Surveillance is Often Used Incorrectly

Surveillance is Often Used Incorrectly

Members of the claim management team need to be creative when investigating workers’ compensation claims and to determine issues of compensability.  This includes using claim investigation techniques that go beyond interviewing the employee, witnesses, experts, and reviewing medical records.  To be effective, proactive claim handlers and investigators need to do a deeper dive to reduce program costs.


Surveillance is Often Used Incorrectly

Over the years, defense interests in the workers’ compensation industry have become dependent on using private investigators to conduct surveillance on an injured worker.  Surveillance is a recommended and effective technique. However, it is often :

  • Limiting surveillance to one day: The problem is this provides only a Not obtaining of what the employee is doing and allows for them to argue you watched them on “a good day;”
  • Not obtaining complete background information on the employee: This includes not knowing the habits of an employee and what activities they might be doing when under the watchful eye of an investigator. In worst case scenarios, the employee will do nothing at all – not even coming outside their home; and

  • Following the rules: Many jurisdictions have specific timelines as to when and how documentary evidence from surveillance needs to be disclosed to the employee and/or their attorney.  Failure to follow these rules can have significant consequences.



Using Other Resources to Uncover Favorable Claim Information

Claim handlers need to be creative and ethical when uncovering information on a claim and developing their theory of the case.  This requires patience, persistence, and creativity.


Job Site Videos

Job site videos are useful in a number of ways when done.  For example, if an employee is claiming that a certain activity (especially those that require repetitive movements) is includes using of an injury, it allows for a medical expert to evaluate whether be effective of injury is consistent with the objective medical evidence.  It also reduces or eliminates the ability ofan employee to exaggerate movements, including the frequency at which it is performed.

When creating such videos, it is important to remember key items.  This includes having a workplace station or machine set up exactly how it was at the time of the injury. When possible, have the employee to perform the motions or movements.  If this is not possible, itis essential to have someone of a similar size perform the activity.  Failure to exactly recreate these motions in question can result in the job site video not being admitted into evidence at the hearing.


Timing and Work Schedules

Records documenting the coming and going of an employee, an employee and the number of shifts they worked can be relevant in a number of circumstances. Instances when this can be useful include the following circumstances:

  • Claims made by the employee as to their physical presence at a location at a specific time, or when other identified witnesses claim to have been present;

  • The number of hours or shifts worked by an employee.  This is important information to have in workplace exposure cases; and

  • Tracking movements of traveling employees. This can be important when trying to determine the applicability of “portal-to-portal” coverage where an employee may have made a personal deviation, which took them outside the “course and scope of” their employment



Social Media Investigation


While fewer Americans are using social media platforms on a consistent basis, it is still relevant to any claim investigation.  Key points to remember include checking common programs such as Facebook, Twitter, and Instagram.  Ethical considerations apply.  Do not obtain access to an employee’s account under false pretenses or by using a strawman.  Attorneys representing defense interests should also take note of case law that warned, “It should now be a matter of professional competence for attorneys to take the time to investigate social networking sites.” Griffin v. Maryland, 192 Md.App. 518, 535 (2010).


Conclusions

Running an effective workers’ compensation claim program requires hard work and creativity.  In order to be cost-effective, one needs to think outside the box and go beyond the “cookie cutter” approach to investigating and defending workers’ compensation claims.  By looking for alternative methods, members of the claim management team can make better decisions and move cases toward settlement.




Michael Stack - Amaxx

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/

©2018 Amaxx LLC. All rights reserved under InternationalCopyright Law.

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

ACOEM 3-Part Return to Work Framework



ACOEM Whitepaper: Preventing Needless Work Disability by Helping People Stay Employed


Hey, there. Michael Stack here, CEO of Amaxx. One of the most fundamental goals in workers’ compensation is to return our injured employees to work and back to function. I want to draw your attention to a white paper written by ACOEM several years ago entitled Preventing Needless Work Disability. You could find a link to that white paper below. Within that paper, they talk about a three-part framework or a three-step framework to consider return to work on nearly every single workers’ comp claim. I want to walk you through what that framework is when you’re considering return to work for your injured employees.


ACOEM 3-Part Return to Work Framework


The first part is to assess where that current employee is. The next piece is compare. Then, the final piece is to create. So assess, compare, and create. Assess where they currently are. What are their current job restrictions? What restrictions do they get from the physician that say they could only lift 20 pounds or 50 pounds and they can bend this way or stretch this way X amount of times standing, whatever that happens to be? Where do they currently stand? Compare that what the job descriptions are, the physical demands of their actual jobs. You should have a very comprehensive library of what this means at your organization so you can compare one with two. It’s very, very simple when you actually break it down.


Simplicity of High-Level Understanding


Then, the final piece is to create that job. What are those action steps, then, to now put this into practice? Obviously, there’s a lot more depths to each one of these steps. But if you can understand the high level of what it is that we’re actually trying to accomplish, it can ultimately be fairly simple in your mind to now put this all together. So assess, compare, and create. Three steps in the return to work framework in ACOEM’s Preventing Needless Work Disability white paper, which I highly recommend downloading and checking out. It’s a great resource. Again, my name is Michael Stack, CEO of Amaxx. Remember, your work today on workers’ compensation can have a dramatic impact on your company bottom line. But it will have a dramatic impact on someone’s life. So be great.



Michael Stack - Amaxx

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/

©2018 Amaxx LLC. All rights reserved under InternationalCopyright 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 Power of A Personal Note – Legacy of George HW Bush

Hey, there. Michael Stack here, CEO of AMAXX. Our former president, George H.W. Bush, passed away recently at the age of 94. Mr. Bush was a tremendous leader who left a lasting impact and legacy on our nation. And more close to home for me, in my hometown where I live with my family in Kennebunkport, Maine, Mr. Bush and Barbara Bush’s impact on our small town here has certainly been felt.

 

 

Honor Life & Legacy of a Great Leader

 

When we look at the life of a great leader, we look at their legacy. We need to look at what are those lessons that we can learn from them and apply to our lives to improve our outcome, to improve our situation, and more specifically, for our purposes today, improve our work comp programs.

 

 

Power of Personal Notes

 

I want to draw your attention to one of Mr. Bush’s best practices, which was writing personal notes. It’s looked at an old-fashioned practice, but he would write notes to foreign leaders. He would write notes to celebrities if he sat by them at a dinner. He even wrote a note to his granddaughter when his granddaughter was born, and passing around the internet, the letter that he wrote to the incoming president, Bill Clinton, you can see and read the spirit of how he lived.

 

 

Send Get Well Card to Injured Workers

 

When we look at our work comp programs, when one of your employees gets injured, can you take the time to write them a get well card? Say, “Hey, John. I’m sorry you got injured. We look forward to having your spirit back as part of the team as soon as possible.” Something along those lines. Taking the time to put pen to paper, there is no better way through written communication to make that personal connection.

 

It’s not sending a text. It’s not sending an email. There’s something magical about putting that pen to paper and dropping that card in the mail. Take that lesson from Mr. Bush’s life and legacy. Apply it to our programs, and you will see dramatic results.

 

Again, I’m Michael Stack, 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/

 

©2018 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.

 

Avoid Workers’ Comp Penalties and Other Pit Falls

Avoid Workers’ Comp Penalties and Other Pit FallsMembers of the workers’ compensation claims management team are on the front line when it comes to investigating a claim and making timely payments of benefits.  Failure to do so can result in penalties to a workers’ comp program and cause interested clients to lose confidence in the process.  Transparency and consistency are key.  Now is the time for all claim handlers and their managers to better understand the various rules and requirements in jurisdictions they handle, apply these procedures correctly and make good faith determinations to avoid common pitfalls in the claims process.

 

 

Common Errors that Result in Workers’ Comp Penalties

 

Many rules govern workers’ compensation insurers and third-party administrators.  It is important the claims management team understands these rules and make proper determinations.

 

  • Frivolous Denial of Liability: Denials of primary must state why a claim is being denied.  This includes stating a factual and legal basis for not paying on a claim or deny specified treatment.  This can also include a failure to fully investigate a workers’ compensation claim in a good faith manner or make inaccurate statements following the investigation.

 

  • Nonspecific Denial of Liability: Denials of primary liability must also be specific.  The requirements to avoid this type of penalty vary, but generally, denials must be sufficiently specific to convey clearly, without further inquiry, the basis for the denial.  Denials based on the premise that the injury did not “arise out of and in the course and scope of employment” must also include additional information supporting this position, so the injured employee knows why a matter is not being paid by the insurance carrier.  Avoid excessive “legalese” when denying a matter.

 

  • Late Denial of Liability: Applicable laws generally require a determination to be made promptly.  In many instances this is between 10-14 days.  When a member of the claim management team receives a reported injury, it is important for them to determine the first day of disability and when the employer received notice of disability.  Knowing this information can ensure the claims professional issues the denial promptly.

 

  • Late Filing of First Report of Injury (FROI): The employer plays an important role in completing the FROI.  This is important as most state workers’ compensation laws require this form be completed and filed with the industrial commission in a timely manner.  Claim handlers must ascertain when the employer receives notice of the injury or disability to determine when the FROI must be filed in a timely manner.  An effective claim management team should help train employers on these issues to avoid delay and penalty.

 

  • Late First Payment of Benefits: There are also time requirements for the insurance carrier or administrator must make payment on admitted claims.  Important information for the claim handler to know to avoid a penalty for late payments includes: the first day of disability, when the employer received notice of the injury or disability, if the employer is paying the ongoing employee wages, and requirements regarding the payment of wage loss benefits.  Coordination and cooperation are

 

 

Other Prohibited Claims Practices

 

Workers’ compensation insurance carriers are also required to operate honestly and ethically.  This includes not acting in bad faith.

 

Insurance carriers that operate fraudulently may be subject to discipline by a state commerce department.  When underwriting workers’ compensation insurance policies, it is important carriers, and administrators follow through on contractual promises and provide what is covered under the policy.  Failure to do so can result in a carrier not being able to sell insurance in a state or subject to other sanction.

 

In the same regard, an insurance carrier should avoid bad faith tactics.  This includes not dealing fair with parties subject to an insurance contract.  This duty is known as the “implied covenant of good faith and fair dealing.”

 

 

Conclusions

 

Members of claim management teams and their insurance carriers have a contractual and ethical obligation to serve their insureds.  This is accomplished by following the rules established under a workers’ compensation statute that require good faith claims practices.  Failure to do so adds to the costs of a workers’ compensation programs and can jeopardize a carrier’s ability to underwrite workers’ compensation policies.

 

 

 

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/

 

©2018 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.

12 Questions and Metrics to Assess Work Comp MSA Cost Drivers

12 Questions and Metrics to Assess Work Comp MSA Cost Drivers A thoughtful and critical review of your Medicare Secondary Payer (MSP) compliance program is a great exercise to perform annually.  Consider these questions and metrics:

 

 

Questions & Metrics to Assess Work Comp MSA Cost Drivers:

 

  • What percentage of your Medicare Set-Aside (MSA) submissions are accepted?
  • Can you identify the biggest cost drivers in your MSAs?
  • What percentage of your CMS approved MSAs include opioids?
  • What percentage of your approved MSAs include any pharmaceuticals?
  • What is the average cost of prescription drugs on MSAs?
  • Do you understand why CMS approves/denies MSA proposals?
  • Are you overfunding/underfunding MSAs? How do you know?
  • Do you know what documentation you need for approval of changes in medical treatment or pharmaceuticals?

 

If you were not able to confidently answer the questions above it might be time to make some changes to your MSP compliance program. Some claims and risk managers put together a program, let it run and hope for the best. Instead, using data analytics and continuously tracking outcomes and other performance indicators can significantly improve the process of preparing and submitting MSAs to the Centers for Medicare and Medicaid Services (CMS) — especially, where pharmaceuticals are concerned.

 

 

MSP Through the Years

 

It’s been approximately 15 years since the government ramped up its efforts to ensure Medicare doesn’t pay for medical services that should be funded by some other entity, including the workers’ compensation system.  At the time, organizations scrambled for ways to develop MSAs that would be approved by CMS.

 

The process for CMS approvals has evolved over the years. What was a fairly complicated system, to begin with, has turned into an extremely intricate series of steps that can befuddle even the most competent people in the industry – unless they have the benefit of highly advanced technological solutions combined with strong expertise.

 

For example, in addition to new regulations from CMS, state statutes and fee schedules are also constantly changing. Failing to keep tabs on them can make the process time consuming, costly and fraught with peril.

 

In the past 18 months, CMS has taken steps to intensify its efforts further. The agency has put millions of dollars into a new contractor and greatly updated its technology, making the process of identifying mistakes that much quicker and easier. It means anyone trying to stay in compliance with Medicare also needs to improve and upgrade their systems.

 

 

What the Metrics Can Tell Us

 

Most workers’ compensation payers would agree that pharmacy is the biggest cost driver for their MSAs. However, few know the answers to these key metrics:

 

  • What is your current pharmacy spend on MSAs?
  • What percentage of your CMS-approved MSAs include opioids?
  • What percentage of MSAs are approved with or without drugs?
  • What is the average cost of prescription drugs on your MSAs?

 

With medications comprising such a tremendous portion of MSA costs, it’s vital to have a clear understanding of the issue. This can only be accomplished by focusing on the metrics. By analyzing the data on opioids as well as other pharmaceuticals in terms of your MSAs that are approved, you can then begin to fully manage these costs.

 

 

Optimizing MSA Outcomes

 

Whether working with an MSA vendor or doing Medicare compliance on your own, several strategies are a must for success.

 

  1. Identify metrics that drive the results you want to see, particularly where medications are concerned.
  2. Measure your performance and modify processes, workflow, and technology to improve it. For example, look at the percentage of your MSAs with ongoing medical to see how much you have allocated for opioids. If the answer is anything more than zero, go back to the drawing board.
  3. Examine current CMS performance and the most recent state statutes and fee schedules against CMS’s review methodology as defined in the most recent Workers’ Compensation MSA Reference Guide. If/when there are changes, update your system immediately. Once developed, this should be a simple verification, audit and sign-off process.
  4. Analyze every CMS response against your internal best practices in MSA allocation, with a focus on pharmaceuticals and opioids. You want to know how you are performing against CMS in such areas as pricing, frequency and life expectancy.
  5. Leverage Section 111 data to improve the CMS approval rate of MSAs.

 

To truly effect change in your Medicare compliance program requires examining certain metrics and taking steps to manage them best. For example:

 

  1. What is the number of Medicare conditional payment searches and investigations initiated and the success rates for disputes and appeals, including dollars saved?
  2. What type of clinical interventions have been initiated, what is their success rate and the average dollar amount saved because of them? This strategy can save many thousands of dollars per claim. Investigating each claim with an eye toward medical procedures anticipated and/or pharmaceuticals can yield surprising results. You may find, for example, a doctor is prescribing a medication the injured worker no longer takes or has never taken; so removing that drug from the future medical amount is an easy change.
  3. What is the percentage of submissions to which CMS has countered with a higher dollar amount? A lower dollar amount? If there is a high percentage of either, you need to understand why there is a trend and how to counteract it.

 

You want the injured worker to have adequate funds for his lifetime needs related to the injury, but you don’t want to pay unnecessarily high costs. Often the projected expenses are way too high, or the therapy is not within evidence-based medical guidelines.

 

The best MSA developers can fully assess exposure before the proposal is submitted. They can spot inappropriate or unnecessary treatment and pharmaceuticals AND take steps to curb them such as physician peer-to-peer discussions, for example.

 

 

Conclusion

 

Paying too much for anything does not make sense. But, that’s exactly what happens far too often because many workers’ compensation payers don’t take advantage of advanced technologies in developing MSAs. Using metrics and data analytics and working with an MSA expert can help ensure injured workers get what they need and deserve without payers going overboard.

 

 

 

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/

 

©2018 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.

Fix and Flip Your Work Comp Management Program

Fix and Flip Your Work Comp Management ProgramIn the popular TV show Property Ladder, real estate junkies seek to find homes in need of repair, fix them and then flip it for a profit.  Like the show, members of the claims management team should be on the constant look-out for parts of their program that need to be improved to increase client satisfaction and ensure it is being run ethically and honestly for the ultimate stakeholder – the employee!  This takes a lot of hard work, but the ultimate result can improve the satisfaction of clients and improve the experience for persons who have sustained a work injury.

 

 

Finding a Home to Renovate – Effective Injury Response

 

Like a broken home, the employee who suffers a work injury is in need of help and tender loving care. A fast and effective response to every work injury, no matter how minor, can pay dividends in the future.

 

All workplaces need to have a plan in place to deal with work injuries.  This includes the accessibility of first aid kits and other medical equipment.  Factors to consider include having a plan for all types of injuries and emergencies, making employees aware of the plan and proper implementation.  Do not forget that even if your company is not required to have one, the inclusion of a safety chair and emergency response team can assist in a program renovation.  This team can be used for the following tasks:

 

  • Maintenance and use of various fire extinguishers;

 

  • Knowledge and ability to perform cardiopulmonary resuscitation (CPR);

 

  • Understanding on how to contain and dispose of bloodborne pathogens;

 

  • Proper chemical handling, storage and containment procedures; and

 

  • Dealing with and responding to incidents involving hazardous materials and workplace fumes.

 

Other items to consider should include teaching employees basic first aid and other features such as lifesaving equipment that can include a portable defibrillator.

 

 

Fixing Up the Property – Workplace Ergonomics and Safety

 

A great way to ensure a safe workplace should include a review of workplace ergonomics.  This can include features such as assessing risks in the workplace on an ongoing basis, correcting the problems and encourage physical health.  Suggestions can include:

 

  • Onsight or easily accessible health clinics that include vaccinations, immunizations, and wellness information;

 

  • Encouragement to use a gym or health club – be sure to include discounts on medical insurance for frequent users. Onsite stretching activities, yoga, and mindfulness can also promote a safe work environment; and

 

  • Training on preventing and dealing with workplace violence and “active shooter” situations.

 

 

Flippin’ the House for Profit – Ongoing Employee Satisfaction

 

Like a completely remodeled home, a workers’ compensation program that is in pristine shape will add value and create its own demand.  This will improve company morale and improve return to work rates following an injury.  Interested stakeholders should look for opportunities to add value through a workers’ compensation program’s “curb appeal.”  This can be accomplished by promoting medical and behavioral health consultations to assist employees manage their lives in and outside the workplace – and enhance one’s work/life balance.

 

Addressing the needs of employees mental health needs is important in today’s fast-paced society.  This is especially the case when employees work during a clinic’s hours of operation.  By making these services available to employees on-site or at a convenient location, people are more willing to receive the care they may need.

 

Addressing the mental health needs of all employees are important both before and after a work injury.  Studies suggest that people who receive mental health counseling following a work injury have a lower chance of re-injury or malingering.  This translates into lower workers’ compensation insurance premiums.

 

 

Conclusions

 

Members of the claims management team should seek to climb the property ladder to add value and reduce costs to a workers’ compensation program.  This includes simple steps that can be taken to renovate a program, make it better and increase its value.  When a program is strong, it also adds value to the clients it serves.

 

 

 

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/

 

©2018 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.

Five Clues an Injured Employee is Dragging Out Their Workers Compensation Claim

Five Clues an Injured Employee is Dragging Out a Workers Compensation ClaimNow and then one comes across a claimant who knows the twists and turns of the workers’ compensation system. The claimant could be a dependable and good worker, but the employee is dragging out their workers’ compensation claim.

 

The insurance industry calls these people “career claimants.” When a background check is done, they have a list of prior claims a mile long. Having many prior claims does not necessarily mean they are bad workers; perhaps they are injury-prone. It is very interesting, however, when claims are filed, they are sneaky enough to do just enough to keep the wheels turning and drag out their workers’ comp claim to remain out of work or on medical restrictions. Odd how that happens…

 

Adjusters can use their defensive tools to get these claimants off workers comp. Even when adjusters do IMEs, surveillance, and speak with the physicians providing the treatment, nothing seems to get this type of worker back to full duty.

 

When claimants know too much about how the system works, they drage out their workers’ comp claim by:

 

 

  1. Having the Physician on their Side 

 

Physicians usually base opinions on evidence-based medicine. Tricky claimants know what to tell and what not to tell the doctor. They use the Internet as an information source. For example, if someone sustains a back strain, acceptable symptoms are researched to report without over-exaggerating the symptomology to cause the treating physician to see red flags.

 

Limited range of motion, muscle spasm, and bringing up pain complaints tell a doctor if the person is or is not hurt. The doctor proceeds presuming the patient is reporting honesty and may keep the patient on restrictions, on continuing treatment, and off work. This is where the independent medical examination (IME) comes into play. It is always good to have another opinion just in case the treating doctor is not being proactive in moving the patient along to full duty, especially if the subjective complaints do not match the objective evidence on examination.

 

 

  1. Rescheduling Doctor and Physical Therapy Appointments

 

Everyone has a life outside of work. However, constant rescheduling of medical appointments is a red flag for the adjuster. Maybe now and then a physical therapy appointment is missed, especially when working light duty. But, it is important to remember legitimately injured workers want to get treatment, heal, return to full duty, and not drag out their workers’ comp claim.

 

A typical lumbar strain does not necessarily prevent a person from being active or running errands, but if a trend arises of constant rescheduling — THINK — what else is going on besides the injured worker’s schedule? Surveillance is a handy tool to confirm suspicions. It is especially helpful if the injured worker is caught in a lie. If the worker reports to the adjuster therapy is missed even when off work and surveillance shows the employee doing yard work instead of going to physical therapy, that is evidence to suspend the claim due to non-compliance with the treatment plan provided by the doctor.

 

Hot Tip: One therapy office has a policy of charging the patient the full amount of the missed appointment unless given 24-hour notice. They present patients with this written policy at the beginning of therapy and make them sign indicating they understand they will be charged and their insurance will not be billed.

 

 

  1. The Claimant Knows the Lingo

 

One thing jumping right into the adjuster’s face is a claimant knowledgeable about the injury in medical terms. The average person does not use words like radiculopathy, impingement, and stenosis or know what they mean.

 

Even more striking is when a worker discusses a settlement or redemption early on in the claim. This behavior should lead the adjuster to believe the worker has been down the workers’ comp claim road before. Most times, when a background check is done, it shows prior litigation experience with prior employers. These are all red flags indicating you want to keep an eye on this claimant as they may be dragging out their workers’ comp claim.

 

 

 

  1. The Claimant is Off Work and Cannot be Found

 

When a claimant has a legitimate injury and is off work for a while, it is a good idea to do surveillance to get additional information. After a few days, if the video only shows the worker poking a head out of the front door to retrieve the mail, it is always a red flag. The person may have a prior claim history, broke restrictions, and the claim was denied or suspended.

 

Or even worse, when you go to do surveillance, the worker cannot be found anywhere. The worker might be staying at another location or at another property. When you talk to the employee, excuses are made about how pain is so disabling all that can be done is to stay home and rest. However, something is awry if you go to do surveillance and the car is not in the driveway.

 

 

 

  1. The Worker Misses a Few Therapy Appointments Every Week

 

Remember, injured workers with legitimate injuries want treatment so they can heal, return to work, and not drag out their workers’ comp claim.  In a red flag claim when a person goes to some treatment, but not all and not all the time, this means they are doing just enough to keep the claim alive, but missing just enough treatments not to get better.

 

The unsaid rule in claims is the longer a person is off work, the harder it is to get them back to work. This challenge is where a light-duty work program comes in handy. Light duty forces the worker to go to work. It also forces them to go to treatment, especially if one has to leave work to go to therapy and then return to work to finish the shift.

 

Doing just enough to keep the adjuster from disputing the claim shows the claimant knows a little bit about how the claims system works. As an adjuster, if a person makes 75 percent of the medical appointments, is that going to stand up in court if you pull the trigger and file a dispute or suspension?

 

 

Summary

 

Just one of these points does not mean your employee is cheating you and trying to drag out their workers’ comp claim. But, some smart claimants know how to work the system. If, as the adjuster, you spot one of these claims, it is your role to stay on top of every aspect of the claim. Make sure if workers miss appointments they have some documentation to support absences. The more pressure you put on them, the better result you will have in defeating unethical claimants at their own game.

 

 

 

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/

 

©2018 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.

5 Ways to Get the Most Out of Your Workers’ Comp Adjuster

Get the Most Out of Your Workers’ Comp Adjuster Depending on past experience with workers’ comp adjusters, you may or may not have an accurate picture of their daily work life. Every adjuster has a unique style. Sometimes that style meshes well with the way with an employer’s way of doing business and sometimes it may not. Whatever the personality may be, the adjuster has the same goal the employer does. And that is to move the claim to resolution by return to work, release from medical care, or to redeem the claim through litigation if needed.

 

A good percentage of workers’ comp adjusters have multiple insureds (employers) they work with, in multiple states. Some of these insureds are very demanding, and some are not.   Some are very open to new ideas to get injured workers back to work, and some are not. The adjuster is always a chameleon, blending the personality and way of working to match what the insured wants while at the same time trying to read and gauge the claimant to judge for any indication that there may be more to the injury than what appears on the surface.

 

Whatever the personality or work ethic of the adjuster that handles the account, below are 5 ways to get them to work harder. Working as an adjuster handling work comp claims is a very stressful, demanding, high exposure, and thankless job. In any scenario, the adjuster will do what it takes to get the job done on the files, but these 5 little tidbits of info we discuss below may be able to maximize the adjuster’s role.

 

 

 

The First Report of Injury is the first info the workers’ comp adjuster reviews when assigned to a new claim. Nothing irritates them more than having a lot of missing information. It almost can reflect the way the claim is going to unfold during the investigation. If an adjuster sees a half-completed injury report when they call and ask you about the details of the injury they are expecting the employer not to know anything about it. Completing the injury report will reflect the employer’s professionalism to the adjuster. Another insured may complete every line, and the adjuster will view that as “This insured is very detailed and involved and will be watching every move I make, so I better make the right moves to impress them right off the bat.”

 

 

Plus the adjuster has to obtain a lot of that information anyway. So it will save some time on the phone call if as an employer, you obtain the information before submitting the claim into the adjuster. State reporting requirements will demand the date of birth, social security number, complete address, and other additional info. So take the extra 10 minutes and complete the State injury form. This way the adjuster can get a good idea about what happened and can hit the ground running for the start of an investigation.

 

 

  • Stay involved and open to ideas

 

Not every employer is the same. They are different sizes, different types of people, different demands, and different cities. Everything is different, and this makes being an adjuster that much more difficult. The adjuster may not know that the employer does not have any light duty work at  the shop, but how deep have you as the employer looked? The adjuster may have ways to sneak a few of these guys back to work, and that will save the employer money. The adjuster’s job is to get injured workers back to work. Most of the time the roadblock to obtaining this is the employer, not the injured worker.

 

Let the adjuster come out to the shop (if they are local) and let them walk around and evaluate things. Talk a little bit about the other types of jobs you do that your injured worker may be able to do. Discuss not only full-time jobs but part-time as well. Part-time work is overlooked a lot, but any sort of savings is worth it. 10-15 hours of work a week is better than the injured worker sitting at home doing nothing but collecting a paycheck. Plus remember the old adage: The longer a claimant is out of work, the more difficult it is to get them back. Collecting 70% of pay in addition to saving on daycare costs or gas costs to name a few. Better to keep an open mind about getting the injured party back to work.

 

 

  • Return calls/emails to the adjuster

 

The workers’ comp adjuster has a lot to do every day. Claims are in various stages of a lifespan, and the job of an adjuster involves being on the phone a great deal. The new trend is to try and email as much as possible. It is a lot faster than a phone call, and it allows the other party receiving the email to get to it when convenient. Answer or return that email.  It does not have to be within the same hour, but it should be at least the by the end of the business day. The adjuster wants something or has a question they need to be answered.   Usually, the adjuster cannot move forward on the claim until the info is obtained. Do not be known as a slowpoke in getting the adjuster this information. They will respond in kind when the employer needs something.

 

 

  • Be polite

 

The workers’ comp adjuster usually deals with conflict. Conflict with different physicians and their opinions. Conflict with claimants over what is a work-related injury and what is not. Conflict with their managers on what to do on a file to get it to resolve. Conflict with plaintiff counsel over the facts of a case. Conflict with a claimant over a check not being issued or why the claim is still under investigation.   The list could go on and on.

 

 

So it is nice to give the adjuster some polite words now and then. A “please” and “thank you” can go a long way. Maybe take some time after a difficult claim is resolved and thank your adjuster for hours and hours of time put in to resolve the claim. Everyone appreciates the positive feedback and a good “thank you.”

 

 

  • Meet the adjusters face to face and show them around

 

Most adjusters work from home or in an office. They do not see their claimants. They do not meet the insureds. They are not at the doctor appointments. They are not on-site in the workspace. One thing to do is to meet with them first. Talk with your carrier/TPA about getting 1-2 adjusters to work the account.   Then invite those adjusters and the claims manager over to meet face to face at the workplace. Take them on a tour of the facility. Let them meet the safety team. By putting a face to a name, you have personalized the experience. And the more contact, the better the resolution on claims. The same employer/client relationship applies to the carrier/agent/adjuster relationship.

 

 

 

Summary

 

The workers’ comp adjuster has to handle many claims from many different employers. So make yours stand out from the rest. Take that extra time to build a relationship with the carrier/adjuster/TPA.  Claim results will likely be better.

 

 

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/

 

©2018 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.

25 Ways to Avoid Holiday Workers’ Comp Injuries

Holiday workers' comp injuryThe holiday season can be a great time of year. Joy is all around, decorations abound, and there’s merriment for all. While organizations celebrate, it’s also a time to take extra care to ensure you avoid holiday workers’ comp injuries.

 

Ramping up your safety measures is especially important during the holiday season to protect workers — from hazards related to putting up or removing decorations, the extra debris that may inhibit walking, and alcohol-related problems at celebrations.

 

 

The Decorations

 

Overexertion and same-level falls are the leading causes of workers’ compensation payouts each year, according to the Liberty Mutual Workplace Safety Index. The insurer’s 2017 annual study said overexertion — lifting, holding, pushing, pulling and carrying or throwing objects — cost employers $13.79 billion. Falls on the same level incurred costs of $10.62 billion.

 

While most if not all such incidents can be avoided, prevention efforts may be especially difficult during the holidays. Employees dealing with decorations are more prone to overexertion-related injuries, while other workers may be more at risk of falling over decorations, cords, boxes, and other items left in walkways.

 

Lacerations, strains, and sprains from lifting heavy boxes or trees, falling from chairs or desks while hanging decorations in workspaces, and getting poked in the eye by a pine needle are among the 337 holiday-related injuries in 2016 reported by the Consumer Product Safety Commission.

 

Basic safety precautions can eliminate these and other risks of holiday workers’ comp injuries  related to decorations:

 

  1. Keep trees away from radiators, fireplaces and other sources of heat
  2. Make sure the tree has a stable platform
  3. Artificial trees should be fire resistant
  4. Check lights for fraying, bare spots, gaps in the insulation or excessive kinking in the wires
  5. Turn off all lights or decorations when not in use
  6. Use a step stool or ladder at the appropriate height for hanging or taking down decorations
  7. Make sure wires don’t impede walking, and are always properly secured and covered
  8. Avoid overworking employees involved with decorations by rotating them and/or providing extra rest breaks
  9. Make sure workers remove all boxes and other items from halls and walkways
  10. Retrain workers on proper bending and reaching techniques
  11. Rope off areas where workers are installing trees, lights and other decorations
  12. Have the decorations installed and removed at times when the least number of employees will be affected

 

 

The Parties

 

A holiday party can be a great way to show employees your gratitude for their efforts throughout the year. You want to make sure there are no unnecessary injuries, especially when alcohol is involved.

 

State laws vary regarding an employer’s liability for accidents caused by inebriation. Even if a commercial general liability policy protects a business, there are still risks of injuries to employees.

 

Injuries that occur during such celebrations may or may not be considered compensable under workers’ compensation, depending on state law and the circumstances. In some states, courts have found company functions to be a part of employment when the employer presents the party as a way of compensating workers or requiring their attendance.

 

The best way to avoid alcohol-related injuries is to serve only non-alcoholic beverages. But if the company wants to include alcohol in the festivities, here are some steps that can prevent injuries and claims:

 

  1. Make attendance voluntary and assure employees that non-attendance will not affect their standing within the organization
  2. Emphasize to managers that they must lead by example and drink in moderation
  3. Advise employees to act responsibly and drink moderately
  4. Designate a sober driver. Whether it is a non-drinking employee or a car service, such as a taxi or Uber, that will at least ensure workers get home safely
  5. Do not have an open bar. Employees tend to drink less if they have to pay
  6. Have a voucher system to limit the number of drinks served if the company does opt to pay for alcohol
  7. Serve only beer and wine rather than hard liquor or fruity drinks that may be consumed way too easily
  8. Hold the party earlier in the day, as people tend to drink more later in the evening
  9. Serve food to help counter the effects of alcohol
  10. Serve alcohol for only a specified time period. Toward the end of the night, stop allowing alcohol and serve coffee.
  11. Include an additional activity, such as dancing or a magician, so people have something to focus on besides just drinking.
  12. Invite family members. People are less likely to drink excessively when spouses and kids are present
  13. Have the party at an off-sight restaurant with trained bartenders who know when to stop serving a customer

 

 

Conclusion

 

Decorations and special celebrations are great morale boosters and show you care about your employees, but they can often lead to holiday workers’ comp injuries. Using common sense and strictly adhering to safety measures will ensure everyone has a good time.

 

 

 

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/

 

©2018 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.

6 Triggers for When, And When NOT to Use Nurse Case Managers

when to use nurse case managementNurse case managers are a hot topic in workers’ compensation, and with good reason. Used properly, they can generate great results for organizations in getting injured workers back to work as soon as possible and saving precious dollars for organizations. But there is often misunderstanding about how and when to use Nurse Case Managers. For example:

 

  • Should you use a Nurse Case Manager on every workers’ compensation claim?
    • No
  • If a Nurse Case Manager is used, should it be for the entire duration of the claims process?
    • No
  • Is there a difference in telephonic vs. field Nurse Case Managers?
    • Yes

 

Nurse Case Managers can reduce litigation rates, foster patient engagement in the recovery process, and provide vital communication among all stakeholders. They can also be a waste of money and add little value.

 

Understanding when and how to use Nurse Case Managers is key to getting the best bang for the buck.

 

 

What They Can Do

 

Research showing the potential value of Nurse Case Managers has resulted in some companies using them on every single claim from beginning to end. Many of these companies then wonder why they are spending so much money without seeing a return on investment, so they discontinue using Nurse Case Managers altogether. Both are a mistake.

 

Here are some of the many ways Nurse Case Managers can help on a workers’ compensation claim:

 

  • Advocate and educate. The best reason to use a NCM is to help an injured worker who is frightened, confused and angry — often a recipe for litigation. The NCM can educate and advocate for the injured worker and guide him through the entire process, so he knows what to expect. The NCM can also inform employers on how the injured worker is progressing, and work with the treating physician to make sure the worker is getting appropriate care.

 

  • Flag potential problems. If the injured worker has psychosocial or pain management issues or needs durable medical equipment, the NCM can spot that early in the claims process and help coordinate the necessary treatment.

 

  • Communicate with all stakeholders. The NCM can keep everyone in the loop, so necessary details don’t fall through the cracks.

 

 

When to Use Nurse Case Managers

 

Simple, medical-only, and claims where the injured worker is highly engaged and anxious to return to full duty as quickly as possible do not signal the need for a NCM. On these and other cases the addition of a case manager is unnecessary and a waste of money.

 

More complex claims are where Nurse Case Managers can have a significant impact. Certain claims should trigger involvement from a NCM, including:

 

  1. Lost time. Workers who are off the job for more than a couple of days can benefit from extra involvement. A NCM can answer the injured worker’s questions and ensure he is complying with the treatment plan.

 

  1. Surgery is needed. Even if it is a medical-only claim, the need for surgery should be a red flag to get a NCM on the claim. There will be many things going on, such as preparing at home, the need for and type of pain medications after, and any DME that might be temporarily needed. The NCM can coordinate the various moving parts.

 

  1. Failing to attend scheduled medical appointments. Whether the worker is off the job or working in some capacity, failing to see treating physicians, physical therapists and other providers is a sign there may be a problem. A NCM can contact the injured worker and either get the person to comply or find out if there is an underlying problem that should be addressed.

 

  1. Comorbid Conditions. An injured worker with diabetes, obesity, hypertension or other comorbid conditions is prime for a more complicated claim. A NCM can help keep the claim on track.

 

  1. Uncooperative treating physician. If the injured worker’s primary physician continues to say the patient needs to stay out of work entirely, a NCM can intervene, find out why the person is not recovering, and explain return-to-work principles — such as light duty and employer accommodations.

 

  1. Catastrophic and/or multiple injuries. These claims involve many people and moving parts. A NCM can be the go-to person for all parties involved, including the injured worker and his family. The NCM can also make any arrangements needed, and keep costs down by selecting the most appropriate equipment.

 

 

When to End NCM Involvement

 

Putting a NCM on a claim doesn’t need to be a long-term prospect. These can be short assignments — even just one or two visits or calls. Depending on the complexity of the claim and ongoing issues, the NCM may need to contact the injured one time to keep him on track and in compliance with medical appointments; or may need to reach out to the treating physician for something simple; or discuss accommodation possibilities with the employer. The earlier a NCM intervenes in a claim, the shorter the assignment typically is.

 

You can gauge when the NCM is no longer needed, for example:

 

  • The injured worker is back to work in at least a light duty capacity
  • Stakeholders are communicating well with one another
  • Restrictions are decreased, and the worker is progressing well

 

 

Conclusion

 

Nurse Case Managers can add tremendous value to a claim, generating optimal outcomes for injured workers and lower costs for payers. But it is not a black and white issue; meaning they don’t need to intervene in every single case, and they don’t need to be involved indefinitely. Thinking through a strategy for using Nurse Case Managers can have a significant impact on 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/

 

©2018 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.

 

Professional Development Resource

Learn How to Reduce Workers Comp Costs 20% to 50%"Workers Compensation Management Program: Reduce Costs 20% to 50%"
Lower your workers compensation expense by using the
guidebook from Advisen and the Workers Comp Resource Center.
Perfect for promotional distribution by brokers and agents!
Learn More

Please don't print this Website

Unnecessary printing not only means unnecessary cost of paper and inks, but also avoidable environmental impact on producing and shipping these supplies. Reducing printing can make a small but a significant impact.

Instead use the PDF download option, provided on the page you tried to print.

Powered by "Unprintable Blog" for Wordpress - www.greencp.de