A Reader Writes:
My company is just starting an injury management program and I’ve discovered several employees who have been out on workers’ compensation “forever.” In fact, I can’t recall the last time anyone got in touch with them. How can I start bringing my out of work employees back into the fold.
Bob Elliott Replies:
A file review is in order for you and your company. Have an independent consultant or your inhouse risk manager, request the files of your out-on-comp workers, open them up and find out what each employee is currently doing. File notes should be available to you online through the RMIS system. Your property/casualty insurance broker should be able to help you get access. For example: Are they ambulatory or bed ridden? If they are the least bit ambulatory, they may be good candidates for modified duty and you can begin to bring them back a few hours a week. You need to consider the following options.
Do you need a Quality Control Medical Review?
A quality control medical review means you obtain a physician consultant with a background in work-related injuries to review, comment and evaluate your open claims. At this time, the physician consultant helps you determine whether your insurers, claims handlers, clinics and medical providers are following the best practices for your industry. In other words, the physician consultant helps you decide whether the people you’ve engaged to handle your claims are dong the best possible job on the medical side of the file, and let’s face it — we are talking about MEDICAL injuries, not simply “claims.”
Here are some earmarks:
1. Is the disability proportionate to the time out of work?
2. What percentage of claims is within boundaries for having a proportionate length of disability to time out of work? In other words, are too many of your claims lasting too long?
3. Have medical treatment services such as physical therapy, chiropractic, diagnostic procedures and surgery been over utilized?
4. How cost effective are your medical cost containment procedures? — nurse management, preferred provider organization (PPO) medical and hospital review services, and others.
5. How complete are the cover letters you send to Independent Medical Examiners(IME)? Are you making the best possible use of every diagnostic service related to the employee’s injury? During the IME did the employee magnify symptoms? Did the adjuster recognize the language indicating symptom magnification?
6. How cooperative is the employee’s treating physician with respect to returning workability forms, and moving the employee toward return-to-work and transitional duty.
Do You Need a Quality Control Claim Review?
Quality Control Claim Review is more aggressive claims management. A claims expert(s) reviews, comments and evaluates your claims to identify aggressive claims management strategies such as investigation, determination of compensability, how benefits are managed, and case management issues.
The team documents claim resolution efforts, and develop strategies for bringing the claim to a close, focusing on negotiation and settlement.
In instances where an injury might be related to third party causal factors, subrogation and recovery might be an option for settling the case. (workersxzcompxzkit)
Your goal in performing a file review is to bring old, out-of-control claims to closure because these types of claims hemorrhage money and send your experience mod skyrocketing. You must develop an action strategy for closing claims (old and new) and begin contacting out-of-work employees and easing them back into modified or full duty employment.
Author Robert Elliott, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, health care, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He can be contacted at: [email protected] or 860-553-6604.
“FRAUD PREVENTION” PODCAST click here: http://www.workerscompkit.com/gallagher/mp3
By: Private investigator with 25 years experience.
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers’ comp issues.
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