NCCI Report Highlights Early Identification of Prescription Drug Abuse

Prescription Drug AbusePrescription drugs continue to contribute to a significant portion of medical costs in workers’ compensation claims nationwide.  This is due in part to opioid addiction and its negative impact.  Gains are being made, which means proactive members of the claim management team need to be continually engaged and implement best practices to avoid addiction and reduce the portion of claims consumed literally by prescription drugs.

 

 

NCCI Report Highlights the Problem

 

The National Council on Compensation Insurance (NCCI) recently released a report regarding prescription drug costs in workers’ compensation case.  The report sets forth the following encouraging conclusions:

 

 

  • While the prescription drug share of medical costs in workers’ compensation cases is at 13.7%, this amount declined by 2% in 2015, and 4% in 2016; and

 

  • Main drivers in prescription drug usage include Lyrica, OxyContin, and Gabapentin, which account for more than 15% of prescription drug costs in 2016.

 

While some of these trends are positive, it should still be understood that more can be done by proactive claim handlers to control the costs of prescription drugs in workers’ compensation claims and run a more effective program.

 

 

Early Identification of Prescription Drug Abuse

 

All interested stakeholders should be on the look-out of for overuse and abuse of prescription drugs.  Signs of misuse include the following:

 

  • Identification of injured employee’s with risk factors that include past/present history of substance abuse, family history of substance abuse, and various psychological and/or psychiatric conditions;

 

  • Injured employees that specifically request prescription medications by their name brand and refuse to accept generics; and

 

  • Instances where someone regularly claims to lose their prescription drugs and is requesting a refill.

 

The existence of a pain management agreement is a common feature in most workers’ compensation laws in instances where an employee is using opioid-based drugs.  This agreement should be strictly followed.  There should also be a renewed effort on the part of everyone to direct an injured employee back to work, even if it is in a light-duty/sedentary capacity.  Studies suggest strong return-to-work efforts significantly reduce the medical spend on any type of personal injury claim.

 

 

Multi-Faceted Approach to Reducing Prescription Medical Expenses

 

Proactive stakeholders in the workers’ compensation system can advocate for change to reduce the cost and human toll prescription drugs – mainly opioid-based – take on injured employees.  This includes an effective three-pronged approach.

 

  1. Prevent new cases of opioid-based prescription medication abuse from occurring: This all starts with the use of a pain management agreement – and making sure it is strictly enforced.  This zero-tolerance approach will ensure powerful pain medications are not misused or abused.  Terms within the agreement should include exactly how the medications are to be used, random drug testing and consequences for false/positives, failed tests and missed testing, how replacement medications are to be dispensed and where all prescriptions are to be filled – avoiding physician dispensing protocols.

 

  1. Treat people who are addicted with compassion: No process is foolproof, and anyone can become addicted.  It is important to treat individuals who suffer from this consequence are treated with respect and dignity.  All reasonable and necessary forms of treatment should be made available; and

 

  1. Use drug utilization measures to better target prevention and treatment: This is one of the most effective tools available to members of the claim management team in combating the abuse and overuse of opioid-based prescription medications.  Drug utilization review (DUR) is the process of reviewing all aspects of prescription drug usage – prescribing, dispensing, and use of medication.  It examines the individual usage of someone against predetermined criteria based on evidence-based medicine to ensure an effective and efficient result.  The recent NCCI report also credited the effective use of DUR in driving down the amount of money spent on prescription drugs in workers’ compensation claims.

 

 

Conclusions

 

There are many negative consequences of prescription drug abuse and misuse in workers’ compensation cases.  Steps are being taken to hold these adverse effects in check and also reducing workers’ compensation program costs.  This can be accomplished by implementing an effective approach that includes drug utilization review in your 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: 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.

Workers’ Comp Mediation – Getting to “YES”

workers' comp mediationWorkers’ comp mediation and other alternative dispute resolution methods can be effective in the settlement of workers’ compensation cases.  It also helps promote program efficiency that frees up funds set in reserve, which in turn can be used to settle other claims.  Notwithstanding the benefits of using dispute resolution mechanisms, it is important for members of the claim management team and other interested stakeholders to prepare.  Failure to do so can waste everyone’s time and energy.

 

 

Selecting the Right Mediator

 

In most jurisdictions, there are no specific requirements or training someone needs to have to serve as a mediator.  The result is the parties to the workers’ comp mediation have the unfettered right to select the person to serve as the neutral.  With this in mind, it is important to note every mediator brings a unique skill set to the table.  This should include someone knowledgeable in a particular workers’ compensation act, and have a reputation for being able to cut through the smoke and mirrors of contentious litigation and get everyone to “YES!”

 

 

Preparing for a Successful Workers’ Comp Mediation

 

A mediator may often ask that parties submit a confidential mediation statement in advance.  This document can serve as the framework for reaching a favorable settlement and avoid wasting time.  Each mediator may have their own preference as to what is covered in the mediation statement.  Common points that should be considered can include:

 

  • An itemization of the benefits claims/defenses and potential recovery/exposure: The value of a workers’ compensation case is the starting point for settlement.  This often includes calculations for the employee’s average weekly wage (AWW), exposure for various indemnity benefits (TTD, TPD, PPD, and PTD) and medical benefits.  Other items to consider include the need for vocational rehabilitation services and the possibility of retraining.  All parties should consider the strengths and weaknesses of defenses such as causation issues, the reasonableness/necessity of medical care.

 

  • Expectations regarding a reasonable settlement range: The goal of mediating a case is to find common ground.  This requires compromise on the part of the defense interests and injured employee.  Attorneys, settlement consultants, and other interested stakeholders need to evaluate their cases and have an understanding as to where this case may settle.  This will allow the mediator to work with all sides in reaching an agreement.

 

  • The status of any prior negotiations, offers, and demands: Any settlement needs to start with a settlement demand.  This information should be communicated by the employee or their attorney to the employer/insurer before mediation takes place.  In the same regard, the defense interests should obtain reasonable settlement authority.  A claim handler ideally will be physically present at the mediation and able to get additional authority if necessary.

 

  • An honest assessment of your cases that includes its strengths and weaknesses: All parties needs to be honest about settlement and participate in good faith.  Attending a mediation just to see how the other side views the case can be unproductive and delay settlement on other cases.  A good mediator will challenge the parties if there is a sense they are not negotiating in good faith.

 

  • Confirmation that all intervenors and/or interested parties have received proper notice. It is important that all interested medical providers, private insurance carriers, and government agencies such as Medicare or Medicaid be made aware of their potential right of recovery.  This should be completed well in advance of settlement negotiations so they can provide all parties with an updated benefit resume.

 

 

Conclusions

 

Reaching a settlement on every case is not practical given the contentious nature of workers’ compensation litigation.  Notwithstanding these barriers, all parties should consider workers’ comp mediation as a tool to resolve cases.   It can also deliver the “win” all parties are looking for as they work hard in resolving disputes.

 

 

 

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.

Case Study: More than $1.5 Million in Savings Through Generic Substitutes

Generic drugs in workers' compensationThe latest Drug Trend Report from myMatrixx once again showed a substantial cost difference between brand-name and generic drugs. In fact, while the costs of brand name drugs are increasing, prices for generics are steadily decreasing. Unfortunately, some workers’ compensation stakeholders overlook this issue when preparing Medicare Set-asides.

 

Medications prescribed for the injured worker are expected to be included in the MSA to gain approval by the Centers for Medicare and Medicaid Services. There are exceptions; however; such as when it can be demonstrated the injured worker is no longer taking the medication. But switching from brand-name to generic medications is one of the most efficient and effective ways to reduce costs.

 

 

Generics vs. Brand-Names

 

Some people are concerned that generic drugs are of lower quality than brand-name medications. The Food and Drug Administration stipulates that all generic drugs must be equivalent to their brand-name counterparts. Additional FDA requirements include:

 

  • That generic drugs have the same active ingredient, strength, dosage form, and route of administration as the brand-name drug.
  • The generic manufacturer must prove its drug is the same (bioequivalent) as the brand-name drug.
  • All manufacturing, packaging, and testing sites must pass the same quality standards as those of brand-name drugs.
  • Any generic modeled after a single, brand name drug must perform approximately the same in the body as the brand name drug.

 

The FDA also points out that many generic drugs are made in the same manufacturing plants as brand-name drugs.

 

Are there differences between generics and brand name drugs? Yes, but as the FDA points out: “There will always be a slight, but not medically important, level of natural variability just as there is for one batch of brand name drug compared to the next batch of brand name product. This amount of difference would be expected and acceptable, whether for one batch of brand name drug tested against another batch of the same brand or for a generic tested against a brand name drug.”

 

Generic drugs are cheaper than brand-names because the manufacturer making the generic version does not have to go through costly clinical trials that new drugs do. Also, they don’t generally pay to advertise, market or promote the drug, since the brand-name maker has already established the drug in the marketplace. The competition created by multiple manufacturers developing a generic version of a brand-name medication further drives down the price of the medication.

 

The only reason for any patient to use a brand-name over a generic medication is if the generic drug causes unusual side effects to a particular person or, in rare cases, is less effective. In the vast majority of cases, patients do just as well with generic medications as with their brand-name counterparts.

 

The biggest difference between generic and brand name medications is the price. A case study of a recent MSA is a dramatic example of this.

 

 

Case Study (Provided by Tower MSA Partners): More than $1.5 Million in Savings Through Generic Substitutes

 

An injured worker who had been diagnosed with Post Traumatic Stress Disorder, anxiety and mood disorders was taking a variety of medications to treat his conditions. Among the more costly drugs were Wellbutrin, Klonopin, Rozerem, and Neurontin — all brand-name medications.

 

When discussions about settling the claim began, the initial MSA included $1,657,022 for medications and $30,058 for future medicals.

 

Total MSA Exposure — $1,687,081.

 

 

Solution

 

After identifying the brand-name medications as the key cost drivers in the initial MSA allocation, Tower recommended working with the injured worker’s attorney and the treating physician to switch to generic substitutes. The switch from brands-to-generics took several months to complete, to ensure the effectiveness of each.

 

When the conversion was completed, a physician’s statement was obtained confirming the switch from brand to generic, as well as an updated prescription history documenting ongoing generic use. Tower promptly submitted an MSA with an allocation of $112,572.

 

Results

 

CMS approved the MSA within eight days, allowing the parties to settle. The switch from brand-name to generic medications resulted in savings of $1,574,509 — and assured the injured worker would have enough funds for his future medicals and medications.

 

Conclusion

 

Developing and getting FDA approval for a medication is a long, complicated process. Drug manufacturers charge for a medication based on their expenses for creating and bringing the drug to market. Once the patent expires for a particular medication, other manufacturers are free to produce the same drug — as long as it meets the FDA standards for generics; i.e., it is the same drug.

 

The cost difference between generic and brand-name medications continues to grow further apart. By carefully looking at the medications prescribed for an injured worker and working with various stakeholders involved, an appropriate, cost-effective MSA can be created.

 

 

 

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.

11 Tips for Safe Use of NSAIDS to Treat Pain in Workers’ Compensation

NSAIDs in Workers' CompensationThere’s good news about the latest drug usage in the workers’ compensation, although it comes with a word of caution. The good news, according to the latest Drug Trend Report from myMatrixx is that the use and spend on opioids have once against decreased. Alternative medications treatments are being used more often to treat pain. While that’s good in the effort to prevent unnecessary use of opioids, one class of medications need to be taken with caution.

 

NSAIDs — nonsteroidal anti-inflammatory drugs— have become one of the medications of choice to treat pain. These can be very effective and don’t carry the risks of addiction or dependence of opioids. However, the problem is the potential negative effects on the cardiovascular system. Care needs to be taken when prescribing them, especially to older workers.

 

The situation is something of a Catch-22; older injured workers often have pain, but they are typically more vulnerable to problems of the cardiovascular system. Payers can help protect injured workers who are prescribed these medications by understanding the risks, educating patients and exercising caution.

 

 

NSAIDs and Cardiovascular Issues

 

NSAIDs are often used to treat mild to moderate pain. They are especially helpful for pain caused by inflammation, such as arthritis or a sports-type injury.

 

NSAIDs are drugs with analgesic, anti-inflammatory, and antipyretic activity. Some of the commonly used over-the-counter varieties are ibuprofen, such as Motrin and Advil; and naproxen sodium, or Aleve and Anaprox. Prescription NSAIDs include Celecoxib, or Celebrex; and diclofenac, known as Cataflam and Voltaren. Aspirin, which is an NSAID, does not pose a risk of heart attack or stroke and is commonly used to prevent those conditions.

 

Gastrointestinal problems associated with NSAIDs are well known. But researchers have also found that these medications can increase blood pressure and lead to congestive heart failure, as well as acute myocardial infarction.

 

The Food and Drug Administration warned of the potential risks of heart attack or stroke from NSAIDs in 2005. Ten years later the agency strengthened its warning, based on the advice of an expert panel that had reviewed additional information.

 

The risk was especially noted when the drug rofecoxib, or Vioxx, was on the market. It was removed in 2004, after being associated with as many as 140,000 heart attacks in the U.S. during the five years it was sold. It prompted further research about the risks of heart attack and stroke from NSAIDs in general.

 

According to the FDA:

 

  • The risks of heart attacks and strokes increase even with short-term use of NSAIDs and may begin within a few weeks of taking the medications.
  • The higher the dose of NSAID, the higher the risk. Also increasing the risk is the length of time the medications are taken.
  • People most at risk are those who already have heart disease, although others can also be at risk.

 

Patients taking diuretics may be at the highest risk of heart attack or stroke, especially during the first few weeks of taking NSAIDs.

 

 

Preventing NSAID Risks

 

Taking NSAIDs for a few days to relieve pain generally carries just a small risk, for most people. Employers and payers can help ensure injured workers are less at risk of developing heart attacks or strokes from the medications through the following strategies:

 

  1. Monitor for signs and symptoms of adverse effects.
  2. Educate injured workers and family members on the risks, especially those more at risk.
  3. Prescribe the lowest dosage possible.
  4. Prescribing taking the drugs for only a limited period of time.
  5. Try alternative remedies for people who have heart disease, if at all possible.
  6. Do not take more than one type of NSAID at a time.
  7. Try alternative medications, such as acetaminophen. Be aware, however, that this drug can cause liver damage if the daily limit exceeds 4,000 milligrams or if the person drinks more than three alcoholic beverages a day.
  8. Suggest week-long NSAID ‘holidays’ on occasion.
  9. Advise the injured worker to get medical attention immediately if he experiences chest pain, shortness of breath or sudden weakness or difficulty speaking.
  10. For muscle or joint pain, suggest hot or cold packs or physical therapy before NSAIDS, for those more at risk.
  11. Injured workers already taking aspirin to prevent a heart attack should talk with their physician first, as some NSAIDs may hamper the aspirin’s effectiveness.

 

Conclusion

 

The workers’ compensation industry has made inroads in curbing the unnecessary use of opioids. However, care needs to be exercised before giving an injured worker a blanket recommendation or prescription for NSAIDS, especially for people who have pre-existing heart-related conditions. As with all medications, moderation is key.

 

 

 

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.

Tips to Get the Most from Your Workers’ Comp Adjuster

 

Hey there, Michael Stack here with Amaxx. So Happy Mother’s Day to all the mothers that are out there. Hopefully you had a lovely celebration over this past weekend celebrating Mother’s Day. We certainly did for my wife, the mother of my four children. We did coffee and pancakes in bed and taken out to a really nice lunch. We had a really lovely day, and hopefully it was the same for you or your mother as well.

 

But it got me thinking about this sort of this day of demonstration of gratitude for mothers and how really for the amount of work that they do, one day is just not enough. It pales in comparison to demonstrating that gratitude. It needs to be delivered on a regular basis.

 

 

Gratitude for Your Workers’ Comp Adjuster

 

And it got me thinking about this other group, sort of this other role within the work comp industry that’s the same way that doesn’t get even a day at all, and that’s your adjusters. For the amount of work that your adjusters do on a day in, day out basis, the importance of their role within the work comp industry, the amount of gratitude that they get is very, very low. There are no pancakes delivered to them in bed, there’s no taking them out to lunch to have a lovely day.

 

So two things I want to talk about and focus on getting the most out of these adjuster relationships in today’s video. First one is demonstrating gratitude. How to demonstrate gratitude and the second thing is about how to set these up. How to set up these adjuster relationships.

 

So very simple, when I talk about gratitude you’re asking your adjuster for a thousand different things every day. Send me this form, send me this recorded statement, I need this, I need this, did you do the investigation, did you the three-point contact, what was this, blah, blah, blah, and it’s coming out in rapid fire all day long via phone, email and now often times text messages. So all these different places that they’re getting demands to respond to regularly.

 

 

Say Please & Thank You

 

Say please, say thank you to your adjuster. May I please have that investigation report? Can you please send me that witness statement? Whatever it is that you’re asking your adjuster, and when they send it to you, say thank you. Say thank you. This is a lost art within our world today. Don’t just apply this to adjusters, apply it to your regular daily life.

 

We have gotten to be so bold in the way that we interact with people that this has been forgotten. Very simple, very necessary, and it’s going to demonstrate a little bit more of that gratitude for your adjusters. And oh, by the way, maybe take them to lunch every once in a while too. They always like that.

 

Second thing is I want to talk about your set up within your account handling instructions. So when you set this up when you’re with your TPA when you’re with your carrier, if you’ve been with them for a long time it’s worth revisiting definitely at least on an annual basis. But a lot of time we like to talk about your account instructions as a living document, something that you can alter or change as necessary throughout the course of your claims handling relationship.

 

 

Set-Up In Workers’ Comp Account Handling Instructions

 

So let’s talk about the set up. Couple of things that I want you to look for in your account instructions when you’re initially setting it up or if you’ve been with them for a while to potentially modify.

 

 

Dedicated vs Designated Adjuster

 

So you can have a dedicated versus a designated adjuster. Now this is about how to set this up as far as who is serving you and what it costs. So who is serving you and what it costs. So dedicated versus designated, I want you to look at their case loads and I want you to look at their experience.

 

So what type of adjuster, who is that individual who is going to be assigned to your case? Again, in your instructions as you’re setting this up or as you’re potentially modifying it on an annual basis.

 

A dedicated adjuster is one that only works directly for you. So you work with Jane Smith, Jane’s your go to girl. She’s there handling all of your cases, or Jane and John if you’ve got more than one. Designated means that Jane or John works only for you, but they also work for XYZ Company as well.

 

You can develop a relationship. We talk about having your adjuster so much as being this key part of your team, demonstrating them gratitude, bringing them along, really having them as a main cog in your wheel. Setting up these relationships is a great way to do this. You could spend more money on a designated or dedicated adjuster. It’s going to cost you more out of the gates, but it can save you a huge amount.

 

 

Adjuster Case Loads

 

Same thing as we’re looking at these case loads. So adjusters with lower case loads do a better job. Adjusters with lower case loads do a better job. You don’t need a lot of research to figure that one out. It’s just common sense. If you’re handling 50 cases versus 500 cases, you’re going to do a better job on the 50 then you are going to do trying to handle the 500.

 

So one little quick tip here, this is something that you can define within your instructions. Also, do they have an admin support? So does your adjuster have administrative support? They can have a higher case load and do an equally good of a job if they have an admin support helping them to process a lot of that paperwork.

 

So something to think about and look at and ask your carrier, ask your TPA if this is an option and then look at those outcomes of how you can really best set that up.

 

 

Adjuster Experience Level

 

Then your experience level, do they have five years, do they have ten plus years of experience? You can negotiate this in your contract. You can negotiate I want my adjusters to have ten years plus experience, or I want them to have ten years plus experiences on these certain types of cases, the lost time cases, the catastrophic cases, whatever it is. You can define that.

 

Another thing you might want to do is if you look at this and they say, “Sure we can that but it’s going to cost you action.” You kind of choke up on that amount. You could say, “We want a mix step. We want ten years plus experience to be working with some of the newbie adjusters on those medical only files so that they have that supervision, they can deliver those outcomes.”

 

So all different things to look at and think about as you’re setting up these adjuster relationships. Once you do, then show them that gratitude. Bring them that coffee in bed. Take them to lunch. Show them that gratitude for the work that they’re doing. When you do, they’re going to deliver much better outcomes.

 

Again, my name is Michael Stack. I’m the CEO of Amaxx, and remember your work today in worker’s 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.

 

 

 

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.

 

Surveillance in Workers’ Compensation

Surveillance in workers’ compensation plays an important role in resolving claims and detecting fraud.  Given its expenses, there are various factors members of the claim management team need to consider before hiring a service provider to conduct surveillance.  If these issues are not considered, the bottom line of a workers’ compensation claims program will suffer.

 

 

Surveillance in Workers’ Compensation Basics

 

The purpose of hiring an investigator in workers’ compensation cases is to observe and document the movements of an injured employee.  This allows the defense interests to introduce first-hand evidence into a hearing on the merits to demonstrate what someone is doing and their functional abilities – when they do not think someone is watching.

 

The first and most important step in hiring a service provider to assist with this activity is to find someone who is credible, ethical, and experienced.  Failing to take these factors into consideration can result in adverse findings.

 

 

When Should Surveillance be Used?

 

Not every case requires the use of a private investigator.  Instances where surveillance in workers’ compensation can either be helpful or have an effective impact include the following:

 

  • Instances where credible information of fraud is received and the injured employee’s movements and activities need to be closely monitored;

 

  • Cases where the employee is working an unreported second job or engaging in “cash” driven business activities. This can include employees who might be more active in certain times of the year;

 

  • Claims involving employees with a long history of work and other personal injuries. “Frequent fliers” should always be given special attention;

 

  • Employee’s who exhibit signs of malingering or are presenting at their medical appointments with conflicting pain complaints; or

 

  • Injuries that occur under unique or interesting circumstances. Examples include the “Monday morning” injury, injuries that occur before or after lay-offs, or during times of labor disputes.

 

 

 

Getting the Right Background Information

 

Background information on the injured employee’s habits is important before using an investigator for surveillance in a workers’ compensation case.  Given the cost and time involved, it is important to know when someone will be at a particular location and at what times.  Information that can be useful and collected via discovery can include:

 

  • Dates and times of doctor appointments;

 

  • The date and location of the independent medical examination or various workers’ compensation proceedings;

 

  • Places where the employee frequents such as attending religious services, social events and clubs, and restaurants or sporting events; and

 

  • Hobbies and other activities such as gardening, other yard work, or coaching a sports team.

 

 

Other Sources of Free Information

 

The advent of the Internet has created a treasure trove of free information.  This includes where they were born, lived (including specific address), and photographing or postings commonly found on social media.  Members of the claim management team who use social media for background information on an injured employee should be mindful of some simple rules:

 

  • Research on information open to the public is generally fair game when it comes to access by an adverse party. If someone does not closely lock down their security settings on platforms such as Facebook, Twitter, or Instagram, the information in the public domain can be used;

 

  • Use of a third party or “straw man” to connect to an injured employee is generally unethical and can result in information obtained from the query to be inadmissible; and

 

  • Asking for passwords from an injured employee is illegal in some states. That does not prevent defense counsel from bringing a motion to compel to obtain a court order for passwords.  Case law in this area is developing.

 

Interested stakeholders should look beyond social media and access genealogy websites.  Again, if information is published online and not obtained via mischievous means, it will likely be admissible.  Any useful information online should be printed and/or electronically stored immediately.  This is because information can be deleted, removed, or locked down just as quickly as it is posted.

 

 

Conclusions

 

Surveillance in workers’ compensation will always be a part of strong defense. When used, it should be done in an ethical and legal manner.  It must also be used in a cost-effective manner to avoid excessive spending and preserving the stability of a workers’ compensation 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.

Successfully Communicate With Your Work Comp Claims Adjuster

5 Workers’ Comp Communication Strategies to Ramp Up Your ProgramA good insurance adjuster can help minimize the costs of a workers’ compensation claim. For your adjuster to do their best job for you, you must give to and get from them thorough information. You must completely document workers’ compensation claims, starting at the time of the injury. As your employee recovers or even worsens, you need to have every step in the process documented. Because a proactive adjuster will coordinate and manage the employee’s medical care and return to work, you need to maintain contact with the adjuster to check on the claim status of your employees’ comp cases.

 

 

Communication is Key

 

After your initial contact with the adjuster following the injury, you must periodically have follow up communication. A good adjuster is a good communicator that documents all contact. Open communication allows for the exchange of information between the employer and adjuster about the claim and ideas on assisting the injured employee while moving the claim forward. The best adjusters completely document each phone call, e-mail, medical bill, medical report, attorney letter, state filing, etc. in their files.

 

The adjuster also needs to have good communication with the injured employee. When an adjuster establishes rapport with an injured employee early on in the process, the probability of future attorney involvement is decreased. The adjuster will also be better able to identify any compensability issues and to make timely payment of benefits. In a severe claim, early employee contact will help with immediate medical management.

 

Use a contact form designed to gather information. Initially, you should use the form for a live interview. On subsequent contacts, you might want to continue to have live conversations rather than just having the adjuster fill out the form. This allows both of you to sign off on the document.

 

We have a form that will help you to remember to ask all appropriate questions in every case. You will also be using the same language each time you have a workers’ compensation claim. This will remove individual personal differences from what should strictly be a professional arrangement.

 

 

Gathering Information

 

Include all the basics. Even if this information is documented elsewhere, it is important to include all basic data. It is easy for a simple mistake or misread number to be repeated if just copied over and over. These typographical mistakes can lead to big hassles in getting employee medical records if not corrected. Be sure to include:

 

o Employee social security number

 

o Date of injury

 

o Your company name

 

The employee’s current condition. The adjuster should be informed about the injured employee’s current medical condition and whether the injury requires physical therapy or surgery.

 

The employee’s medical history. The adjuster needs to know about the injured employee’s medical history as this may affect the causality of the injury, the course of treatment and what a typical timeline for recovery may be.

 

The relationship with the doctor. Ask the adjuster what their relationship is with any medical providers and whether thorough communication is being provided.

 

Claim validity. Document if there are any questions as to the validity of the claim and about the employee’s attitude about returning to work.

 

Specific time deadline. Give your adjuster a deadline, no more than 24 hours in advance, for the adjuster to get back to you with specific suggestions as to how to resolve the case.

 

 

Workers’ Comp Cost Containment Program

 

Your adjuster can also help you implement your workers’ comp cost containment program. Once you implement your program, gain your adjusters’ cooperation and participation by telling them you appreciate them.

 

 

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.

 

Expertise of Senior Nurse Reviewers Generates Work Comp Savings

when to use nurse case managementComplex and severe injury claims are a leading driver of workers’ compensation claims costs. The greater the complexity and severity of an employee’s injury the larger the number of medical providers involved in the medical treatment. The primary physician often engages other specialists, therapy services, diagnostic testing, pharmacy usage, etc. The result of involving many different medical providers in the injury claim is the primary physician is often not fully aware of all aspects of the injured employee’s medical treatment.

 

 

Doctor Standard Treatment Protocol Not Designed in Employees Best Interest

 

A primary doctor has many individual patients, making it difficult to impossible to spend the time evaluating the overall best course of medical treatment for a particular injured employee. To compensate for the limited amount of time a physician can spend with any one patient, it is the doctor’s normal practice to follow a standard protocol for each injury type. These standard treatment protocols tend to have various built-in tests and procedures designed not in the best interest of the injured employee but designed to protect the doctor from claims of negligence and/or medical malpractice when the injured employee does not achieve expected results.

 

 

Senior Nurse Reviewer Provides Medical Expertise to Help Adjuster Make Good Decisions

 

Workers’ compensation adjusters often wonder if all the diagnostic tests, therapy sessions, injections, prescriptions, and repetitive office visits are really worthwhile. Adjusters, not being trained medical professionals, may doubt the need for various medical procedures and attendant costs but are without the skill set needed to discuss with the primary medical provider the various medical services being utilized. Fortunately, there are workers’ compensation medical professionals – senior nurse reviewers – who have the expertise to review with the primary medical provider, and all other medical service providers, the need for each medical service provided to the injured employee.

 

Senior Nurse Reviewers – nurse case managers with the highest level of medical expertise and experience – assist employers, adjusters, medical providers, and severely injured employees with guidance and coordination of complex injury claims. By overseeing the medical care and coordinating medical treatment, the senior nurse reviewer reduces or eliminates unneeded medical services while the injured employee receives all necessary medical services promptly.

 

 

A senior nurse reviewer reduces claim costs in a variety of ways, including:

 

• Assisting the injured employee in the navigation of the medical universe.

• Facilitating communication between the injured employee, the medical providers, the adjuster, and the employer.

• Creating a care plan for the injured employee and updating the care plan as needed.

• Questioning and addressing unnecessary medical treatment.

• Keeping all medical care on track, eliminating delays in treatment, thus reducing the time the injured employee is off work.

• Coordinating the timely delivery of diagnostic testing, therapy, and medical appointments with other medical specialists.

• Providing on-going case oversight to eliminate unnecessary medical services.

• Identifying and addressing obstacles to the employee’s recovery.

• Addressing any deviation from established disability duration guidelines.

• Facilitating the quickest possible light duty or full duty return to work for the employee.

 

Senior nurse reviewers are not physicians but nurses with many years of experience. If the senior nurse reviewer and the medical provider disagree on what is the best interest of the injured employee, the senior nurse reviewer turns to doctors and medical specialists, who have contracted with the senior nurse reviewer’s company to provide a high level of expertise within their medical specialty. The senior nurse reviewer then has the contracted medical specialist consult with the injured employee’s doctor on a peer-to-peer basis to arrange for the best course of medical treatment for the employee.

 

 

Overall Impact of Senior Nurse Reviewer is Reduction in Claim Costs

 

The overall impact of using a senior nurse reviewer on complex and severe workers’ compensation claims is a reduction in the employer’s overall claim costs. The use of senior nurse reviewers results in two types of savings:

 

• Lower indemnity cost by the injured employee quicker return to work.

• Lower medical cost by eliminating unnecessary medical services.

 

For assistance in locating a senior nurse reviewer for your complex and/or severe claims, please contact us.

 

 

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.

The 411 on Functional Capacity Evaluations

functional capacity evaluationA functional capacity evaluation (FCE) is a comprehensive series of test administered by an occupational therapist or a physical therapist who has had specialized training in performing a FCE.  The tests are specifically designed to measure:

 

  • stamina
  • dynamic strength
  • mobility
  • flexibility
  • body mechanics
  • cardiovascular condition
  • balance
  • coordination
  • dexterity
  • ability to tolerate functional activities

 

Used to Determine Employee’s Readiness to Return to Work

 

In workers’ compensation claims, a functional capacity evaluation is often utilized to determine the injured employee’s physical readiness to return to work and to measure any physical limitations the employee will have as a result of the work comp injury.  A FCE can also be utilized to determine the injured employee’s physical capabilities for vocational retraining when the injured employee will be permanently unable to return to his/her prior vocation.

 

A functional capacity evaluation can be one of two types, either a job-specific FCE or a general purpose FCE. In a job-specific FCE, the therapist is provided a detailed job description prior to the testing in order to tailor the FCE to the specific job of the employee.  To have a very accurate FCE, the therapist should visit the job site to have a detailed understanding of the functions of the job.  In a general-purpose functional capacity evaluation, the testing measures the employee’s strength and tolerance in completing standardized or common work task.

 

 

 

Test Can Last Several Hours to Two Days

 

After a determination of the type of FCE, the appointment date is scheduled for the injured employee.  An FCE can last from several hours to two days, depending on the nature and extent of testing.

 

At the start of the functional capacity evaluation, the therapist will perform a comprehensive interview of the injured employee.  The interview is designed to identify any factors that could impact the employee’s ability to participate in the FCE.  The therapist will want to know if the employee has any issues with asthma, COPD or other lung/breathing problems, high blood pressure, physical limitations besides the work comp injury, and obtain the employee’s own assessment of their physical condition including the employee’s perception of his/her pain level.

 

 

Measure Various Physical Tests

 

In conjunction with the interview, the therapist will complete a clinical assessment of the employee to establish a baseline for the FCE.  The therapist will measure the employee’s range of motion, balance, grip strength and coordination to establish the testing plan.

 

In a job-specific FCE the therapist will measure the employee’s ability to lift, carry and perform other tasks in comparison to the performance levels identified in the employee’s job description guidelines. In the general purpose FCE, the therapist will measure the employee’s maximum ability to lift, carry and perform routine work-related task.

 

 

 

5 Categories of Physical Demands

 

The U.S. Department of Labor characterizes jobs in 5 categories depending on the physical demands of the job.  For instance, an over-the-road, or long-haul truck driver is classified as a “heavy” physical demanding job.  The 5 categories are defined as:

 

  • Sedentary:  exerting up to 10 pounds of force occasionally

 

  • Light:  exerting up to 20 pounds of force occasionally or up to 10 pounds of force frequently

 

  • Medium:  exerting 20 to 50 pounds of force occasionally or 10 to 25 pounds of force frequently

 

  • Heavy:  exerting 50 to 100 pounds of force occasionally or 25 to 50 pounds of force frequently

 

  • Very Heavy:  exerting in excess of 100 pounds of force occasionally or in excess of 50 pounds of force frequently or in excess of 20 pounds of force constantly

 

 

If the therapist is performing a general purpose functional capacity evaluation on a truck driver, the therapist would determine the truck driver’s job is a “heavy” physically demanding job. The general purpose FCE testing would measure the employee’s ability to meet the requirements of the “heavy” job classification.  However, some truck drivers are “drive and drop” drivers where they never touch the cargo.  The hardest part of their job is cranking the landing gear of the trailer up and down and disconnecting the fifth-wheel.  Their job requirements would fall in the “medium” job classification for physically demanding.  Therefore, when there can be different levels of physical effort needed for a job title, it is to both the employer’s and the employee’s benefit to provide a detailed job description to the therapist and to request a job-specific FCE.

 

 

 

Biggest Issue is Validity of Effort by Injured Employee

 

The biggest issue with FCE is the validity of the effort put forth by the injured employee.  If the injured employee has been advised by his/her attorney that the better they do on the FCE, the lower their permanent partial disability settlement will be, the employee is given a financial incentive to put forth less than their best effort.  If there is any concern the employee may not make a sincere effort in the FCE, the therapist should be advised prior to the FCE.  The therapist can give the employee several different tasks or activities that measure the same physical ability.  If the test results reflect a variation in the employee’s ability within a specific category when measured by two or more different methods, the therapist will be able to identify the employee who is trying to game the testing and include in their post testing report the fact that the effort put forth by the employee was inconsistent.

 

 

 

Results Compared Against Specific Job Description

 

When the FCE testing is completed, the therapist will compile the employee’s test results.  The test results will be compared against the specific job description requirements or the general physical level classification of a job to see if the employee can return to performing the job. The results of the FCE are then reported to the treating doctor and workers’ compensation adjuster and/or nurse case manager.

 

 

 

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.

Confusion and Workers’ Comp Abbreviations Can Add to Costs

Creating confusion costs you money. Creating confusion costs you and your organization or your clients organization money. Hello, my name is Michael Stack, I’m the CEO of Amaxx. And today I want to talk with you about the language we’re using to communicate with our injured workers. The language we’re using to communicate with our injured workers. Are you causing confusion? Are you causing them to be fearful of the words you’re using?

 

 

Workers’ Comp Abbreviations and Confusion

 

So let’s go over an example. Say an injured worker gets hurt and you tell them, “We’re going to pay you TTD until the time at which point you’re able to return to work. And then we’re going to work on your medical until you reach MMI. And then at that point, you may need to go see an IME in order to help us establish a permanency rating to settle your case. And depending on the severity of your injury, you may need to then apply for SSDI.” Excuse me? I’m sorry, what was that that you said? We tend to forget that the terminology and the abbreviations and the words that we’re using that are specific to our industry, just like any other industry, are not commonplace among everyone else outside of our industry.

 

 

Clear and Simple Communication

 

So I want you to establish this idea of clear and simple communication. First off, are you calling your injured workers or injured employees claimants? Does that sound very nice? Does that present a very welcoming picture that you’re going to take care of them, that there’s going to be an established level of trust? I think not. So let me challenge your communication and that verbiage that you’re using.

 

Next piece, I want to outline very simply for you this employee brochure. So when an employee gets injured, you want to establish that trust, that communication right out of the gates. I want to give you a little bit of framework, three-part framework here, or simplified three-part framework for this employee brochure. And you can download this value piece below here, The Nine Elements to Employee Brochure, that I’m going to dive into this a little bit deeper. I want to outline this very quickly.

 

 

Set Expectations with Employee Brochure

 

So first off, first piece, you want to establish when an employee gets injured, even before they’re injured, the time prior you’re going through this with them and then at the time of injury you’re running through it. Work comp 101, what it is, what they can expect from you as far as their benefits. This includes, their wages, how are they going to get paid and are you calling this an indemnity, are you calling it wages? A lot of people don’t know what the heck indemnity means. So are you calling it your wages or wage loss? Your medical and their pharmacy, how are they going to get medical treatment? How are they going to get their prescription drugs et cetera. Establish these expectations. What does it look like as far as return to work? And don’t call it RTW, call it returning to work, getting back it the workforce. Use language that makes sense to people that are not in the work comp industry.

 

And then lastly, what you expect of them. We expect you to report to work, this is an established part of our organization, we expect you to communicate with us, we expect you not to commit fraudulent acts, et cetera, et cetera. You establish this expectation right out of the front using simple words that everyone can understand and it’s going to get you off to the races as far as getting that claim going in the right direction.

 

Again, my name is Michael Stack, I’m the CEO of Amaxx. And remember, your work today in workers compensation can have a dramatic impact on your companies’ 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.

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