Understanding Work Comp in the Healthcare Industry

Hospitals Nursing Homes Workers CompInterested stakeholders in the healthcare industry face many unique challenges in terms of finding affordable workers’ compensation insurance coverage.  This is especially the case when it comes to those who operate hospitals, clinics, and nursing homes.  These challenges include rising premiums based on the nature and extent of work injuries and accompanying restrictions on activity that serve as a barrier when it comes to getting an injured employee back to work.



Understanding Nursing Homes and Work Comp


Nursing homes can be found in every state.  Many are privately owned and managed, but regional and national nursing home companies are gradually increasing their share of the market.  The workforce of the nursing home will consist of:


  • Registered nurses (RN);


  • Licensed practical nurses (LPN);


  • Nurses’ aides;


  • Administrative staff;


  • Food service; and


  • Housekeeping


The primary workforce issue is often the training and turn-over among the nurses’ aides.



Dealing with Work Injuries at Nursing Homes


Safety is normally emphasized in nursing homes to protect both the patients and the staff.  Nursing homes are built to protect the patients and staff, which tends to lower the risk of injury.

Physical hazards and causes of injury to nursing home employees include:


  • Lifting and moving of patients, the most common cause of work-related injuries;


  • Musculoskeletal injuries; and


  • Needle sticks and dealing with infectious diseases communicated via bodily fluids.


Medical care for workers’ compensation injuries in this line of work is readily available because most states require a duty nurse to be on duty at all times.  Minor work-related injuries, including cuts, bruises and abrasions, can be treated by the on-staff nurse or by other nurses on duty.  For more severe injuries, medical facilities are often located nearby.


Reducing Indemnity Benefits in Healthcare Settings


The cost of indemnity benefits for workers’ compensation injuries at nursing homes averages approximately the same as work comp benefits for all industries. Occupational diseases and associated disability benefits occur infrequently among nursing home employees.


Some categories related to nursing homes that would have the same or similar work comp issues include:


  • Hospitals including acute care hospitals;


  • Home health services;


  • Retirement centers;


  • Boarding homes; and


  • Assisted living facilities.


While many of the jobs in this industry require the ability to lift patients (heavy lifting), accommodation may be possible. Equipment such as mechanical lifts and friction-reducing devices decrease both the frequency and severity of the injury and make temporary accommodation easier to accomplish.  A union contract may serve as a barrier to return-to-work issues in some instances.  It is important to keep these issues in mind when negotiating a labor contract and to seek cooperation from union representatives on these issues.


Notwithstanding this matter, there are ways to get injured healthcare employees back to work in a timely and efficient matter.  Possible temporary transitional work includes:


  • Office Workers: Look for ways to accommodate prolonged sitting and standing as needed, or to elevate a broken limb.  Lifting beyond physician assigned abilities could be done by another employee.


  • RN, LPN & Nurses’ Aides: Utilize other employees to do the “heavy” lifting of patients or equipment. Provide equipment to make patient transport non-strenuous.


  • Food Service: Identify tasks within the cafeteria or snack bar within physician assigned abilities such as light cleaning or working the cash register.


  • Other Employees: Consider placement at an Information Booth to help visitors with directions or assistance.


  • Light Janitorial: Employees can use a broom and long handle dustpan to clean up spills and litter.




Engaged stakeholders in the healthcare and nursing home industry need to be creative in managing workers’ compensation claims and reducing program costs.  This required them to seek creative solutions to manage medical care based on the severity of the work injury, and look to get an employee back on the job within their restrictions.  This may require compromise, but will promote savings in the long run.




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.


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.

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.





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.

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

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



Step into My World – The Life of a Claim Handler


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



What do you know about the injury details?


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


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


  • Who was injured?


  • Did the worker tell someone?


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


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


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



Just the Facts Ma’am


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


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



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


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


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



The Devil is in the Details


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



Avoiding Spoliation of Evidence – Saving Money through Subrogation


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



Conducting a Complete and Accurate Investigation


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





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




Amaxx LLC is a workers’ comp educational company focusing on cost containment systems to help employers reduce their workers’ comp costs by 20% to 50%.  Amaxx offers Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is the Certified Master of Workers’ Compensation designation through the Amaxx Workers’ Comp Training Center.

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

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


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


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

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

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


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


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


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


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



How can I protect my employees from slip and falls?


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


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



How do slip-resistant shoes prevent slip and falls?


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


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



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


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



What styles of slip-resistant shoes are there?


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


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


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


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


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




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




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


Contact: mstack@reduceyourworkerscomp.com.

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


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


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

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

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



Background on ORM Reporting


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


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



ORM Termination Key to Cutting Off Liability to Medicare


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


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


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


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


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


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



Case Study (provided by Tower MSA)


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


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


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


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



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


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


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



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


If You Are Not Preventing Work-Related Injuries, You Are Causing Them

prevent work injuriesIn the world of safety, day to day, operations revolve around trying to prevent injuries. Proper lifting techniques, guarding on machines, and other safety measures are constantly being scrutinized to prevent work injuries from occurring. If you are working on preventing injuries, you are stopping them at the root cause.



“That Will Never Happen At My Company” Is The Wrong Thinking


What if you have no real safety program, or no loss control techniques? Well, to be blunt, you are just waiting for the next injury to occur. Why would any company want to wait around for the next injury to happen? Most employers think that the worst injuries will never occur at their plant because everyone uses their heads when working and everyone practices using proper safety when operating machinery. This is far from the truth.


The truth is, risk of injury is everywhere at every moment of the day. Each worker has the responsibility of operating safely. Unfortunately, this is not the way it works. Workers get caught in their routines, and their attention can get diverted away from what they are doing at the current time. This distraction can, and will, lead to injury.


Also to blame are poor training programs. If you have a lot of new hires, they may start off learning bad habits from their veteran employees that are training them.


But the new hires are not the only ones to blame. Veteran workers can also become injured because they pay less attention to their work routines. They think because they have worked there a long time and know the machinery that they can get away with more. Examples such as removing machine guarding, improperly using machines, or not wearing safety equipment are usually to blame. These are easy corrections to a widespread problem.


So if this is the case, who is policing the veterans to make sure they are performing the jobs the proper way? Are the supervisors on the floor enforcing safety each day? Are there disciplinary measures in force for those that break the rules? If so, are these measures always enforced or is it just some of the time? Does your supervisory program ever have any type of audit or follow-up to make sure management is actually supervising their workers or are they just babysitting them and turning the other way to keep production levels where they want them to be?



Worker Accountability is Key To Safety Success


Slip and fall injuries are very common. Who is in charge of making sure the carpets are in good shape? Who is in charge of making sure any fatigue mats in front of machines are free from wear and tear? Are workers falling in areas that they should not be in the first place? Why are they allowed in these areas? Who is in charge of being responsible for these areas? If your answer is that you do not know, then you have a problem.


Are any management personnel soliciting feedback from the employees that are working these jobs each day for hours and hours, week after week? What are their thoughts on how you can perform each job in a safer manner? One of your best resources for safety is your employees. Sure can be great to bring in an outside expert to review each job and comment on how they could be performed better and in a safer manner. However, if you are not soliciting feedback from your staff, then you are missing out on a great opportunity for safety ideas.


Worker accountability is key. Each worker has a duty to perform. Each supervisor has a duty to supervise and enforce rules. Each safety person appointed to that position has a duty to review tasks and implement safety measures. Why has accountability been pushed to the side?




Consider Indirect Cost of Workers Comp When Evaluating Bottom Line


In my experience, worker accountability, responsibility, and safety are often pushed aside due to production demands. The focus is on the bottom line, and on quality, rather than on safety. Everyone turns a blind eye to hidden indirect costs of injuries. If you have a few injured workers, other workers must pick up their slack. This hurts their production and the production of the work floor as a whole. More corners then get cut to keep up with production demands.


It is the classic iceberg effect. Executives see work comp claim costs only at the surface. They see the medical and wage loss expenses as the only “expense” of a work comp claim. The indirect costs hidden under the surface are so much worse. Decreased production, increased strain on remaining workforce, decreased morale, increased hazards, increased shortcuts, decreased quality, etc. All of these have a larger cost to the company as a whole rather than just medical and wage loss expense.


When you are thinking about your safety program and accountability, think of the hidden costs beneath the surface. A proper guard on a machine could cost $10,000, but what are the costs to someone being injured because the guard is not there? Chances are, that cost is going to be 10x more expensive.




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.

Protecting the Injured Employee in Workers’ Compensation is Paramount

injured employee workers' compensationThe injured employee is the reason workers’ compensation laws exist.  Without employees and their sacrifice, businesses would not accomplish their goal.  Now is the time for every member of the claim management team to approach claims with this critical mindset.



Forget the Golden Rule – Follow the Platinum Rule!


The “Golden Rule” taught us to “treating others as one’s self would wish to be treated.”  This is a common denominator handed down in both secular and religious societies. The problem with this Rule when applied to workers’ compensation claims is it view things from the perspective of the claim handler.  Now is the time for members of the claim management team to put themselves in the shoes of the injured employee, and follow the Platinum Rule – To treat others as you would want to be treated!


By adopting this mindset, one will realize the following:


  • Being a true professional in every sense of the word is essential;


  • Treating all employees – regardless of ability with the respect and dignity they deserve is essential; and


  • Engaging every claim with good faith, fair dealing, and placing ethics at the pinnacle of every decision is essential.



Protecting the Injured Employee Through Injury Prevention


Members of the claim management team can be proactive when it comes to preventing injuries in the workplace.  This can include educating their insureds on best safety practices.  Their obligations also extend to their post-injury response.  Here are some important steps include in every workers’ compensation claim:


  • Avoid unfair claims practices and bad faith denials;


  • Complete a timely and thorough investigation of all injuries;


  • Not exploited the financial vulnerabilities of policyholders;


  • Not make unreasonable demands on the policyholder during the claim process; and


  • Take all reasonable steps to preserve evidence.


Employers also play a role in this process.  It must include promoting a culture of safety.  Steps should include:



  • Allow regular breaks for employee – especially those performing repetitive tasks;


  • Ensure the proper use of machinery, tools, and safety equipment – never cut corners; and


  • Lead by example!



Getting the Injured Employee Back to Work


Interested stakeholders need to take the lead on return-to-work issues and dispel the common myths that prevent employers from protecting their MVPs.  Common misconceptions of injured employees include:


  • Injured employees are lazy – they sit around all day and do nothing;


  • Injured employees would rather stay at home;


  • Injured employees will only get re-injured – we need to get a voluntary resignation on every workers’ compensation claim; and


  • Injured workers receiving Social Security Disability are not allowed to return-to-work.



FACT: A vast majority of injured employees would rather get back to work.  Getting them back to work can reduce program costs. 



The challenge of effective return-to-work requires all interested stakeholders to move past the physical, educational, medical, and emotional barriers inherent in the workers; compensation system.  Important steps to consider include:


  • Communication with the injured worker. This can include having a dedicated liaison for any employee off work.  Employers can buy goodwill by returning phone calls from an employee not able to work due to restriction.  They should also be proactive in initiating contact with an employee.


  • Communication with treating doctor. A return-to-work liaison can also serve as a point of contact with the employee’s treating physician.  This can also include making certain communications between the physician and workers’ compensation insurer is taking place.


  • Providing legitimate written job offers. The requirements of job offers vary in each jurisdiction.  It is important specific elements are satisfied.  There are other legal requirements where consultation with an attorney may help facilitate this objective.


Interested stakeholders should also consider learning more about, and implementing a “Work on Loan” program, or hiring an injured employee through the Social Security Administration’s “Ticket to Work” program.





Employees are of paramount importance to every workers’ compensation program.  Treat them respect and dignity.  To run an effective and efficient program, interested stakeholders need to understand their claims, assess and evaluate risks, and look for opportunities to engage all parties in the process.




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: https://blog.reduceyourworkerscomp.com/


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


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


Stop The Bleeding! Control Workers’ Comp Leakage

control hard and soft workers' comp leakageSelf-insured employers and insurers understand that workers’ comp leakage costs money.  The overpayment of medical cost, indemnity benefits and claim expenses is a waste of money and weakens the overall financial stability of the employer or the insurer.  What to do about workers’ comp leakage is a frequent topic of discussion.


When there is no doubt that a payment should not have been made (example:  a non-recovered duplicate payment), it is referred to as hard leakage.  When a payment is made that is questionable and is subjective (example: a higher than normal settlement), it is referred to as soft leakage.


Employers and insurers frequently attempt to mitigate both hard and soft workers’ comp leakage by providing additional training to the claims staff. Additional training definitely has benefits and will reduce leakage, but additional training normally addresses only the issues the work comp supervisor or claims manager has identified.  This approach will often continue to overlook different types of leakage that is not on the company’s radar.



Independent Claims Auditors Bring Perspective


To identify leakage that is being overlooked, companies have been turning to independent claims auditors who bring in an outside perspective when reviewing claim files.  Senior management often recognizes adjusters, supervisors and even claims managers have a built-in conflict of interest in identifying every source of leakage – the more leakage they identify, the lower their level of competency appears to be.


The independent claims auditor can be completely objective, as the independent claims auditor does not have to worry about the impression the results of a workers’ comp leakage audit will create. The outside auditor is looking for the financial mistakes (leakage) in an effort to assist the insurer or self-insured employer to lower its overall claims costs without the worry that senior management may be critical of the adjuster’s/ supervisor’s/claims manager’s performance.



Hard Workers’ Comp Leakage


The independent claims auditor will identify types of hard workers’ comp leakage including:


  • Payment of non-compensable claims
  • Payment of claims occurring outside of the insurance policy period
  • Failure to utilize the medical bill fee schedule for all medical bills covered by the schedule
  • Payment of the same medical bill, including overlapping medical bills, more than once
  • Incorrect calculation of the employee’s average weekly wage
  • Incorrect calculation of the employee’s indemnity benefit
  • Incorrect calculation of the number of days or weeks of indemnity benefits owed
  • Incorrect handling of the waiting period and the retroactive period
  • Erroneous payment of indemnity benefits after the employee has return to work
  • Failure to properly calculate the impairment rating value
  • Failure to utilize the pharmacy benefit management program
  • Failure to apply offsets including unemployment benefits, social security benefits, over governmental programs
  • Failure to identify and pursue subrogation
  • Failure to obtain Second Injury Fund recoveries
  • Failure to obtain reinsurance company recoveries
  • Failure to arrange for modified duty work when approved by the medical provider
  • Payment of temporary total disability benefits when temporary partial disability benefits are owed
  • Overpayment of medical mileage
  • Over reserving of the long-term claim resulting in a higher than appropriate experience modification factor with Underwriting



Soft Workers’ Comp Leakage:


The independent claims auditor will identify possible soft workers’ comp leakage including:


  • Failure to thoroughly investigate the claim prior to acceptance of compensability
  • Failure to complete the Insurance Services Office inquiry
  • Failure to properly evaluate future medical benefits when settling a claim
  • Poor settlement negotiations
  • Failure to properly manage defense counsel
  • Failure to properly utilize medical case management, either overutilization or underutilization
  • Failure to utilize medical triage
  • Failure to settle dispute claims at the optimum cost point



Controlling Workers’ Comp Leakage Can Mean Large Savings


Controlling leakage is frequently the difference between an insurer or self-insured employer making or losing money.  While no claims operation will eliminate all leakage, a five percent (5%) leakage factor on a small self-insured program with $20 million in paid claims each year is an extra $1 million dollars spent, and 3% leakage on a $100 million a year paid out by an insurer is an extra $3 million dollars spent.


The above lists of how leakage occurs in workers’ compensation are not complete.  There are various other ways leakage can occur.  For a workers’ comp leakage audit to provide the maximum benefit to the insurer or self-insured employer, an auditor with a high level of expertise in workers’ compensation is needed.



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: https://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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