Expecting the Unexpected in Work Comp – Part 2

The first article explored the topics of workplace exposure and various types of injury. This article will look at other unique situations the claim team may face unexpectedly. It is vital that whenever someone on the claim team is tackling an issue, they remain focused and seek the best result.

Multiple Injuries – Single Incident

An employee occasionally sustains injuries to multiple body parts in a work injury. Typical incidents include work injuries that arise in a motor vehicle accident, injuries in heavy labor positions and falls from heights. Claim handlers and other interested stakeholders need to take care when handling these matters.

• Timely Injury Reporting: Injuries that are reported promptly reduce the chances of errors. All interested stakeholders should take steps to include tools to report the injury that are web or smartphone-app-based to ensure

• Post-Injury Medical Care: Effective post-injury medical care can reduce workers’ compensation program costs. Steps that can be taken beforehand include using telephonic nurse case management to best direct post-injury medical care. It is also crucial employees are directed to an employer-sponsored Preferred Provider Organization (PPO) to control costs. Frequent and consistent follow-up via telephone or in person by an employer representative can also reduce costs.

• Empathy and Compassion: Every employee who sustains a work injury should be treated with sympathy and compassion. Supervisors and managers who deal with injured employees should receive training on working with them and ensure they are not treated skeptically. Information regarding the injury is received professionally.

Any claim that involves multiple injuries will cause extraordinary problems for the claim handler. Expect the unexpected on these claims and prepare by encouraging timely injury reporting, exploring options in advance for the best post-injury medical care, and empathy.

Employees Receiving SSDI and Medicare Benefits

Employees who are receiving federal government benefits require special attention. This is especially the case when there is no proper planning. Focus on these areas requires special attention when the employee is receiving or applying for Social Security Disability Benefits (SSDI) or is on Medicare.

• It All Starts with SSDI Entitlement: Be on the lookout for injured employees who apply for or receive SSDI benefits around the time of injury. Injured employees can qualify for these benefits when their injury and other comorbid conditions take them off work with little chance of a return in the foreseeable future. This indicates that their benefits will be approved during the application process.

• Selecting the Proper Service Providers for Medicare: It is crucial to work with a service provider with a legal, medical, and financial team to deal with all Medicare Secondary Payer compliance issues. These service providers can guide settling cases when a Medicare Set-aside should be prepared and provide guidance on the voluntary review and approval process. Coordinate all activities with defense counsel.

• Explore Ticket to Work Options: The Ticket to Work program is administered by the Social Security Administration. It allows injured employees receiving SSDI benefits to return to work without losing entitlement to their disability benefits. This is an option that is infrequently explored.

Employees who suffer work injuries and receive federal government benefits can cause unexpected delays. It is not the time to prepare to deal with these claims.

Unusual Employment Relationships

Not every employee is working or just one employer at the time of the employee. Countless claims provide unique work situations that can raise unexpected problems.

• Independent Contractors: Examine the actual employment situation of the injured party. Just because they might be considered an “independent contractor” does not guarantee a compensation judge will agree. Issues concerning these matters can be explored during payroll audits of the insured.

• Share employment: These situations can create issues in terms of insurance coverage. When handling claims of this nature, it is critical to review agreements between the two employers and determine what carrier’s policy is primary.

• Traveling Employees: These situations arise when an individual performs work outside the usual workplace. Unexpected issues arise when the employee sustains an injury while driving a car, spending the night at a hotel, and engaging in non-work-related activities that are expected of someone on a business trip.

Many situations can arrive in this category. A close review of the facts and a complete investigating needs to occur. Be prepared to handle these types of claims.

Conclusions

Many unexpected situations happen with some frequency, but the claim handler has not mastered them. As is the case with any claim, working with fellow team members to identify the issue and seek creative and effective solutions to resolve them promptly is essential.

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

Contact: [email protected].

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