provides a sense of security that his medical needs are being covered – even if he doesn’t necessarily like the providers and does not always get approval for treatments he believes he needs. Settling the claim means the injured party is on his own to manage whatever funds he has agreed to. Additionally, where there has been a claims adjuster and/or nurse case manager helping him locate and schedule medical appointments, they are now gone. Many injured workers become anxious when they realize they will have to manage their case on their own once they settle.

 

Professional administrators work on behalf of the injured worker post-settlement in multiple ways.

 

  • Clinical help. The professional administrator essentially takes over the role of adjuster/nurse case manager and provides the expertise, guidance, and logistical help so the injured party gets the medical care he needs. However, rather than having a specific group of physicians available and having to seek approval for treatments, the injured party is free to see any physician of her choosing and decide for herself whether to undergo certain medical treatments.

 

  • Money management. All too frequently people settle their claims, take the money in a lump sum, and exhaust the funds within a few years. That is why experts strongly recommend structured settlements for injured parties who settle their claims. Depending on the injured party’s desires, the professional administrator can establish a bank account and act as custodian – receiving bills and paying them on behalf of the injured party.

 

  • Savings. Well-established professional administrators can make a significant difference in an injured party’s life through medical discounts; for physicians, medications, treatments, and other medical-related items. The best ones have partnerships with many providers and can provide deep financial savings, helping to ensure the injured party’s money lasts longer.

 

  • Medicare reporting. One of the issues that is often problematic for injured workers is addressing all the rules and regulations associated with Medicare Set-Asides. Injured workers who have an MSA as part of their settlements must strictly adhere to CMS’ requirements or risk losing Medicare benefits in the future. Professional administrators handle all annual reporting for MSAs and ensure that the funds are not used for the wrong purposes.

 

 

The Right Professional Administrator

 

There are many professional administrators and finding one that is the ‘best’ for a particular injured worker is not a decision that should be made lightly. Along with the injured party and his advocates, stakeholders working on a claim should also research various companies to help make the best choice. Stakeholders want to know the injured party is taken care of and won’t call them six months after settlement with complaints and threats to sue.

 

There are certain questions that can differentiate the best professional administrators and how well they will meet the injured party’s needs:

 

  • Costs/savings. There is no free lunch, and just like any organization, professional administrators need to generate income. For those in the market, the price should balance against the savings to the injured party. One company may charge $1,000 while another charges $2,000. However, asking for the average savings in medical/pharmaceutical costs and savings on the MSA funds tells the real story of the ‘costs’ to the injured party over the long term. If a company does not track this information or won’t provide it upon request, that should serve as a red flag.

 

    • The vast amount of medical and other personal information provided to a professional administrator must be protected. Find out what, if any steps the company takes to protect members’ information, whether they undergo routine technology and financial audits, and if they are HIPAA compliant.

 

  • Customer service. The relationship between the injured party and the professional administrator is lifelong, so it’s important to know all questions and concerns will be taken seriously and addressed appropriately. Find out if and how the organization measures its customer service, such as through surveys of members. Talking with existing members is also a good way to determine the quality of a company’s customer service. The company should be willing to provide references and a look at a survey of members, if they exist.

 

  • Technological convenience. Many people want to be able to get information online. Some professional administrators provide easy-to-access information, such as funds spent/remaining, names/addresses of providers, medications prescribed, recent visits, analyses of spending and savings, etc. On the other hand, some people are not comfortable with doing everything via phone/tablet/computer and should have the option of a phone number to call with their questions.

 

  • Additional services. Professional administrators should have partnerships with many other experts that can help with post-settlement issues. The company should be able to provide lists of additional services, and experts offered.

 

 

Conclusion

 

A well-run professional administration company is an invaluable asset for an injured party who settles his claim. Those that have the most experience and expertise not only help these workers post-settlement, but their inclusion in the process often helps move claims to settlement more quickly.

 

 

 

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 the 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.

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