Work Comp Roundup -

Five Clues an Injured Employee is Dragging Out Their Workers Compensation Claim

November 20, 2018 by Michael B. Stack

Now and then one comes across a claimant who knows the twists and turns of the workers’ compensation system. The claimant could be a dependable and good worker, but the employee is dragging out their workers’ compensation claim.

The insurance industry calls these people “career claimants.” When a background check is done, they have a list of prior claims a mile long. Having many prior claims does not necessarily mean they are bad workers; perhaps they are injury-prone. It is very interesting, however, when claims are filed, they are sneaky enough to do just enough to keep the wheels turning and drag out their workers’ comp claim to remain out of work or on medical restrictions. Odd how that happens…

Adjusters can use their defensive tools to get these claimants off workers comp. Even when adjusters do IMEs, surveillance, and speak with the physicians providing the treatment, nothing seems to get this type of worker back to full duty.

When claimants know too much about how the system works, they drage out their workers’ comp claim by:

Having the Physician on their Side

Physicians usually base opinions on evidence-based medicine. Tricky claimants know what to tell and what not to tell the doctor. They use the Internet as an information source. For example, if someone sustains a back strain, acceptable symptoms are researched to report without over-exaggerating the symptomology to cause the treating physician to see red flags.

Limited range of motion, muscle spasm, and bringing up pain complaints tell a doctor if the person is or is not hurt. The doctor proceeds presuming the patient is reporting honesty and may keep the patient on restrictions, on continuing treatment, and off work. This is where the independent medical examination (IME) comes into play. It is always good to have another opinion just in case the treating doctor is not being proactive in moving the patient along to full duty, especially if the subjective complaints do not match the objective evidence on examination.

Rescheduling Doctor and Physical Therapy Appointments

Everyone has a life outside of work. However, constant rescheduling of medical appointments is a red flag for the adjuster. Maybe now and then a physical therapy appointment is missed, especially when working light duty. But, it is important to remember legitimately injured workers want to get treatment, heal, return to full duty, and not drag out their workers’ comp claim.

A typical lumbar strain does not necessarily prevent a person from being active or running errands, but if a trend arises of constant rescheduling — THINK — what else is going on besides the injured worker’s schedule? Surveillance is a handy tool to confirm suspicions. It is especially helpful if the injured worker is caught in a lie. If the worker reports to the adjuster therapy is missed even when off work and surveillance shows the employee doing yard work instead of going to physical therapy, that is evidence to suspend the claim due to non-compliance with the treatment plan provided by the doctor.

Hot Tip: One therapy office has a policy of charging the patient the full amount of the missed appointment unless given 24-hour notice. They present patients with this written policy at the beginning of therapy and make them sign indicating they understand they will be charged and their insurance will not be billed.

The Claimant Knows the Lingo

One thing jumping right into the adjuster’s face is a claimant knowledgeable about the injury in medical terms. The average person does not use words like radiculopathy, impingement, and stenosis or know what they mean.

Even more striking is when a worker discusses a settlement or redemption early on in the claim. This behavior should lead the adjuster to believe the worker has been down the workers’ comp claim road before. Most times, when a background check is done, it shows prior litigation experience with prior employers. These are all red flags indicating you want to keep an eye on this claimant as they may be dragging out their workers’ comp claim.

The Claimant is Off Work and Cannot be Found

When a claimant has a legitimate injury and is off work for a while, it is a good idea to do surveillance to get additional information. After a few days, if the video only shows the worker poking a head out of the front door to retrieve the mail, it is always a red flag. The person may have a prior claim history, broke restrictions, and the claim was denied or suspended.

Or even worse, when you go to do surveillance, the worker cannot be found anywhere. The worker might be staying at another location or at another property. When you talk to the employee, excuses are made about how pain is so disabling all that can be done is to stay home and rest. However, something is awry if you go to do surveillance and the car is not in the driveway.

The Worker Misses a Few Therapy Appointments Every Week

Remember, injured workers with legitimate injuries want treatment so they can heal, return to work, and not drag out their workers’ comp claim. In a red flag claim when a person goes to some treatment, but not all and not all the time, this means they are doing just enough to keep the claim alive, but missing just enough treatments not to get better.

The unsaid rule in claims is the longer a person is off work, the harder it is to get them back to work. This challenge is where a light-duty work program comes in handy. Light duty forces the worker to go to work. It also forces them to go to treatment, especially if one has to leave work to go to therapy and then return to work to finish the shift.

Doing just enough to keep the adjuster from disputing the claim shows the claimant knows a little bit about how the claims system works. As an adjuster, if a person makes 75 percent of the medical appointments, is that going to stand up in court if you pull the trigger and file a dispute or suspension?

Summary

Just one of these points does not mean your employee is cheating you and trying to drag out their workers’ comp claim. But, some smart claimants know how to work the system. If, as the adjuster, you spot one of these claims, it is your role to stay on top of every aspect of the claim. Make sure if workers miss appointments they have some documentation to support absences. The more pressure you put on them, the better result you will have in defeating unethical claimants at their own game.

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

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Fight Workers Comp Fraud & Abuse

Create an Effective Wellness Program with 6 Milestones

November 19, 2018 by Rebecca Shafer, J.D.

Many small and medium-size companies wish to create an effective wellness program like their larger competitors, but due to budget concerns and lack of personnel in the Human Resources Department, have not started their own wellness program. It is not as difficult as one might think.

Here are some guidelines on how to create an effective wellness program:

Management Support of Wellness is Step One

Gaining management support for the implementation of a wellness program is the first step. As senior management is all about the financial success of the company, explaining how the wellness program will improve the company’s financial picture is a good place to start. Read the study on wellness programs completed by the Wellness Council of America. Explain how for every $1 spent on wellness programs, there was a $3 reduction in the cost of the health insurance program. If management is still not sold after learning the wellness program has an ROI of 3 for 1, an article published in Forbes states “According to the Centers for Disease Control, more than 75% of the employers’ health care costs and productivity losses are related to employee lifestyle choices.”

There is a similar correlation in workers compensation cost as healthier employees have fewer accidents, and when they do have an accident, they return to work sooner. This was supported by a combined 56 studies on worksite wellness programs. Per the American Journal of Health Promotion, there was a 32% reduction in workers compensation.

Form a Wellness Committee

After gaining the support and participation of senior management in the creation of a wellness program, form a wellness committee. Whether electing to utilize an outside company that has a wellness program already structured that can be implemented quickly or deciding to build your own company wellness program, the involvement of additional personnel from various departments will expand the ideas and ensures the success of the wellness program. Broad representation of the wellness committee will be drawn from human resources, finance, risk management, safety, union, senior management, and production. You can also invite volunteers from any department within the company. The wider the variety of specialties the better.

Establish Wellness Benchmarks

The goals and objectives of the wellness program should be the first order of business for the wellness committee. By establishing benchmarks, you will be able to measure the success of the wellness program. The primary reason companies abandon wellness programs is the failure to have benchmarks showing the success of the wellness program. Some benchmarks that can be considered include:

absenteeism
health care cost
employee retention rate
employee participation (percentage) in the wellness program
reduction in the number of workers compensation claims
reduction in overall workers compensation cost

Employee Involvement Is Essential

The wellness program should not be based solely on the ideas of the wellness committee. Employee interest and involvement are essential to the success of the wellness program. Obtain the input of the employees themselves in what they want to see in the wellness program. An anonymous survey, whether online or on paper, can be used to obtain employee input. Some categories that can be considered for inclusion in the survey for the wellness program include:

diet and nutrition
weight loss solo and weight loss groups
exercise equipment
walking solo /walking groups
muscle toning
reduction in blood pressure
reduction in cholesterol level
reduction in body mass index (BMI)
cessation of smoking
cessation of illicit drugs
cessation of alcohol abuse
healthier food options in company cafeteria/snack machines
on-site flu shots
hand sanitizers and other sanitizing items in a public area
ergonomics at work and home
seat belt use
safe driving
pamphlets and posters reminding employees of health topics ( pamphlets on cancer screenings)
vision screenings provided on-site (mandatory for all employees who drive on duty)
yoga classes before/after work hours

In addition to these topics, leave three or four blank lines on your survey for the employees to suggest their own wellness topics and concerns they would like to know more about or to have assistance with.

Implement and Promote Wellness Quickly

Once you have established the employees’ wellness program interest, implement and promote quickly to increase your odds of creating a successful wellness program. This can be done in a variety of ways including:

provide non-smokers with a $5 per week credit on their health insurance program
provide employees with a BMI under 30 with a $3 per week credit on their health insurance program
a $6 per week credit for the employees with a BMI under 26
provide pamphlets on wellness topics
have posters on wellness issues
offer “lunch and learn” on wellness topics
organize group walks before work/after work/lunch time
have wellness calendars
schedule on-site flu clinic (ask a nearby medical clinic for a group rate discount or inquire if the health insurance carrier will pay for it)

Give Enough Time to Realize Impact

After implementation of the wellness program, it is important to give the program enough time to have an impact. The above-mentioned benchmarks should be established on the first day of the wellness program, and the results measured after one, two and, three years. Evaluate what has worked and what has not. A repeat survey asking the employees who participated their impression of the wellness program is a good way to get additional feedback. Also, a survey for the employees who have not participated in the wellness program asking why they do not participate can provide insights on ways to improve the wellness program.

By establishing and creating a successful wellness program, you will improve the financial picture of your company, reduce absenteeism, reduce work comp claims, reduce health insurance claims and improve employee morale. It will also reduce your workload if you deal with human resources issues or workers compensation.

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the co-author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:.

Contact: RShafer@ReduceYourWorkersComp.com.

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

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

Filed Under: Wellness Programs and Workers Compensation

5 Ways to Get the Most Out of Your Workers’ Comp Adjuster

November 15, 2018 by Michael B. Stack

Depending on past experience with workers’ comp adjusters, you may or may not have an accurate picture of their daily work life. Every adjuster has a unique style. Sometimes that style meshes well with the way with an employer’s way of doing business and sometimes it may not. Whatever the personality may be, the adjuster has the same goal the employer does. And that is to move the claim to resolution by return to work, release from medical care, or to redeem the claim through litigation if needed.

A good percentage of workers’ comp adjusters have multiple insureds (employers) they work with, in multiple states. Some of these insureds are very demanding, and some are not. Some are very open to new ideas to get injured workers back to work, and some are not. The adjuster is always a chameleon, blending the personality and way of working to match what the insured wants while at the same time trying to read and gauge the claimant to judge for any indication that there may be more to the injury than what appears on the surface.

Whatever the personality or work ethic of the adjuster that handles the account, below are 5 ways to get them to work harder. Working as an adjuster handling work comp claims is a very stressful, demanding, high exposure, and thankless job. In any scenario, the adjuster will do what it takes to get the job done on the files, but these 5 little tidbits of info we discuss below may be able to maximize the adjuster’s role.

Complete all fields of First Report of Injury

The First Report of Injury is the first info the workers’ comp adjuster reviews when assigned to a new claim. Nothing irritates them more than having a lot of missing information. It almost can reflect the way the claim is going to unfold during the investigation. If an adjuster sees a half-completed injury report when they call and ask you about the details of the injury they are expecting the employer not to know anything about it. Completing the injury report will reflect the employer’s professionalism to the adjuster. Another insured may complete every line, and the adjuster will view that as “This insured is very detailed and involved and will be watching every move I make, so I better make the right moves to impress them right off the bat.”

Plus the adjuster has to obtain a lot of that information anyway. So it will save some time on the phone call if as an employer, you obtain the information before submitting the claim into the adjuster. State reporting requirements will demand the date of birth, social security number, complete address, and other additional info. So take the extra 10 minutes and complete the State injury form. This way the adjuster can get a good idea about what happened and can hit the ground running for the start of an investigation.

Stay involved and open to ideas

Not every employer is the same. They are different sizes, different types of people, different demands, and different cities. Everything is different, and this makes being an adjuster that much more difficult. The adjuster may not know that the employer does not have any light duty work at the shop, but how deep have you as the employer looked? The adjuster may have ways to sneak a few of these guys back to work, and that will save the employer money. The adjuster’s job is to get injured workers back to work. Most of the time the roadblock to obtaining this is the employer, not the injured worker.

Let the adjuster come out to the shop (if they are local) and let them walk around and evaluate things. Talk a little bit about the other types of jobs you do that your injured worker may be able to do. Discuss not only full-time jobs but part-time as well. Part-time work is overlooked a lot, but any sort of savings is worth it. 10-15 hours of work a week is better than the injured worker sitting at home doing nothing but collecting a paycheck. Plus remember the old adage: The longer a claimant is out of work, the more difficult it is to get them back. Collecting 70% of pay in addition to saving on daycare costs or gas costs to name a few. Better to keep an open mind about getting the injured party back to work.

Return calls/emails to the adjuster

The workers’ comp adjuster has a lot to do every day. Claims are in various stages of a lifespan, and the job of an adjuster involves being on the phone a great deal. The new trend is to try and email as much as possible. It is a lot faster than a phone call, and it allows the other party receiving the email to get to it when convenient. Answer or return that email. It does not have to be within the same hour, but it should be at least the by the end of the business day. The adjuster wants something or has a question they need to be answered. Usually, the adjuster cannot move forward on the claim until the info is obtained. Do not be known as a slowpoke in getting the adjuster this information. They will respond in kind when the employer needs something.

Be polite

The workers’ comp adjuster usually deals with conflict. Conflict with different physicians and their opinions. Conflict with claimants over what is a work-related injury and what is not. Conflict with their managers on what to do on a file to get it to resolve. Conflict with plaintiff counsel over the facts of a case. Conflict with a claimant over a check not being issued or why the claim is still under investigation. The list could go on and on.

So it is nice to give the adjuster some polite words now and then. A “please” and “thank you” can go a long way. Maybe take some time after a difficult claim is resolved and thank your adjuster for hours and hours of time put in to resolve the claim. Everyone appreciates the positive feedback and a good “thank you.”

Meet the adjusters face to face and show them around

Most adjusters work from home or in an office. They do not see their claimants. They do not meet the insureds. They are not at the doctor appointments. They are not on-site in the workspace. One thing to do is to meet with them first. Talk with your carrier/TPA about getting 1-2 adjusters to work the account. Then invite those adjusters and the claims manager over to meet face to face at the workplace. Take them on a tour of the facility. Let them meet the safety team. By putting a face to a name, you have personalized the experience. And the more contact, the better the resolution on claims. The same employer/client relationship applies to the carrier/agent/adjuster relationship.

Summary

The workers’ comp adjuster has to handle many claims from many different employers. So make yours stand out from the rest. Take that extra time to build a relationship with the carrier/adjuster/TPA. Claim results will likely be better.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Claims Adjuster & Employer Relationship

25 Ways to Avoid Holiday Workers’ Comp Injuries

November 14, 2018 by Michael B. Stack

The holiday season can be a great time of year. Joy is all around, decorations abound, and there’s merriment for all. While organizations celebrate, it’s also a time to take extra care to ensure you avoid holiday workers’ comp injuries.

Ramping up your safety measures is especially important during the holiday season to protect workers — from hazards related to putting up or removing decorations, the extra debris that may inhibit walking, and alcohol-related problems at celebrations.

The Decorations

Overexertion and same-level falls are the leading causes of workers’ compensation payouts each year, according to the Liberty Mutual Workplace Safety Index. The insurer’s 2017 annual study said overexertion — lifting, holding, pushing, pulling and carrying or throwing objects — cost employers $13.79 billion. Falls on the same level incurred costs of $10.62 billion.

While most if not all such incidents can be avoided, prevention efforts may be especially difficult during the holidays. Employees dealing with decorations are more prone to overexertion-related injuries, while other workers may be more at risk of falling over decorations, cords, boxes, and other items left in walkways.

Lacerations, strains, and sprains from lifting heavy boxes or trees, falling from chairs or desks while hanging decorations in workspaces, and getting poked in the eye by a pine needle are among the 337 holiday-related injuries in 2016 reported by the Consumer Product Safety Commission.

Basic safety precautions can eliminate these and other risks of holiday workers’ comp injuries related to decorations:

Keep trees away from radiators, fireplaces and other sources of heat
Make sure the tree has a stable platform
Artificial trees should be fire resistant
Check lights for fraying, bare spots, gaps in the insulation or excessive kinking in the wires
Turn off all lights or decorations when not in use
Use a step stool or ladder at the appropriate height for hanging or taking down decorations
Make sure wires don’t impede walking, and are always properly secured and covered
Avoid overworking employees involved with decorations by rotating them and/or providing extra rest breaks
Make sure workers remove all boxes and other items from halls and walkways
Retrain workers on proper bending and reaching techniques
Rope off areas where workers are installing trees, lights and other decorations
Have the decorations installed and removed at times when the least number of employees will be affected

The Parties

A holiday party can be a great way to show employees your gratitude for their efforts throughout the year. You want to make sure there are no unnecessary injuries, especially when alcohol is involved.

State laws vary regarding an employer’s liability for accidents caused by inebriation. Even if a commercial general liability policy protects a business, there are still risks of injuries to employees.

Injuries that occur during such celebrations may or may not be considered compensable under workers’ compensation, depending on state law and the circumstances. In some states, courts have found company functions to be a part of employment when the employer presents the party as a way of compensating workers or requiring their attendance.

The best way to avoid alcohol-related injuries is to serve only non-alcoholic beverages. But if the company wants to include alcohol in the festivities, here are some steps that can prevent injuries and claims:

Make attendance voluntary and assure employees that non-attendance will not affect their standing within the organization
Emphasize to managers that they must lead by example and drink in moderation
Advise employees to act responsibly and drink moderately
Designate a sober driver. Whether it is a non-drinking employee or a car service, such as a taxi or Uber, that will at least ensure workers get home safely
Do not have an open bar. Employees tend to drink less if they have to pay
Have a voucher system to limit the number of drinks served if the company does opt to pay for alcohol
Serve only beer and wine rather than hard liquor or fruity drinks that may be consumed way too easily
Hold the party earlier in the day, as people tend to drink more later in the evening
Serve food to help counter the effects of alcohol
Serve alcohol for only a specified time period. Toward the end of the night, stop allowing alcohol and serve coffee.
Include an additional activity, such as dancing or a magician, so people have something to focus on besides just drinking.
Invite family members. People are less likely to drink excessively when spouses and kids are present
Have the party at an off-sight restaurant with trained bartenders who know when to stop serving a customer

Conclusion

Decorations and special celebrations are great morale boosters and show you care about your employees, but they can often lead to holiday workers’ comp injuries. Using common sense and strictly adhering to safety measures will ensure everyone has a good time.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Safety and Loss Control

8 Steps For A Staffing Agency to Reduce Workers Comp Costs

November 13, 2018 by Rebecca Shafer, J.D.

Imagine trying to calculate your workers’ compensation premium when you do not know the number of employees you will have at any one time or their job classifications. That’s life for the temporary staffing agencies – in their own peculiar world when it comes to workers’ compensation. Temporary staffing agencies often have a difficult time obtaining and maintaining workers’ compensation insurance.

In most jurisdictions, the temporary staffing agency is responsible for the workers’ compensation insurance as the worker is considered an employee of the temporary staffing agency, not an employee of the client.

While the broker for the temporary staffing agency can meet with an employer to get an estimate of the numbers and types of positions the agency may fill, it is only an estimate, or sometimes a” shot in the dark.”

Misclassification of Employees Is Ongoing Problem

The workers’ comp premium classification code system did not have the temporary staffing agency in mind when the system for calculating workers’ comp premiums was created. Misclassification of employee job codes and under-reporting of payroll is an on-going problem for workers’ compensation insurance companies. The workers’ compensation premium audit is definitely necessary at the end of every policy year to get an accurate premium.

Some workers’ compensation insurance companies who do insure temporary staffing agencies take the process a step further. They created what is referred to as “pay as you go program” where the temporary staffing agencies workers’ comp insurance premiums are adjusted monthly or quarterly based on actual payroll data.

Captives or Assign Risk Pools

National staffing companies in the temporary staffing agency business set-up their own captives to self-insure their workers’ comp claims with the benefit of re-insurance to cap their total loss exposure. Smaller temporary staffing companies have joined “rent-a-captive” insurance programs in their effort to reduce their workers’ comp cost. Temporary staffing agencies with poor claim records (and some with not so bad of claim history) are forced into assigned risk plans or state pools.

In the past workers’ compensation premiums were such a big burden for temporary staffing agencies, some agencies were forced out of business. (For many temporary staffing agencies, the workers’ comp insurance premium is their second largest expense after payroll.) These were the staffing agencies who did not try to control their workers’ comp losses or who did a poor job screening potential employees.

8 Steps For Staffing Agency to Reduce Workers Comp Costs

All temporary staffing agencies regardless of size can take certain steps to reduce overall workers’ comp cost.

Proper vetting and screening of employees you place with your clients. The screening process includes drug testing, background checks, and prior injury history.
Refusing potential clients involved in hazardous or dangerous work.
Testing and verifying the skill sets of employees before they are placed with an employer as improperly or inadequately trained employees are much more prone to injury.
Verifying the employee has the proper safety equipment and protective gear, or the client has the equipment and gear necessary and will provide it to the employee.
Training the staff of each placement office on proper and timely reporting of workers’ comp claims.
Have a workers’ comp claim coordinator who actively follows up on a regular basis with any employee who is off work.
Have a return-to-work program allowing you to place the employees who do get injured back to work at a different client who can accommodate any work restrictions.
Have an insurance broker who is familiar with the temporary staffing agency business and who can place your company with more than one workers’ compensation insurance company.

Temporary staffing agencies can expect to experience periods of fluctuation making it difficult for them to obtain workers’ compensation insurance. The best way to protect your business profits and to be able to purchase future insurance coverage is to actively manage your workers’ comp insurance program now to reduce the number of claims.

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

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

Filed Under: Buying Workers' Comp

6 Triggers for When, And When NOT to Use Nurse Case Managers

November 12, 2018 by Michael B. Stack

Nurse case managers are a hot topic in workers’ compensation, and with good reason. Used properly, they can generate great results for organizations in getting injured workers back to work as soon as possible and saving precious dollars for organizations. But there is often misunderstanding about how and when to use Nurse Case Managers. For example:

Should you use a Nurse Case Manager on every workers’ compensation claim?
- No
If a Nurse Case Manager is used, should it be for the entire duration of the claims process?
- No
Is there a difference in telephonic vs. field Nurse Case Managers?
- Yes

Nurse Case Managers can reduce litigation rates, foster patient engagement in the recovery process, and provide vital communication among all stakeholders. They can also be a waste of money and add little value.

Understanding when and how to use Nurse Case Managers is key to getting the best bang for the buck.

What They Can Do

Research showing the potential value of Nurse Case Managers has resulted in some companies using them on every single claim from beginning to end. Many of these companies then wonder why they are spending so much money without seeing a return on investment, so they discontinue using Nurse Case Managers altogether. Both are a mistake.

Here are some of the many ways Nurse Case Managers can help on a workers’ compensation claim:

Advocate and educate. The best reason to use a NCM is to help an injured worker who is frightened, confused and angry — often a recipe for litigation. The NCM can educate and advocate for the injured worker and guide him through the entire process, so he knows what to expect. The NCM can also inform employers on how the injured worker is progressing, and work with the treating physician to make sure the worker is getting appropriate care.

Flag potential problems. If the injured worker has psychosocial or pain management issues or needs durable medical equipment, the NCM can spot that early in the claims process and help coordinate the necessary treatment.

Communicate with all stakeholders. The NCM can keep everyone in the loop, so necessary details don’t fall through the cracks.

When to Use Nurse Case Managers

Simple, medical-only, and claims where the injured worker is highly engaged and anxious to return to full duty as quickly as possible do not signal the need for a NCM. On these and other cases the addition of a case manager is unnecessary and a waste of money.

More complex claims are where Nurse Case Managers can have a significant impact. Certain claims should trigger involvement from a NCM, including:

Lost time. Workers who are off the job for more than a couple of days can benefit from extra involvement. A NCM can answer the injured worker’s questions and ensure he is complying with the treatment plan.

Surgery is needed. Even if it is a medical-only claim, the need for surgery should be a red flag to get a NCM on the claim. There will be many things going on, such as preparing at home, the need for and type of pain medications after, and any DME that might be temporarily needed. The NCM can coordinate the various moving parts.

Failing to attend scheduled medical appointments. Whether the worker is off the job or working in some capacity, failing to see treating physicians, physical therapists and other providers is a sign there may be a problem. A NCM can contact the injured worker and either get the person to comply or find out if there is an underlying problem that should be addressed.

Comorbid Conditions. An injured worker with diabetes, obesity, hypertension or other comorbid conditions is prime for a more complicated claim. A NCM can help keep the claim on track.

Uncooperative treating physician. If the injured worker’s primary physician continues to say the patient needs to stay out of work entirely, a NCM can intervene, find out why the person is not recovering, and explain return-to-work principles — such as light duty and employer accommodations.

Catastrophic and/or multiple injuries. These claims involve many people and moving parts. A NCM can be the go-to person for all parties involved, including the injured worker and his family. The NCM can also make any arrangements needed, and keep costs down by selecting the most appropriate equipment.

When to End NCM Involvement

Putting a NCM on a claim doesn’t need to be a long-term prospect. These can be short assignments — even just one or two visits or calls. Depending on the complexity of the claim and ongoing issues, the NCM may need to contact the injured one time to keep him on track and in compliance with medical appointments; or may need to reach out to the treating physician for something simple; or discuss accommodation possibilities with the employer. The earlier a NCM intervenes in a claim, the shorter the assignment typically is.

You can gauge when the NCM is no longer needed, for example:

The injured worker is back to work in at least a light duty capacity
Stakeholders are communicating well with one another
Restrictions are decreased, and the worker is progressing well

Conclusion

Nurse Case Managers can add tremendous value to a claim, generating optimal outcomes for injured workers and lower costs for payers. But it is not a black and white issue; meaning they don’t need to intervene in every single case, and they don’t need to be involved indefinitely. Thinking through a strategy for using Nurse Case Managers can have a significant impact on claims.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Medical & Pharmacy Management

18 Items in Your Work Comp Adjuster’s Three-Point Contact

November 8, 2018 by Rebecca Shafer, J.D.

THE MOST IMPORTANT PART of and adjusters initial handling of a workers’ compensation claim is the contacts with the parties involved in the claim. The contacts are often referred to as “three-point contacts” which refers to the three principal players the adjuster is involved within every workers’ comp claim. The three principals are the employee, the employer, and the medical provider.

To successfully handle a workers’ comp claim, it needs to be investigated both timely and thoroughly. The contact with the injured employee, the employee’s supervisor and the employer’s claims coordinator, and the medical provider all provide valuable information to the adjuster in the handling of the workers’ comp claim. Each of the contacts, if properly managed, allows the adjuster to maintain control of the developing claim.

Definition of Contact

A recent audit of a claims office found the definition of “contact” was not spelled out in the claims handling requirements or the company’s Best Practices. The workers’ comp adjusters were sending form letters to the employer and the employee saying “call me” on the day they received the assignment. Their supervisor was accepting the form letters as contact with the employer and employee. The adjusters and supervisor were bending the meaning of contact to their own purposes and not making proper three-point contact.

Three-point contacts are almost always be handled by telephone, except in severe cases where an in-person contact would be justified. With most adults having cell phones, there is no reason for not making voice contact. If the principals cannot be reached by telephone, a contact letter should be sent while continuing the effort to reach the principals by telephone.

The insurers who have quality Best Practices consider voice contact as “the exchange of information between the principals and the adjusters.” Leaving a message on the employer’s or employee’s voice mail is not considered contact in the true meaning of three-point contact.

Timeliness of Three-Point Contact

Each workers’ compensation insurer and each third party administrator (TPA) has set their own time frames as to when three-point contact should be completed. Some insurers are requiring their adjusters or TPA to make three-point contact within 2 hours or 4 hours of the time of the accident. Other insurers and TPAs are being less stringent and requiring the three-point contacts to be completed within 24 hours or 48 hours of the time of the assignment.

Workers’ comp adjusters prefer the 48-hour goal of making three-point contacts as that is a relatively easy goal to make. Various studies, however, have shown that immediate (same day) contact has the most positive influence on the outcome of a case.

While the goal of the adjuster should be to make the three-point contacts the same day as the assignment is received, in reality, the other parties to the claim may not be available. Persistence is an absolute must for the adjuster. If the adjuster has left a voicemail for the employer, employee or medical provider’s office, the adjuster should call again if the other party has not responded by the end of the workday. The persistent adjuster will leave at least two voice mails the day the assignment is received and will follow up with a contact letter if a response is not received. The adjuster should continue to try daily to reach each of the principals of the claim until voice contact is made with them.

Employer Contact

Upon receipt of the new assignment, the workers’ comp adjuster immediately verifies coverage for the insured/employer. If there are no coverage issues or questions, the adjuster’s next step is to make contact with the employer.

The purpose of the employer contact is several fold. The Employer’s First Report of Injury has essential information the adjuster needs but normally does not contain all the information that would be of value to the adjuster in accessing the claim. By discussing the accident with the employer’s claim coordinator, the adjuster can learn additional information that may be helpful in the development and handling of the claim. Some of the information the workers’ comp adjuster can obtain from the claims coordinator includes

Prior claim history of the employee
Verification of the facts on the Employer’s First Report of Injury
The return to work status or the disability status of the employee
Description of job duties
Availability of modified duty or light duty work
Length of employment
Identification of employee’s supervisor and witnesses to the accident
Subrogation potential

If there are any questions about the circumstances of how the claim happened or any issue of any kind, the adjuster will need to also interview the employee’s supervisor about the workers’ comp claim. A recorded statement from the supervisor may be necessary if the facts of the claims are questionable, if the claim appears to be severe, or if there is the potential for subrogation.

If there are still questions about the claim after the adjuster has spoken to the employer’s claims coordinator and the employee’s supervisor, the adjuster should also interview any witnesses to the accident.

Employee Contact

The adjuster’s prompt contact with the employee will build rapport and assist in establishing a non-adversarial working relationship with the employee. When the adjuster establishes early contact with the injured employee, the probability of future attorney involvement is decreased. The adjuster is also in a better position to identify any compensability issues and to make timely payment of benefits, both medical and indemnity. If the claim is severe, the early contact with the employee will allow for immediate medical management.

When the adjuster makes the initial contact with the employee, the adjuster should consider a recorded statement if the accident is severe or there is potential for subrogation. Also, the adjuster should consider a recorded statement if there has already been inappropriate or excessive medical treatment, if there is a pre-existing condition, if the claim is for a serious occupational disease, if there were other employees injured in the same accident or if there any question of compensability. Whether the interview is recorded or not, the initial conversation with the employee should cover:

The facts of the accident
The identity of any witnesses
A description of the employee’s job, including job title, job requirements, equipment utilized, etc.– (this will assist the adjuster in arranging for an early return to work on modified duty or light duty)
The details of the injury and the medical provider’s proposed treatment plan. This should include the medical provider’s diagnosis and prognosis, the employee’s comments about pain, medications, prior injuries, treatment issues, etc.
The employee’s attitude about the employer, the accident, the medical treatment, the willingness to return to work, etc.

The adjuster, during the initial contact with the employee, should advise the employee of all state required forms that will be sent to the employee and in those states that require a medical authorization, advise the employee of the importance of signing and returning the medical authorization immediately. The adjuster should request a copy of any off-work notes from the medical provider. The adjuster should also advise the employee of the actions the adjuster will be taking and encourage the employee to contact the adjuster with any questions, issues or problems.

Medical Provider Contact

The medical provider whether an occupational injury doctor, a hospital emergency room or a walk-in clinic, should be contacted by the adjuster as part of the three-point contact. The adjuster purpose in contacting the medical provider’s office is to obtain the necessary information to determine the process the claim. They would include:

The diagnosis
The prognosis
The estimated length of time before the employee can return to either light duty or full duty work
The date(s) of the next medical appointment(s)
Information on any referral to another medical specialist

The adjuster should advise the medical provider to send to the adjuster the complete medical records including the medical history provided by the employee, the doctor’s notes, the results of any testing and a copy of any off work slips provided to the employee.

Summary

The importance of three-point contact cannot be overstated. Getting the claim file off to a proper start has a major impact on the course of the claim and the adjuster’s ability to handle the claim fully and properly. By completing a timely and a thorough three-point contact, the adjuster sets the tone for the outcome of the claim.

Contact: RShafer@ReduceYourWorkersComp.com.

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

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

Filed Under: Claims Adjuster & Employer Relationship

4 Ways to Discover Repeat Workers’ Comp Claim Offenders

November 7, 2018 by Michael B. Stack

Most employees injured at work are honest and want to recover and return to their jobs as soon as possible. There are workers, however, who are repeat workers’ comp claim offenders, creating headaches for their employers and those handling their TPA/carrier.

Repeat workers’ comp claim offenders are annoying at best and their claims can be extremely time-consuming and expensive at worst. Before casting aspersions on these employees with multiple workers’ comp claims, or giving up altogether, there are steps you can take to determine a) if the worker is committing workers’ compensation fraud and b) stop him from sustaining repeat injuries.

Legit or Not?

While it may seem obvious that a worker who has frequent injuries is trying to game the system that may not be the case. Diligent employees who are willing to do whatever it takes to get the job done may take safety shortcuts or act in others ways that place them at increased risk of injury; the person may be just naturally clumsy, or he may be unaware of the proper ways to undertake certain tasks.

It’s important to separate those who are intentionally getting injured (or claiming to get injured) from those who just need more and better training and education. Once that is done, you can address the issue(s) at play.

The key to determining why a particular employee has sustained multiple injuries and whether he is intentionally claiming injuries is to conduct a thorough investigation and let the worker know you are aware of it and concerned about him.

Steps to Uncover Intent

You want to find out why the worker continues to be injured. Several strategies should be undertaken before you jump to the wrong conclusion.

Resist your first temptation. All employees deserve respect — even repeat offenders. Dealing with the same worker multiple times for injuries can be frustrating. But you won’t uncover the problem unless you approach each injured worker the same and evaluate each claim on its merits. That means giving the worker the benefit of the doubt — at least until and unless you determine something untoward is happening.

Investigate the injury. This is always important, but especially so if the person has a history of injuries. The steps should include

Gather statements about the injury from the employee, supervisor, witnesses, and the treating physician. Try to understand how and why the injury occurred, the extent of the person’s injury and what he is or is not capable of doing during his recovery.
Determine causation. Talking with the physician and other stakeholders will help determine if the workplace was the actual cause of the injury, or if it was something else. Several steps to determine causation include

Evidence for a causal relationship – do studies support a link
Evidence of exposure – highest quality data are quantified personal measurements of the worker’s tasks, while lowest quality are job title or self-report of exposure
Other relevant factors – comorbidities, prior injuries, etc.
Judge the validity of the testimony – make a judgment call on what is true or false
Evaluate and conclude

Talk to the treating physician. You might get some insights into whether there is a specific problem causing frequent injuries with the worker. You might also determine that the worker is physically incapable of doing the job without risking injury. Even if the employee was cleared to do the work initially, something might have changed in his physical abilities.

Get peer reviews. If the treating physician is not forthcoming or if you suspect the physician is not providing the best treatment for the injured worker, have another physician intervene. The insurance carrier or TPA may have a medical provider who can speak directly with the treating physician and get answers.

Consider root cause analysis. While a formal root cause analysis may be unnecessary, you want to look closely at all the circumstances surrounding the incident, especially if the worker gets repeatedly injured doing the same types of tasks. Rather than laying blame on the worker, you may uncover something else. For example, the worker may put the ladder he uses at the same height as another colleague who is much taller. That could force the worker to have to reach above his head, putting him at risk of injury. His physique may be such that the equipment he’s using is inappropriate for the specific task. Uncovering such a simple cause can be easily rectified.

Talk to the injured worker. You may find there is a simple reason the person continually gets injured. Or you may get a sense the worker has something else going on

Unhappy with supervisor
Personal challenges at home. Problems with spouses and/or children can distract a worker, so he becomes sloppy with safety practices
Psychosocial issues
Anger at the company. The employee may feel overworked, or that he was unfairly passed over for a promotion

If your investigation leads you to believe the worker is truly a frequent claim filer, you should still treat him with respect but make his fraudulent actions more difficult. You want to investigate the claim aggressively. Also, any psychosocial issues of which you are aware should be shared with the claims adjuster and/or TPA.

You may want to find out if the worker has been a frequent claim filer at other companies. Doing an ISO claims search, for example, may point up other instances where the worker has filed multiple workers’ compensation claims.

Conclusion

Employees who file multiple workers’ comp claims can be a drain on money and other resources. If you have a worker who is often injured, you need first to determine if the person is experiencing legitimate injuries or abusing the system. Then determine how you can prevent further injuries or — in the case of a repeat offender — deal head-on with the worker and explain you will be watching him carefully and taking aggressive action up to and including termination.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Claim Management

Tips for Effective Use of an Interpreter in Workers’ Comp

November 6, 2018 by Senior Editor

The need to use an interpreter in workers’ comp has increased with the changing dynamics of the American workforce including those individuals who do not fluently speak English – whether it be as a primary language, limited use or no working knowledge at all. The use of an effective translator to assist when communicating with non-English speaking people during the claims investigation process is beneficial for improved claim outcomes.

English as a Primary Language – A Changing Dynamic

There is no “official language” in the United States. Although roughly 30 states have enacted laws making English (American English) the official language for business purposes, our country remains a melting pot filled with numerous languages and dialectics. Recent estimates indicate about 350 languages are spoken in the US. This creates many challenges when a work injury occurs. Members of the claims management team and other interested stakeholders need to be aware of these issues and use interpreters to make sure their claims are properly investigated, and the information is received accurately.

Goals of Using an Effective Interpreter in Workers’ Comp

Using an interpreter is a relationship where all parties need to be on equal footing and involvement. It is important to set the right tone at the beginning of the process.

Get to know the interpreter. Understand how they interpret – simultaneous or consecutive. When using consecutive translation, get a good idea of the length of sentences or phrases one should use. Patience is key.

Set expectations for best practices. Understand a good interpreter in workers’ comp is not an advocate for either party. They should never be used to add persuasion or in a coercive manner.

Set timelines for translation. Translation services are taxing physically and mentally. A good interpreter will need frequent breaks. Understand these limitations and respect them.

Signs of a Good Interpreter

Finding a good interpreter in workers’ comp can be a challenge even if it is a language that is common. Because work comp claims involve legal matters, it is important to use a court certified interpreter in all instances. This includes translations taking place during recorded statements, witness interviews, depositions, independent medical examinations/independent vocational evaluations and hearings. Characteristics of a good interpreter will include the following:

Interpretation of every word: Accuracy is key. When an interpretation is “word for word,” it ensures the information is being relayed completely and avoids issues for appeal.

Not providing one-word answers when there was clearly a longer answer: When this takes place, it is noteworthy that accuracy is not valued. It may be time to stop what is taking place and locate a new interpreter. This might mean stopping a deposition and re-setting the proceeding. Although there are additional expenses, it will avoid problems down the road.

No side conversations: It is important that all parties are involved in a conversation and what is being shared by the non-English speaking person is provided to all. In some instances, an interpreter may need to ask a question to clarify a term being used. If this is the case, it is important for the interpreter to note this and translate the “side conversation” completely.

Be aware of regional dialectics: This is something that should be discussed well in advance of using an interpreter. As is the case in English, words in other languages have different meanings to people in different regions.

Other Barriers and Challenges

It is also important to understand people from other cultures may have misconceptions on the American legal system. Examples of this may come from people who immigrated from oppressive regimes and governments. They may have a distrust of the legal system in the United States based on prior experiences. Other cultures may also view someone with a personal injury differently. Best practices in claims management must include cultural competence. Remember to treat all people with respect and dignity.

Conclusions

While there is an added cost, members of the claims management team cannot avoid the demand to use an interpreter in workers’ comp for an injured worker with limited use of the English language – or none at all. These costs can translate into savings when done correctly. This includes using a qualified court-certified interpreter, getting to know the person and using one in the right (and necessary) circumstances.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Uncategorized

Workers’ Comp Wellness: 6 Tips for Better Sleep

November 5, 2018 by Peter Arens

Getting sustaining and plentiful sleep is among the top wellness lifestyle practices and guiding health principles. According to a recent poll by the National Sleep Foundation, 65% of Americans say they are more effective when they get enough sleep. If sleep is key to helping us be more effective, shouldn’t we put effort into making sure we get enough quality sleep?

There are many actions you can take to improve both your sleep quantity and quality. Your bedroom environment is a great place to start. Researchers and experts from the Division of Sleep Medicine at Harvard Medical School and the National Sleep Foundation share the following advice to improve your sleep.

Routine and Consistency

Your body has an internal “clock” that regulates your sleep. Going to bed and waking up at the same time each day will help improve your sleep and waking hours. By doing relaxing things before bed like taking a bath or reading a book, you help cue your body to prepare for sleep. On the other hand, doing stressful activities before bed can increase your alertness and make it difficult to fall asleep.

Temperature

Our body temperature naturally decreases as we begin to fall asleep and the air temperature in the room can affect sleep quality. If it’s too hot, our natural dip in body temperature can be affected, causing restlessness. While the most favorable temperature varies from person to person, research suggests that a temperature around 65 degrees is best for quality sleep.

Light

As darkness settles, our bodies pro duce the hormone melatonin to help us prepare for sleep. Artificial light can hinder this process and trigger our brains to stay awake. Inspect your room for sources of light and consider using darkening curtains or shades to block out light. Make it a habit to keep light-producing electronics like cell phones, tablets, and TVs out of the bedroom.

Sound

Noise can disturb your sleep, even in subtle ways that you do not remember upon waking. It is important to create a quiet and constant bedroom environment to get quality sleep. White noise can help drown out sounds that disturb sleep like doors shutting or cars passing by. A fan, air purifier, or even a white noise app and speaker can provide a consistent background sound. Avoid using a TV as your noise filter since the sounds and light constantly change.

Smell

The air you breathe can positively or negatively affect your sleep. Studies suggest that the smell of lavender can have relaxing effects (even to the point of lowering blood pressure and heart rate). Using lavender essential oils or lavender scented candles before bed may help prepare you for a good night’s sleep.

Conversely, allergens can prevent or interrupt a good night’s sleep. To reduce allergens in your environment, wash bed sheets in hot water once a week and blankets regularly. Also, use an air purifier that removes allergens, and keep windows closed when pollen counts are high.

Food

Some research suggests that foods containing the amino acid tryptophan can make you drowsy, helping prepare you for sleep. Turkey, eggs, chicken, fish, and nuts are common sources. But remember: Eating big meals or foods that upset your stomach before your regular bedtime can cause you discom fort and make it hard for you to sleep. So can alcohol (which has both sedative and stimulant effects) and true stimulants like caffeine.

Sleep is essential to our health and productivity. Make a conscious effort to establish bedtime routines and create an environment that improves your sleep quality. Talk with household members and seek their support. For more sleep tips and research, visit the National Sleep Foundation website and the Healthy Sleep website from Harvard here:

http://sleepfoundation.org/bedroom/

http://healthysleep.med.harvard.edu/healthy/

pete arens medcor Author Pete Arens, Medcor, Wellness Manager. Medcor helps employers reduce the costs of workers’ compensation and general health care by providing injury triage services and operating worksite health and wellness clinics. Medcor’s services are available 24/7 nationwide for worksites of any size in any industry. Headquartered in McHenry, Illinois, the company operates 174 clinics and provides triage services to over 90,000 worksites across all 50 states and US territories. Medcor’s triage methods are covered by U.S. & foreign patents, including U.S. No. 7,668,733; 7,716,070; & 7,720,692; other patents pending. Medcor is privately held. Learn more at www.medcor.com.