Responsibilities of a Workers’ Comp Claims Investigation Leader

workers comp claims leadershipCentral to successful leadership is attention to detail, solid work ethic and commitment.

 

Members of the claim management team and fully-engaged employers must exhibit these same traits when it comes to workers’ compensation claims.  All claims must be investigated promptly – by the book with no corners cut.  This process also includes the development of best practices to manage risk and control workers’ compensation program costs.

 

 

Responsibilities of a Claims Leader

 

There are several goals a good leader must undertake when developing a program.  This is something that can be done inside an insurance carrier or company.  Items to consider should include:

 

  • Develop a program to sniff out fraud. This program includes being proactive to prevent it from taking place and detecting it early on to mitigate program costs;

 

  • Update upper management within the organization on issues concerning the overall workers’ compensation program. This position should be able to effectuate and promote change;

 

  • Understand how to conduct an effective investigation. This is especially important in more complex claims or those which involved special or unique circumstances; and

 

  • Coordinate all efforts between defense counsel and the clients. This should include all interested stakeholders to promote an effective program.

 

 

Special Investigation Unit: Dealing with the Tough Claims

 

Not all workers’ compensation claims are the same.  Some claims are more difficult than others.  This can include instances where the employee sustains a severe injury, the circumstances surrounding the claim are suspect, but difficult to prove it did not occur or fraud.  Proactive claim management teams and employers can address these barriers by developing a “special investigation unit.”

 

Teamwork is key when working on special claims. It all starts with a dedicated leader who knows how to peel back the layers and get to the bottom of things.  Important characteristics of this leader should include:

 

  • Someone with law enforcement or military background. These are people who faced difficult challenges in the past and are resourceful;

 

  • A person who has a reputation for being fair and honest. Remember, all injured employees need to be treated with dignity and respect. Integrity is paramount;

 

  • Knowledge of the law and other applicable tools to complete the goal. An attorney can be considered for this role, but not necessarily required; and

 

  • A leader who can effectuate change within an organization.

 

 

Leading from the Front – Taking the Lead

 

The leader of a special investigations unit needs a strong supporting crew.  This can include assistance from the following departments:

 

  • Human Resources: This area brings an understanding of other applicable rules and regulations together to assist in claim investigation and help an organization avoid countless pitfalls;

 

  • Legal Department: An attorney can advise the unit on legal issues and provide advisory opinions, guidance and assist in the development of a legal strategy;

 

  • Medical: Having an on-call nurse or doctor who can assist in complex issues such as utilization review of medication or other procedures will drive down costs.  They can also assist in injury response; and

 

  • Management: It is important to include a representative from senior management. This person can help clarify the mission of an organization and desired results.

 

 

Conclusions

 

Workers’ compensation claims present challenges that call for special measures.  To be successful, proactive employers and insurance carriers can develop special units to tackle these matters head-on.  This includes engagement from a variety of areas within an organization to resolve claims and reduce workers’ compensation program costs.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: 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.

Why Work Comp Claims Become Old Dog Claims

old dog claimsEvery self-insured employer who has been managing their own workers’ compensation claims program for 3 years or more have “old dog” claims, or for the politically correct folks, legacy claims. These claims include the injured employees who take longer than normal to reach the level of maximum medical improvement (MMI), the injured employees who have reached MMI but need on-going medical maintenance medical care, and the employees who are permanently totally disabled.

 

 

Claims Can Stay Open For Many Reasons

 

If you ask the third party administrator (TPA) adjuster why any particular claim is still open, the adjuster will recite the employee’s medical condition and possibly the industrial commission ruling on the particular claim. While the medical condition and/or the industrial commission ruling are factors in why the claim is still open, there are often many other factors and reasons that the adjuster does not recite (and frequently does not recognize). Some of the reasons that a work comp claim becomes an old dog claim include:

 

  • Inadequate initial investigation into the nature and extent of the injury
  • Inadequate claims training of the work comp adjusters
  • Inadequate medical management throughout the claim
  • A change of adjusters during the life of the claim resulting in a loss of continuity in the claim handling
  • The original adjuster, prior adjuster(s) and/or the current adjuster have had inadequate training on how to deal with complicated claims
  • The adjuster handling the claim has too many other claims assigned, causing the adjuster to miss opportunities when they occur to settle the claim
  • The TPA puts too much focus on closing claims, so the adjusters give priority to the smaller, easier to resolve claims
  • Other priorities keeps the adjuster from focusing on the legacy old dog claim
  • The TPA does not have a ‘home office examiner’ reviewing and providing guidance to the adjuster on the large or older claims
  • The claim is still being handled by a prior TPA who no longer values your business as the prior TPA is not receiving any new assignments

 

 

Legacy “Old Dog” Claims Can Be a Financial Burden

 

When legacy (old dog) claims drag on, they become a financial burden to the self-insured employer. As time goes by, the claims become a bigger and bigger drain on the financial resources of the company. If nothing is done to resolve the claim, it becomes a permanent drain on the company.

 

To move these claims forward, while mitigating the ultimate claim cost, an in-depth review (file quality audit) of each claim is needed. While the audit can be done internally, most self-insured employers do not have the resources needed to do the audit. Plus, a fresh set of eyes reviewing the claim will often pick up points previously missed. An outside, highly-experienced, independent claims auditor can review each legacy file and craft a detailed action plan with completion dates for each specific file.

 

 

Independent Claim File Audit Can Uncover Solutions

 

The independent auditor’s detailed action plan for each file should provide:

 

  • A review of the reserves to determine the adequacy of the current reserves and make reserve change recommendations to the ultimate value where appropriate
  • If the employee is not currently working, a recommended return to work process, whether it is with your company, or vocational training to work somewhere else
  • An analysis of the current medical situation and what future medical steps are necessary
  • A review of the litigation plan if the case is currently being litigated or appears headed into litigation
  • Confirmation or recommendations on compliance with state filing requirements
  • Recommendations on whether or not to attempt an all-inclusive settlement of the claim
  • Recommendations on whether or not to use a structured settlement of the claim
  • Recommendations on possible financial offsets (subrogation, social security disability, state disability, second injury fund or subsequent injury fund, recovery from the excess carrier, etc.)

 

While the independent, experienced claims auditor cannot undo the damage already done due to prior claim handling mistakes, the independent audit can assist you in mitigating future financial damage from the legacy old dog claims.

 

 

 

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.

How to Build Your Return to Work Program

return to work workers compensationA successful transitional duty/return to work program is much more than having an injured employee answering the telephone or sweeping the floors. Unfortunately, too many employers see a transitional duty program, also known as a return to work program as a “make work” situation for both the employer and the injured employee. This approach to a return to work program often ends in frustration for both employer and employee.

 

Employers who recognize the advantages of a formal return to work program are the employers who benefit the most from having one. A transitional duty program reduces the time the employee is off the job, and by providing physical activity for the employee, speeds up the recovery process. The employer receives a reduction in the cost of both medical benefits and indemnity benefits. Other advantages of an employee working in a modified duty position include:

 

  • The employee is able to contribute some productivity toward the company’s goals while the employee who is sitting at home contributes no productivity
  • The employee has higher morale knowing a job is waiting for him/her when they are healed as opposed to the employee being at home wondering if the company will have a job for him/her when he/she is healed
  • The employee who is physically active on the job recovers from an injury faster than an employee who is physically inactive at home
  • The employee does not develop a ‘disabled’ mindset and does not learn to expect to be paid for doing nothing
  • Employees who know that their company has a formal return to work program are much less likely to submit a fraudulent work comp claim

 

 

Develop Transitional Duty Job Description Before Injury Occurs

 

To build your own return to work program (or to improve your existing return to work program) start with examining the job requirements of each position within the company. A transitional duty work description should be developed for each type of job. By having a ready to go transitional duty job description before an injury occurs there is no delay in bringing the injured employee back to work in a modified duty position.

 

In physically demanding jobs where musculoskeletal injuries are common, some employers develop two transitional duty job descriptions for each position. The first transitional duty job description is for severe restrictions and limitations on the physical capabilities of the employee and the second job description for employees with less severe work restrictions.

 

 

Transitional Job Should Not Be Limited To Original Position

 

Too many employers make the mistake of limiting the transitional job to a variation of the injured employee’s original job. The transitional job can be anywhere in the company, it does not have to be in the same department or the same location. The transitional job that is different from what the employee was doing before the injury will broaden the employee’s skill set making the employee more valuable to your company in the future.

 

 

ALL Employees Should Participate in Transitional Duty

 

For the return to work program to be successful, the employee must cooperate and be a willing participant. The best way to ensure the employee’s cooperation and participation is for the employee to know ahead of any injury that all injured employees are automatically enrolled in the modified duty return to work program. The fastest way to destroy your return to work program is to be selective in who participates. If you pick and choose which employees will be provided transitional duty and which ones will not, you create a situation where the injured employee feels he/she is being singled out. This hurts morale and often leads to the employee hiring an attorney, which complicates the resolution of the claim.

 

As noted above, all employees should know that the company has a transitional duty program requirement for all injured employees. All supervisors and managers should be trained on how the return to work program works. The injured employee’s supervisor should be provided the work restrictions of the injured employee following each of the employee’s doctor appointments. This will allow the supervisor to verify the employee’s transitional duty work assignment meets the doctor’s restrictions.

 

The first day the injured employee is back on the job, the transitional duty work restrictions should be reviewed with the employee. It should be explained to the employee that the transitional duty job requirements will change each time the treating doctor reduces the employee’s work limitations. This prevents the employee from developing the idea that he/she is going to permanently have an easier position.

 

If the transitional duty position requires any training for the injured employee, the training should be provided during the first days the injured employee is in the temporary position.

 

 

Transitional Duty Should Be Temporary

 

The transitional duty position should be temporary. If the injured employee has not been released to full employment after 30 days, the work restrictions should be reviewed with the medical provider. Whenever possible, the employee should be given more work within the most recent work restrictions. If the work restrictions are not decreasing, the nurse case manager or the adjuster should be determining why the injured employee is not improving medically.

 

The employee’s attendance at medical appointments is of utmost importance. The transitional duty job should never be allowed to interfere with the employee’s medical appointments, even when the employee has multiple physical therapy appointments each week.

 

Be sure to share your transitional duty program with all of your business partners – especially the triage nurse, the treating doctor, the work comp adjuster, and the nurse case manager. With everyone knowing that transitional duty is a requirement at your company, you will get better buy-in from all parties.

 

By incorporating each of these recommendations into your return to work program, you will build a more successful return to work program.

 

 

 

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.

Intervention Claims In Workers’ Compensation

Intervention Claims In Workers’ CompensationIntervention claims play an important role in workers’ compensation claims and come from many different sources.  These include various government interests (e.g., Medicare, Medicaid, Veterans Administration) and private sources such as health insurance providers and carriers, disability benefit carriers, and attorneys.  The list is endless.

 

To control workers’ compensation costs, it is important that members of the claim management team and attorneys identify these interests promptly and resolve them either via a hearing on the merits or settlement.  Failure to do so can add time and expense on a claim.

 

 

Policy Reasons for Resolve Intervenors

 

Many states allow interested parties and potential intervenors to have a role in the workers’ compensation process.  The policy behind this is to promote the judicial economy and promote efficiency.  A classic example of this could be a workers’ compensation claim that involves multiple medical providers, intervenors and government agencies that pay benefits in conjunction with a work injury.  Instead of having many hearings and conferences, the matters are consolidated into one process.  It also provides for certainty and consistency in the result.

 

 

Placing Potential Intervenors on Notice

 

Establishing a best practice is important in the identification and handling of intervention claims.  It should be the responsibility of all parties to the claim to coordinate and place these interested parties on notice.  Failure to do so can lead to a potential intervenor not being aware of a matter and result in a delay.

 

The process for giving notice to a potential intervenor is usually defined by statute, rule or case law.  This usually includes:

 

  • Providing notice via written communication mailed to the potential intervenor and including all pertinent documents and pleadings;

 

  • Information concerning the potential intervenor’s rights and responsibilities; and

 

  • Required steps to formally intervene and become a party.

 

This process also includes the ability of the defense interests to dispute the claims made by a potential intervenor.  Even if a potential intervenor is added to the case, the new party still carries the burden of proof, which can possibly include the burden of establishing the injured employee suffered a compensable work injury.

 

 

Pitfalls in Adding Potential Intervenors

 

All interested parties should avoid the following pitfalls when notifying potential intervenors of their rights.

 

  • Notifying potential intervenors too early: Best intentions sometimes result in mistakes.  This includes notifying a potential intervenor before treatment actually occurs or treatment can be processed.  When placing a part on notice, make sure enough time has elapsed so they will be able to identify the claim(s).

 

  • Notifying potential intervenors too late: Most jurisdictions allow for a 30 to 45-day time period for a party to search the pertinent billing records, identify associated treatment and make the correct filings with the court.  There needs to be enough time for the potential intervenor to accomplish these tasks.

 

 

 

Overcoming Other Barriers

 

 

Cooperation is key when it comes to placing all potential intervenors on notice.  This is something all interested parties and their attorneys should accomplish constructively.  Common barriers that go beyond parties not working together can include:

 

  • HIPAA regulations: Federal and state privacy laws place limits on the disclosure of medical information. While HIPPA does specifically exclude state workers’ compensation matters, the overly cautious and uninformed can create a delay.

 

  • Internal Privacy Policies: A medical provider may have additional safeguards in place, which is permitted in certain instances under HIPAA.  This can include the requirement a specific release authorization be used before the disclosure and release of an injured employee’s medical records.

 

  • Debt collection rules/regulations: The federal government and states have a myriad of debt collection guidelines that need to be taken into consideration.  Under the Fair Debt Collection Practices Act, a collection agency is limited in their ability to communicate with an injured employee and other parties.

 

 

Conclusions

 

The identification, notice, and resolution of intervention claims in an essential part of many workers’ compensation claims.  It is important that all interested stakeholders understand the rules of the road and guidelines that cover these matters.  Failure to do so can result in additional litigation and unnecessary expenses.

 

 

 

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.

Course and Scope of Employment: Questions of Compensability

course and scope of employmentIssues of compensability are factually driven and require attention to detail by members of the claim management team.  This is extremely important in cases where the claim comes down to whether the injury was in the “course and scope of” employment.  The correct decision can only be made when the individual claim handler has a good understanding of the law and knows how to apply it to the facts.

 

 

Case Study:  The Workplace Fall

 

Frank Rizzo is a day laborer for Acme Construction Company and dresses for success by wearing his steel-toed work boots and favorite blue jeans.  Given his hard work, he is invited to a corporate meeting and was told to “dress like a boring c-Suite professional.”  Frank is excited and goes out and purchases a $1,000 suit and wing-tipped dress shoes.  While the shoes make his feet uncomfortable, he attends the meeting.  The meeting was exciting, and he is looking forward to prime rib for lunch.  While walking down a hallway to the banquet room, his right knee buckles and now needs a total knee replacement.

 

Personal injuries “arising out of and in the course and scope of” employment is generally compensable under workers’ compensation laws.  Frank was on the clock at the time of the meeting, but the question remains as to whether the “course and scope of” element has been satisfied.  The hallway Frank was walking on did not have any slippery surfaces and was free of imperfections.

 

Is the injury compensable?  These are questions claim handlers must answer daily.

 

 

Questions of “Risk” and “Position”

 

Courts across the country answer questions of “course and scope of” on a regular basis.  The result is a maze of tests interested stakeholders must confront to evaluate a claim and whether to accept it:

 

  • Increased Risk Test: Under this test, courts will examine whether the employment creates a “special hazard” that gives rise to the work injury.  If this is the case, there is a necessary causal relationship between employment and work injury.  Common examples of this include instances where something is located in the workplace that increases the risk of injury.  Idiopathic injuries (those that are unknown or without explanation) are typically found not to be compensable and are denied.

 

  • Positional Risk Test: This test examines whether the employer placed the employee in a location or “position” that gave rise to the work injury.  Under this rather low threshold, just being at work and sustaining an injury can give rise to a claim being compensable.

 

 

Applying the Standards – Differing Results

 

The application of these two tests would likely give rise to different results in the scenarios outlined above.

 

  • Increased Risk: The injury likely would not be compensable. Although the employee was asked to wear clothing and footwear he normally did not wear, nothing in the workplace exposed Frank to a heightened risk of injury.  The defect-free surface would be an important factor.  There is also no explanation as to why his knee gave out.

 

  • Positional Risk: Frank was required to be at the meeting.  It is also important to note he was specifically asked to dress in a certain manner, and testimony at hearing that his new shoes were uncomfortable are important.  Although the walking surface was defect-free, his presence in the workplace gave rise to the injury.  A court applying this test would find it compensable.

 

Based on the divergent results, members of the claim management team should understand the importance of how to evaluate the risk.

 

 

Investigating Troublesome “Course and Scope of” Claims

 

Members of the claim management team need to peel back the layers when investigating matters like Frank’s claims.  This should include the following areas:

 

  • Knowledge of the applicable legal standard – “positional” or “increased” risk;

 

  • Obtain a detailed statement from the employee and possible witnesses. Is there an explanation for why or how the injury occurred? This is key;

 

  • Determine the type of surface involved in the injury and its condition at the time the incident occurred. Documentary evidence such as photographs and security video should be preserved; and

 

  • Instructions on workplace attire such as footwear, etc.

 

 

Conclusions

 

Claim handlers are called upon to make daily decisions on whether to accept a claim and commence the payment of workers’ compensation benefits.  Not making the correct decisions can lead to increased costs on claims.  This includes money spent on litigation costs, sanctions/penalties and setting incorrect reserves.

 

 

 

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.

2 Ways To Help Injured Workers Get By With A Little Help From Their Friends

 

Hey there, Michael Stack here with Amaxx.

 

If I asked you to think of a friend of yours, who immediately comes to mind? What value does that individual bring to your life?

 

This past weekend, I connected with some old friends of mine, some good friends from college, guys I’ve known for over two decades. We spent a couple of days together back at Indiana University where we went to college. It was a heck of a lot of fun. A heck of a lot of fun connecting with those very valuable relationships and longstanding relationships in my life, and it just gives you a little bit of a boost connecting with such good friendships and good connections.

 

 

Injured Workers’ Often Cut Off From Work Friendships

 

It got me thinking today about injured workers, and how in general, we as adults make our friends. A lot of times we’ll have old friends, old college friends like I did, that just connected with. But a lot of times as we grow older, as adults, we make those connections, a lot of connections, through the people we work with, kind of through those social connections. Then of course, through our kids and all that kind of stuff as that develops.

 

But that piece of the social fabric, those friendships and social connections at work, some of them stronger than others, oftentimes for injured workers, get cut off right at the time of their injury, at the time when they need it most. When we talk about that little boost, they need that little boost, but they’re not getting it, it often has that negative effect because they’re not connecting with those individuals in their life any longer.

 

 

Friendships Can Be Positive Support For Injured Workers’ Recovery

 

I want you to think about the meaning of that for that friend that came to mind when I asked you to think about that individual. Think about those social connections that you have at work, and the meaning that has in your life and the boost that sometimes that gives to you, and the importance of that in an injured worker’s recovery process.

 

I’m going to give you two techniques to foster that, to give that to those individuals when they could use that little boost as well. So let me give you these two techniques, and I want you to think about these and have them implemented in your program.

 

 

Visit Injured Workers at Hospital

 

The first one, very simple, go to visit that injured worker at the hospital. Go to visit that injured worker at the hospital, make that person-to-person connection with them when they’re in that recovery, immediately following that injury. Go to visit that person at the hospital. You talk about sending a get well card as well, this is really significantly more effective. Bring some flowers, bring something that they like. If they don’t like flowers, bring something else that they might enjoy.

 

 

Meet With Injured Worker Weekly at Company

 

Then number two is meet weekly at the company. So meet weekly at the company. We talk about weekly meetings with the injured workers. Have that weekly meeting be at the organization, physically at the organization. If it’s at the manufacturing plant, if you have a construction site, whatever it is that you have, wherever it is that you’re working, meet with them, personally have them come in, if at all possible, to the organization.

 

They can make some of those physical connections, those emotional connections, reconnecting with the fabric that may be for that person, a big support in their life that can really help draw them through which might be a very difficult recovery. If you can meet with them, stay connected with the company, stay connected with those relationships, it can not only give them that boost, but it can oftentimes help push them over the edge.

 

Don’t discount the importance of a lot of this impact on those injured workers, because it can be very, very positive and create very positive outcomes.

 

Again, my name is Michael Stack, I’m the CEO of Amaxx. Remember, your work today in workers’ compensation, can have a dramatic impact on your company’s bottom line, but it will have a dramatic impact on someone’s life. So be great.

 

 

 

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/

 

©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.

Case Study: $270,917 in MSA Savings Through Physician Follow-up

Reduce your workers' comp case studyDeveloping a Medicare Set-Aside is not only a time-consuming and arduous process, but can also be unnecessarily expensive. There are many instances where tremendous sums of money are included in an MSA just because stakeholders were not diligent in analyzing what was included.

 

A case in point was a recent situation in which a medication the injured worker had taken only one time was set to be part of his lifetime medications in the MSA. Had this seemingly simple oversight not been flagged, it would have driven up the cost of the MSA by hundreds of thousands of dollars!

 

We hear all too often about injured workers who, unfortunately, fall through the cracks in the workers’ compensation system and are not appropriately cared for. While these represent only a small minority of cases, they generate headlines. Equally disturbing are stories of injured workers who’ve settled their cases and soon after find themselves out of money with no hope of paying for their future medical expenses, let alone moving on with their lives.

 

The goal of developing an MSA is to identify as accurately as possible the total cost that will be incurred during the injured worker’s life. The amount needs to include all expenses related only to the specific injury, as well as other treatments that may be needed later on.

 

Either party – injured worker or employer/payer – can wind up on the losing end of a settlement if it is not done correctly. This is why it is so important for all parties to carefully review the medications, procedures, and costs involved before signing off on an MSA.

 

 

Case Study (Provided by Tower MSA Partners): $270,917 in Savings from Physician Follow-up

 

An injured worker had been diagnosed with a variety of conditions stemming from a workplace injury, including depression, anxiety, complex regional pain syndrome and bilateral hand/arm pain with radiation to his right shoulder and neck. He was ready to settle his claim and leave the workers’ compensation system.

 

Among the six RXs included in the MSA projection was Nucynta 50mg. This opioid is meant to be a short-term treatment for moderate to severe pain. Not only is it highly addictive, but also extremely expensive. It comprised $245,721 of the MSA amount.

 

The worker had, understandably been treated by several physicians in the year before he agreed to settle. But the medical records were less than complete.

 

Total MSA Exposure — $326,925.

 

 

Solution:

 

With so many physicians involved, Tower’s physician follow-up team first obtained statements from each of the six providers involved in the worker’s treatment. They confirmed the last dates of services and whether medications had been continued or not. If they were, the name of the drug, dosage, and frequency for each was requested.

 

The physician who had prescribed Nucynta confirmed it was a one-time fill that was subsequently discontinued. The team identified several additional discrepancies in the statements from the physicians and had the physicians document the medical records with a revised medication list that reflected what the injured worker was actually taking and expected to need going forward.

 

 

Results:

 

Removing Nucynta from the medication list reduced the projected amount of the MSA by more than $245,000. An additional $81, 204 was also eliminated, based on the physicians’ statements

 

The MSA went from $326,925 to $56,008 — a savings of $270,917 and, with no negative impact on the injured worker!

 

 

Conclusion:

 

While the particular medication involved in this case was on the high-end of errors, the situation is all too familiar. Stakeholders often take information about current and future medications and treatments at face value, without delving into what is behind the numbers.

 

This case is typical in that a variety of physicians were involved, their records in many cases were incomplete, and there were medications included that had no bearing on the injured worker’s current, let alone future status.

 

Creating accurate MSAs takes time and skill. Those who undertake them need to ask questions and obtain all relevant information in order to come up with an amount that is fair to all sides.

 

 

 

 

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.

Video Kinematics Produces Physical Job Demand Descriptions on Steroids

video kinematicsHow familiar are you with the physical demands of every job in your company? That may sound like a loaded question, but the more understanding you have of each job, the better you’ll be at preventing injuries, reducing workers’ compensation costs and improving your bottom line.

 

However, many companies face the challenge of lack of time or resources to do a thorough and complete job of developing a physical demands database. The development of technology and artificial intelligence now makes this easy.

 

 

Why It’s Important

 

Let’s take drivers at a trucking company as an example. We know that long hours of sitting are required. We know when the drivers reach their destinations they must unload and reload the truck. And let’s say we even know that the items being off- and on-loaded weigh approx. 50 lbs. each.

 

Based on the 5 strength categories outlined by the Department of Labor – sedentary, light, medium, heavy, very heavy — we might conclude this particular job fits in either the ‘medium’ or ‘heavy’ strength category.

 

This is good information. But is it enough to ensure job applicant Fred can handle it, or Joe the returning injured worker won’t reinjure himself? Maybe there is more information we could use.

 

For example, how many 50-lb items are lifted per day on average? What percentage of the lifting time is spent with the item held at shoulder height, between waist and shoulder, or above shoulder height? Does the worker need to bend or twist in a certain way while moving the items on and off the truck? What, if any hand movement is required; i.e., are the items in boxes with handles, or does the worker pick up each item from the bottom? What surface heights are involved?

 

If Joe, returning from a shoulder injury, is to do this job, a basic description plus the DOL strength category of ‘medium’ might indicate he is a good fit. But if the job requires him to spend 1 – 2 hours each day with his hands reaching above shoulder level to off- and on-load the truck, Joe will be at high risk for reinjuring himself. In that case, we’d put Joe in another position that would not put undue stress on his shoulder. That is the benefit of accurate, precise and detailed job descriptions.

 

 

Physical Job Demand Descriptions

 

Physical job demand descriptions should provide as much detail as possible. In addition to the basic summary of the tasks involved, it should drill down to the specifics of the impact on any affected body part. For example, it should include the precise required angles of elbows, shoulders, and trunk; hand height; and reach distance.

 

Organizations should know exactly how much stress a job will put on a worker’s body and which parts specifically. Such knowledge will help make a much better decision about what workers can do which jobs without risk of injury.

 

Ergonomists are often called upon to help provide job descriptions, and with good reason. Their training gives them more insight into the physical demands of each task. However, advanced technology may be able to generate job descriptions that are at least as good and in less time, freeing up ergonomists to focus on developing programs to prevent injuries.

 

Researchers in Canada recently conducted a study to see how job descriptions created by video kinematics compared to those produced by two groups of ergonomists; experienced and novice.

 

 

Study

 

The researchers compared video-based joint angle and reach envelope measures for 10 simulated work tasks to the physical job demand descriptions from the ergonomists.  As they pointed out, “physical job demand descriptions often lack detail and format standardization, require technical training and expertise, and are time-consuming to complete. A video-based physical job demands descriptions tool would significantly decrease the time burden on ergonomists in documenting job parameters and may aid practitioners in determining the suitability of a job for a worker returning from injury.”

 

Tasks were recorded using a fixed position smartphone camera that was synced with the motion capture. The video was analyzed by Canadian company MyAbilities Technologies, Inc., who uses digital job profiles for injury prevention, fitness for duty, as well as to facilitate timely return-to-work to the worker’s own or modified job.

 

Physical job demand descriptions identifying the same angle and distance measures were done by the ergonomists for each task. The ergonomists estimated trunk angle, shoulder angle, elbow angle, hand height, and reach distance for the posture that represented the ‘greatest amount of the work cycle.’

 

“Overall percent agreement for video kinematics compared to motion capture was 82.5 percent,” the study said. “ video-based analytics had an equal or lower (i.e., better ) posture score than [either group of] ergonomists for 85 percent of ratings and was outright lower than both groups [of ergonomists] for 50 percent of ratings.”

 

The researchers said the study suggested that “video-based job task assessment may be a viable approach to improve accuracy and standardization of field physical demands analysis and minimize error in joint posture and reach envelope estimates.”

 

 

Conclusion

 

The study results are great news for organizations trying to prevent injuries — or re-injuries. By simply taking a video via smartphone of a worker doing job tasks and uploading it organizations can instantly have access to detailed job descriptions to help them make well-informed decisions when fitting workers to jobs and ensure they keep their workers safe and healthy.

 

 

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.

3 Elements Needed In Workers’ Comp Medical Networks

 

How to Select the Right Workers' Comp Doctor

 

So last week I’m having lunch with a business associate and he says to me, “You know, I haven’t done a lot of business in work comp. Can you explain to me how it all works?” Hello, my name is Michael Stack and I’m the CEO of Amaxx and that question is a great question, particularly for those outside of our industry and also for many, many of individuals within our industry, trying to figure out the complexity of the work comp industry itself. As you look at it from the outside, it’s extraordinarily complex but at its core, it’s extraordinarily simple.

 

 

Getting Injured Employees Proper Treatment Is Core of Workers’ Comp

 

You’ve got an employee and an employer, that employee gets hurt and our job is to just help them get better and get back to work. Very, very simple and to do that, you need a lot of help and you need a lot of people. One of those individuals and one of the emerging markets and emerging sub-markets even within the physician world, is the emergence of networks and specialty networks. Today I want to talk about that specialty network and what you should look for when you’re setting this up so you can get those individual employees the treatment they need and help them get back to work. Let’s talk about a couple things here.

 

 

Broad vs Narrow Networks

 

First thing you’re going to do is you’re going to look at whether you’re going to be using a broad versus a narrow network. The narrow network, these are the ancillary networks, these are the specialty networks that has been really quietly emerging within our industry over the last several years. It’s not a bad idea to have a combination of the two. You’ve got the broad network to cover most of your organization, and then the narrow network to bring in some of those experts in those particular fields. Now, these can be physical therapy, these can be mental health, these can ambulatory service centers, these could be chiropractic, a whole host of specialties within the medical field that put together these ancillary or specialty networks.

 

A couple things that I want you to just be aware of. There’s a lot that obviously goes into this, but what we’re trying to do, think about the core of what we’re trying to do is, we’re trying to get that individual employee the treatment that they need to get them back to work. Now, how do we do that? Bringing in these best medical providers, leveraging the fee schedules, the discounts on the fee schedules that can often come from these. So, a couple of things that I want you to just look for, particularly if you’re evaluating a network and evaluating whether or not to bring in some of these specialty or ancillary or networks, which again have been emerging in the last several years.

 

 

Network Coverage

 

First thing that I want you to look at his coverage, next is access and the last one, or at least the last one we’re going to talk about today, is credentials, so coverage, access and credentials. Can you cover the entire geographic area of where your employees are? If you’re a regional or a national employer, is there the appropriate coverage that that employee could actually get to that provider in a reasonable amount of time to get the treatment that they need?

 

 

Network Access

 

Number two, are they accepting new patients? Are they accepting new patients? Workers’ comp specific patients. I can’t tell you how many conversations I’ve had with injured workers where they said, “You know, I got a list of five doctors and the first three I called, they didn’t take work comp at all and the fourth one I called, he wasn’t taking any new patients, and then the fifth one did take new patients and took work comp, but he was two hours away.” Coverage and access, incredibly important to get to that fundamentally simple concept of what it is we’re trying to do in this industry, help our employees get better, help them get back to work. You got to have the right doctors that are going to help them do that.

 

 

Credentialing

 

And then finally, particularly as it comes to network, what credentialing are they doing? Are they board certified? Do they have X amount of experience? Do they have certain criteria as far as the outcomes that they’re delivering? What is their credentialing of the networks? Work comp can be extraordinarily complex in how it’s all put together, but remember at the core, what it is we’re trying to do. Just get our employees the treatment that they need and help them get back to work. These couple of tips in regards to providers and network can help you do that.

 

 

Again, I’m Michael Stack, CEO of Amaxx and remember your work today in workers’ compensation can help you have a dramatic impact on your company’s bottom line, but it will have a dramatic impact on someone’s life, so be great.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: 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.

3 Criteria Determine If A Workers Comp Claim is Covered

Most workers’ compensation claims are clear cut, and there is no question by the employer that the claim is ‘covered’ for workers’ compensation.  However, when an unusual situation occurs, the employer may not know if the work comp claim is ‘covered.’  By ‘covered’ the employer is actually asking “is the claim a compensable workers’ compensation claim?”

 

The compensability of workers’ compensation claims is determined by three criteria.  The criteria that must be met for a claim to be ‘covered’ are:

 

  • There must be an injury or an illness
  • The injury or illness must arise in the course of employment
  • The injury or illness must be caused by the employment

 

 

There must be an injury or an illness:

 

This is the most basic requirement for a workers’ compensation claim.  Most employees understand that an accident that they are involved in which damages the employer’s property but does not cause them any bodily harm, is not a workers’ compensation claim.  “Near misses” where the employee almost got injured by a falling object, failed machinery or other sudden events do not create a workers’ compensation claim, regardless of how scared the employee may have been. (However, many states allow the employee to bring a stress claim if there is also a physical injury to the employee).

 

 

The injury or illness must arise in the course of employment:

 

An injury to the employee or an illness of the employee must occur during the employment.  If an employee injures his back while at home (or anywhere other than the employer’s worksite for that matter), it is not a workers’ compensation claim.  [The most frequent fraudulent claim is the injury that occurred while the employee was not working for the employer].  To determine if the injury is compensable, the employer should verify, preferably through independent witnesses, that the injury occurred while the employee was at work.

 

 

The injury or illness must be caused by the employment

 

‘Caused by the employment’ is often the most difficult aspect for both employees and employers to understand about workers’ compensation.  Just because an injury or illness occurs on the worksite does not by itself create a workers’ compensation claim.  The injury or illness must be caused by the employment.  For example, the employee who is on her lunch break and burns her lips, tongue and mouth with coffee that was too hot, does not have a workers’ compensation claim as the cause of her injury is drinking a very hot beverage.  The employment did not cause the injury.  Another type of occurrence that often becomes contentious is the heart attack that occurs while the employee is working.  If there are no work-related factors that caused the heart attack, the occurrence in the work place does not make it a compensable claim.

 

 

If the employer is unsure if the alleged claim is ‘covered’ by workers’ compensation, the employer should contact the adjuster and be prepared to discuss all the details surrounding the event that is being claimed as a work comp claim.  The adjuster will be able to assist the employer in determining whether or not they have a compensable workers’ compensation claim.

 

 

 

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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