3 Criteria Determine If A Workers Comp Claim is Covered

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

 

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

 

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

 

 

There must be an injury or an illness:

 

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

 

 

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

 

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

 

 

The injury or illness must be caused by the employment

 

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

 

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

 

5 Ways to Ensure a Workers’ Comp Claim Investigation Is Off to a Good Start

Effective Workers’ Comp Claim Investigation TechniquesIf you’ve ever been intrigued by police investigations in TV shows or detective novels, you might want to use that enthusiasm to investigate workplace injuries. Approaching a workers’ comp claim investigation claim in ‘detective’ mode will lead to better results; meaning, reduced costs and superior outcomes for injured workers.

 

 

The Workers’ Comp Claim Investigation

 

The ultimate goal of managing a workers’ compensation claim is to help the injured worker recover and get back to work as soon as possible, without the payer spending unnecessary costs. But often there are many gray areas to a claim. Determining exactly what happened and, therefore, what should be covered by workers’ compensation can be difficult.

 

Investigating a claim should uncover as many details as possible. Employers/payers can get all the information they need by implementing a precise system that kicks in immediately after an injury occurs. At the very least it should include:

 

 

  1. The Basics

 

The workers’ comp claim investigation process should begin with statements from the employee, employer, and any witnesses. There should be separate forms for each which should have open-ended questions, rather than boxes to check.

 

Additionally, there should be a separate attachment for details on each form. A form from a witness that says, ‘Joe slipped and hurt his back,’ really doesn’t reveal anything and won’t help determine whether and to what extent the claim is compensable.

 

The essential pieces of information that should be included about the injured worker and the incident include:

 

  • Date of birth
  • Name of the employee
  • Social security number
  • Average weekly wage
  • Date of injury
  • Date of hire

 

Too often such information is either not included or is inaccurate.

 

Another ‘basic’ procedure that makes a tremendous difference in a claim is the way the injured worker is treated. Anyone involved with managing the claim at any point should treat the person as if it is a friend or spouse and approach the employee in the same way as they would want that person treated.

 

 

  1. Preserve the Scene

 

Preserving the scene is where reading and watching cases in which detectives try to understand what has happened comes into play. Just as a detective on a case is trying to get to the truth, so too is the employer/payer.

 

Once an accident occurs, the area should be roped off to whatever extent is possible. If it is an area in which many people are working and is crucial to business operations, this might take some creativity. But the idea is to ‘protect’ any evidence that could indicate what and how the injury occurred.

 

Looking at the scene might reveal a cause. For example, water on the floor could indicate the worker slipped and fell. Or, there might be evidence that a piece of equipment was faulty, which could result in subrogation from a third party.

 

A thorough examination of the accident scene may help reveal the mechanism and extent of an injury. That could be advantageous if, say several months later the injured worker claims additional injury from the initial accident.

 

 

  1. Talk to Others

 

Witnesses play an important role in a workers’ comp claim investigation. While the injured worker experienced the accident, he may not know exactly how it happened. Someone who saw it might be able to fill in some of the blanks; for example, that a heavy box on an upper shelf fell, triggering the worker’s fall.

 

Also, identifying all witnesses as soon as an injury occurs prevents ‘new’ witnesses the injured worker may try to bring in later on.

 

 

  1. Record

 

While witness accounts of a situation are important, they may not always be reliable. Sometimes what people think they saw or remember may vary greatly from one witness to another. That’s why it’s also important to record the scene in as many ways as possible.

 

Just as a detective investigating a crime scene might seek out video footage of the area, getting recorded descriptions of the scene can help determine how the injury occurred and can be extremely valuable later on, if the case is litigated.

 

Video cameras may be present in or near the work area. There may also be video cameras around the building, or even on nearby buildings. The footage may reveal more information about the incident.

 

If no videos were present in or near the accident scene when it happened, taking a video of the accident area via a smartphone can also help provide information about what may have contributed to the injury. The person filming should also include narration to describe various objects, direction, location, etc.

 

Photos can also provide details. These can be taken from a distance as well as close up, to get different perspectives and angles.

 

 

  1. Document, Document, Document.

 

Every step taken during the workers’ comp claim investigation should be written down; from interviews with witnesses and others, to bits of information observed at the scene, and any other potentially relevant information.

 

Documentation pertaining to maintenance and training schedules and previous corrective actions involving the injured worker should also be included in the investigation materials. Information about prior medical treatment to the injured body part can also be relevant and should be included in the documentation

 

 

Conclusion

 

Conducting a thorough workers’ comp claim investigation provides the best opportunity to ensure the payer covers all of what should be funded and nothing more. It also signals the entire workforce that this is a normal process; meaning a worker will think twice before trying to fake an injury.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Clear and Responsive Employer Contacts in Account Instructions

 

 

If you fail to plan, you plan to fail. That quote was originally stated by Benjamin Franklin.

 

 

Account Handling Instructions Are Planning & Communication Tool

 

Hello, my name is Michael Stack, I’m the CEO of Amaxx. That concept of planning comes to light in the world of worker’s compensation in the form of your account handling instructions, your account services instructions, client instructions, et cetera. Various different TPAs and carriers have different names to mean the same thing, which is this tool, this communication tool between the employer and the claims handling organization, whether that’s your TPA or carrier. It’s a highly effective way to get on the same page for how you’re going to approach your worker’s compensation claims, how you’re going to handle them. What are those set of instructions for what to do as far as a communication tool, and then on the back side, an accountability tool.

 

You say, “Well, this is what we’re supposed to do,” and did we do it or not? And then you can come together with that and adjust as needed, tweak as needed, if the plan isn’t going as planned.

 

A number of things that I want you to address, and we cover this really in full detail in our course called How to Script Winning Account Handling Instructions, you can see the link to register for that below. One of these pieces that I want you to really focus on and highlight, because I feel like it gets missed the most, we’ve come up with all these things about settlements, settlement authority, and how to use medical vendors, and all this different stuff, and look at what term it is we want to use, et cetera, et cetera, et cetera in our planning. But the key piece that is so critical is this chain of command or communication or reliable contacts for the adjuster at the employer site.

 

 

Clear and Responsive Employer Contacts

 

For the adjuster at the employer site, who are those reliable, clear contacts that know their contacts and know that they need to get the adjuster information when the adjuster needs it? Because if you come up with this great plan, it’s like, “Okay, adjuster, I want you to do X, Y, and Z, and I want you to do all this stuff, and I want you to do this report, I want you to give me this data on X number of days, and I want you to get it all right all the time. Oh, but by the way, when you have a problem, you have a question, or you need to ask the employer something, we may or may not get back to you. I know Jane is your contact, but Jane’s on vacation. So you’re going to have to wait in order to get that information,” and that just doesn’t work.

 

So a number of things that I want you to do when you come up with this clear and concise list of reliable contacts for the adjuster at the employer site. Number one is, what is the chain of command. What is the chain of command at the employer site? So how does that adjuster kind of get to understand what’s going on at the company? Who’s going to send in, or who needs to receive, that notice of injury whenever an injury occurs? What are the injury details? How do they find out what happened? When the adjuster is going through their three-point contact, who are they calling? And who is that number, are they going to be reliable, are they going to be there to answer that phone?

 

 

Who Is The Back-Up Employer Contact?

 

Number four, who do they call to get the wage history? Who do they call to get the wage history? And then last piece here, there’s a number more, but these are just a couple of highlights. Who’s in charge of the light-duty program, who do they contact for light duty? And then, just in that example that I just gave, if Jane’s the contact and Jane’s on vacation, who’s the back-up? Who’s that back-up person that they’re going to contact?

 

So for every piece within your account instructions, who is the contact at the employer that’s going to be reliable and that’s going to get that adjuster the information they need to do their job appropriately? If you have that information, then it’s going to run just that much smoother.

 

Again, my name is Michael Stack, I’m the CEO of Amaxx. 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.

10 Helpful Tips For Managing Angry Workers’ Comp Claimants

Angry Work Comp ClaimantsUnfortunately, angry workers’ comp claimants are often part of the workers’ compensation business. As hard as you try, you are never going to please all people all of the time.  Experienced professionals know how to properly diffuse a tense situation.  But it is an asset that is learned over time.

 

Here are a few important tips to remember:

 

1. Stay Calm

 

Regardless of the negative attitudes or unpleasant tones an angry caller may have, it is essential that you do not get emotional as well.  Using phrases such as “I hear what you are saying” or “I understand” can help to calm angry callers.  Remember they usually have no idea what is going on or why these decisions are being made on their claims, so take the time to let them vent a bit then calmly explain to them the situation.

 

 

2. Listen & Be Patient

 

Do not attempt to interrupt angry callers.  Be patient and let them finish speaking.  Sometimes they just need to vent their frustrations.  After that, they will relax a bit and work with you to resolve their issue.  Explain to them what is going on, and what options they may have for moving forward.

 

 

3. Remain Professional

 

Above all remain professional.  Remember you are in the customer service industry, and there is a lot of competition out there.  Every phone call should be dealt with in a professional matter, no matter the conversation.

 

 

4. Do Not Raise Your Voice

 

Raising your voice or talking in a sarcastic tone is only going to irritate your angry workers’ comp claimant further, which will resolve nothing.  If anything, you can get in trouble with your supervisor.  Many carriers record telephone conversations, and if this discussion gets pulled for review you are going to look foolish.

 

 

5. Try Not to Argue

 

Your main goal in diffusing a heated conversation is to resolve the problem.  But a direct argument will rarely resolve anything.  Instead, explain to them what is going on, and what they can do to help themselves.  It may be that getting medical records or a more detailed report from their doctor is the piece of evidence you need to complete your investigation.  Remember the claimant does not have the experience that you do in handling claims day in and day out, so cut them some slack and try to help them instead of just arguing point/counterpoint.

 

 

6. Speak Slowly and Clearly

 

Nobody likes to have to repeat themselves, so speak in a clear voice. Also, try to avoid talking in legal terms or in claim shorthand.  The angry workers’ comp claimant will probably have no idea what you are talking about, which will frustrate them.  Pretend you are explaining the issue to someone who has zero experience in this situation, and you may end up with better results than you planned.

 

 

7. Empathize & Apologize

 

How would you feel if you are in the same situation?  What would you want to be said to you to make you feel better about the call?  Angry workers’ comp claimants want to know that you understand where they are coming from, and they want the reassurance that you can help them with whatever issue they may have. Even if you know the caller is wrong, take a moment and apologize for the confusion.  Many callers simply want acknowledgment from the carrier that a mistake may have been made, if applicable to your scenario.  An apology is the first step to overcoming their anger and opening a dialogue about resolving the issue.

 

 

8. Offer Solutions

 

People are coming to you with questions about their claim, or why a decision was made.  But oftentimes these decisions are not written in stone.  Denied claims can be accepted later, and vice versa. Maybe your claimant can file for mediation on their denied claim.  Or maybe they did not submit enough information in the beginning for their claim to be accepted.  Whatever the reason may be, explain to them what options they have for moving to the next level.  If you cannot answer a question immediately, let them know that you will work on it and get back to them with some answers or options and go from there.

 

 

9. End the Call if the Person is Repeatedly Abusive

 

Your goal is to bring a successful closure to each phone call.  However, you do not have to tolerate abuse.  Kindly interject with an “Excuse me” if necessary and inform the caller that their language or behavior is not acceptable, and it will not help them resolve their conflict.  It is well within your ability to end the call if the person continues to be belligerent and abusive if you have asked them to calm down several times beforehand.

 

 

10. Do Not Take It Personally

 

In the end, this is your job.  A lot of claims adjusters have a lot of hours of work invested into each file, and sometimes they can wear their heart on their sleeves.  But at the end of the day, you have to accept the decisions you made on a claim.  I recall a young adjuster I knew that was first starting out in work comp, and he used to agonize over his decision about whether a claim was compensable or not, and if he was making the right call.  This is a good asset to have, but only if it is a healthy concern.  The process that is in place with supervisor reviews and audits is there to catch your errors, if you have any, and to help you make confident decisions on claim outcomes.  Trust in the process in place, and believe in your decisions that you make. Sometimes you have to go with your gut decision.

 

 

Summary

 

An adjuster is on the phone for the majority of their day, every day.  And in the field of claims, conflict will arise.  There is often no way to avoid dealing with an angry workers’ comp claimant.  But you have to be armed with the proper way to handle yourself on the phone–not just for certain calls but for every call.  Implement the tips above, and hopefully, you will be known around the office as a person that can diffuse any tough situation that is thrown their way.  Knowing how to work the phone is one of the best assets an adjuster can have.

 

 

 

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.

You’re Fired! Using Employment Release and Resignations in Work Comp Cases

Employment Release and Resignations in Work Comp CasesRunning an effective workers’ compensation program revolves around managing risk and reducing it when necessary.  In some workers’ compensation cases, this includes the demand the employee voluntarily resigns their employment from the employer and agree to never work for them again, also known as an employment release and resignation.  Before making such demands, it is important to understand the numerous pitfalls associated with an employment release and resignation and how to use it in an effective manner.

 

 

Understanding an Employment Release

 

A voluntary resignation and release of any and all employment claims by the employee are outside the scope of the workers’ compensation insurance policy.  It is important for all defense interests to coordinate via their defense counsel.  The Release must be found in a document separate from the settlement of the workers’ compensation claim and the consideration (money paid to the employee) must be paid by the employer.

 

An effective Employment Release should be written with the interests of the employee and their employer in mind.  Given the numerous legal issues, attorneys representing the employer/insurer are often hesitant to draft such a document as it is outside the scope of their representation.  Retaining separate counsel who understands employment law issues may be something to consider.

 

It is also important that the employee understands what they are giving up under the terms of an Employment Release.  Points of contention include:

 

  • The inability of the employee to make a claim against the employer for future unemployment compensation benefits;

 

  • The inability of the employee to make an application for employment with the employer at any point in the future; and

 

  • The inability of the employee to make any employment claims against the employer such as age, gender, and race discrimination, along with claims for interference with and/or retaliation for making a workers’ compensation claim.

 

 

Essential Terms to Include in an Employment Release

 

Any Employment Release that is included in a workers’ compensation claim should be either drafted by and/or reviewed by an attorney specializing in employment law matters.  They should also know and understand all applicable state-specific and federal laws governing employment law matters.

 

Common terms found in such an Employment Release include the following:

 

  • Discrimination: Prominent federal laws in the area of employment prohibit employers from discriminating against employees on the basis of race, color, religion, sex, or national origin.  These provisions are found under Title VII of the Civil Rights Act of 1964.  Other important federal laws include the Americans with Disabilities Act and equal pay laws.  State laws typically mirror federal standards, but can also exceed the minimum thresholds or include other classes (g. – sexual orientation, marital status, economic status/receipt of public assistance) of employees.

 

  • Retaliation: Most states have anti-retaliation provisions in their workers’ compensation laws that create a civil cause of action against employers who harass or intimate employees who file claims.  Case law in many states has extended legal protections to all employees, including those not legally authorized to work inside the United States.

 

  • Sexual Harassment and Emotional Distress: The #MeToo Movement has given rise to a renewed national consciousness regarding sexual harassment and assault in the workplace.  Claims can include the intentional or negligent infliction of emotional distress under tort law.

 

  • Contract Claims and Breach of Contract: Employees can also allege their employers violated the terms of a workplace contract.  This is often the case in dealing with employee’s subject to a collective bargaining agreement. While employees are generally considered “at will,” claims can be made for implied or express contracts.

 

  • Payment of Wages: Wage disputes are common for employee’s subject to overtime pay.  The non-payment of a bonus can also be an issue when an employee is subject to termination at the end of a quarter or year-end.

 

It is important to avoid using forms.  Failure to fully understand the law may prove catastrophic for all defense interests involved in a workers’ compensation claim.

 

 

Conclusions

 

Members of the claim management team need to seek opportunities to reduce risk and maximize the effectiveness of a workers’ compensation settlement.  One such option is to seek a global settlement where the employee agrees to voluntarily resign their employment from the employer.  It is important that the claim management team, employer and defense counsel discuss these issues and coordinate in an effective manner.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: 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.

9 Spring Cleaning Tips for Your Workers’ Comp Program

9 Spring Cleaning  Tip for Your Workers’ Comp ProgramCold winter nights and non-stop snow storms across the country should not delay claim management teams from preparing for springtime.  Now is the time to do some “spring cleaning” in your claims management program to make sure you are ready for summer.  Part of this process includes a complete review of your program to ensure efficiency and effectiveness.

 

 

Know the Goals of Your Clients

 

Everyone talks about “meeting the goals” of your clients.  Do you really know what those goals are?  The process starts with meeting with your clients to better understand what they are trying to fix, accomplish or avoid.  This will allow your team to concentrate their efforts on these areas to meet – and hopefully exceed their expectations.  Common themes can include:

 

  • Complete Required Documents in a Timely Manner: Members of the claim management team are required to perform a number of functions in a timely manner.  This includes the prevention of unnecessary costs associated with administrative penalties, excessive litigation costs, and delayed return-to-work.

 

  • Avoid Communication Breakdowns: Workers’ compensation claims are driven by information.  Not having correct and accurate information results in time lost by individual claim handlers.  Physical and psychological barriers need to be removed so all interested stakeholders can communicate in an effective manner.

 

  • Full Regulatory Compliance: The workers’ compensation system is driven by the details.  This includes ever-changing requirements on when, how and where forms are to be filed.

 

 

Implementation of Claim Management Decisions

 

Proper execution of a client’s decisions is essential when running an effective claim management team.

 

  • Empower all team members to make decisions: Surround yourself with people who exercise good judgment and make informed decisions.

 

  • Keep the goals and objectives of the client, and keep them in mind at every decision. This includes using preferred service providers when necessary and a willingness to make recommendations.

 

  • Be a zealous advocate for the claim – integrity is key! Treat all injured employees with respect and dignity.  This can be accomplished by returning calls in a timely manner and making all decisions in good faith.  Never cut corners or try and save a buck by issuing frivolous denials.

 

 

Coordinate Efforts on Risk Assessment

 

There are numerous ways claim management teams can be involved in the risk management process. Key areas to focus on include the following:

 

  • Preparing effective job descriptions: There are a number of challenges employers face when engaging in the hiring process by the posting of an open position.  Potential barriers include the American with Disabilities Act and other affirmative action considerations.  A proper job description should be written in a comprehensive manner that includes the ability to accommodate all prospective employees.

 

  • Interviewing process: This part of the hiring process is fraught with dangers that lurk in every question asked of a candidate.  During the interview process, it is important to focus on someone’s experience, training, and planning ability.  It is also essential to set the right tone when it comes to workplace safety.

 

  • Global Settlement and Release of Employment Claims: Seeking a voluntary resignation and release of all employment claims is often a term of settlement employers request when settling a workers’ compensation claim.  While employees are a valuable asset, seeking their resignation of employment can be a tool to reduce future exposure and limit liability.  Consultation with an attorney who understands employment law issues is important when making these requests.

 

 

Review of Return-to-Work Policies and Procedures

 

Countless studies indicate that returning an employee back to work following an injury pays dividends.  It is important for employers and other interested stakeholders to be fully invested in these measures as part of their workers’ compensation programs.  This should not be limited to returning an employee to work with the date of injury employer.  Other considerations should include the Ticket To Work program and “work to loan” efforts.

 

 

Conclusions

 

Spring is in the air – now is the time to review one’s workers’ compensation program.  This includes a proactive claim management team meeting with their insureds and better understand their goals.  Suggestions can also be made when it comes to assessing risk and getting injured employees back to work in a timely manner.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: 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.

Fentanyl in Workers’ Compensation – 4 Ways to Keep Injured Workers’ Safe

Fentanyl in Workers' CompensationFentanyl is 100x stronger than morphine. Carfentanil is 100x stronger than fentanyl. For injured workers who become addicted to prescribed opioids, that can be a death sentence.

 

Armed with information about the latest illicit drugs and a willingness to adopt certain strategies, payers can ensure their injured workers get the most appropriate treatment and avoid becoming victims of the latest drug nightmare.

 

 

Heroin, Fentanyl, and Analogues

 

The dangers of unnecessary opioid use have been well documented and publicized for several years. To its credit, the workers’ compensation has been at the forefront of efforts to stem what has become a national crisis. But often overlooked are injured workers who already are, or become addicted to these prescription drugs and turn to the illicit drug market for relief.

 

Opioid prescribing dropped by nearly 9 percent in 2017, according to some accounts. However, some injured workers who were already addicted turned to heroin, leading to fatal overdoses from that drug. More recently, additional drugs have taken over the market, many of which are far more potent than opioids.

 

As described in It’s Not Just Heroin Anymore, a white paper from myMatrixx, synthetic opioids such as fentanyl have risen on the black market, mainly due to economics. Where heroine requires growing the opium poppy plant, harvesting the resin and processing it into the final product, fentanyl is purely synthetic, meaning it can be made easily and cheaply.

 

“Fentanyl is 50 times more potent than heroin and 100 times more potent than morphine,” according to the research paper. “Even more alarming, however, is the fact that there are compounds with molecular structures closely similar to fentanyl (analogues) that are drastically more potent and these are now making their way into the hands of drug addicts.”

 

Illicit makers of fentanyl have found in analogues a way to circumvent the regulations of the Controlled Substances Act. The CSA classifies substances based on their chemical identity. Since the fentanyl analogues are not on the list as identified controlled substances, they, technically, are not illegal substances.

 

There are 4 fentanyl analogues that are legal for medical use, including:

  • Carfentanil, only for veterinary use, it is normally dispensed as an elephant tranquilizer. It is 100 x stronger than fentanyl. myMatrixx notes it has been linked to increases in overdoses in the Midwest in particular.
  • Sufentanil
  • Alfentanil

 

 

Other analogues of fentanyl are Schedule I under the Controlled Substances Act.

 

 

What to Do

 

Most people prescribed opioids do not become addicts; however, anyone can develop an addiction. That is why it is imperative for workers’ compensation stakeholders to take every precaution to prevent addiction and address it appropriately in injured workers affected.

 

Here are ways payers can keep their injured workers safe:

 

  1. Educate providers. Despite their good intentions, some treating physicians are not trained in dealing with pain and/or opioid prescribing. They may also not follow evidence-based guidelines. Payers who develop solid relationships with network and/or area physicians can work with them and make sure they understand how to mitigate the risks.

 

For example, providers should know to:

 

  • Avoid prescribing opioids as a first line therapy
  • Screen patients for addiction before starting opioid therapy and continuously throughout treatment
  • Conduct urine drug screenings to monitor compliance
  • Be aware of, and adhere to formulary restrictions
  • Watch for, and address aberrant behavior
  • De-escalate or discontinue opioid therapy when necessary

 

  1. Provide strong clinical oversight, of physicians and pharmacies. Working with a pharmacy benefit manager and/or carrier is a place to start.
  2. Ensure providers are aware of alternative therapies to opioids and encouraged using them
  3. Intervene when there are concerns of opioid overprescribing. Having another physician talk with the provider can be effective. Insurers and/or third-party administrators often have medical personnel available to help.

 

 

Summary

 

The opioid crisis within the workers’ compensation system has improved in recent years. However, it is far from over. Stakeholders should stay up-to-date on the latest issues surrounding the problem and take steps to protect their injured workers.

 

 

 

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.

5 Critical Pieces of Information to Confirm Following a Work-Related Injury

 

How to Execute A Bulletproof Workers' Comp claim

 

There is no time in a worker’s compensation injury claim more important than that time immediately following the injury to find out actually what the heck happened. Hello, my name is Michael Stack. I’m a CEO of Amaxx and today I want to walk you through the five critical pieces of information that you need to confirm immediately following an injury.

 

 

Employer Injury Report / Adjuster Recorded Statement

 

Now, this is either done by the employer when they’re filling out those forms. You’re going to get a certain piece of this information. But also then by the adjuster when the adjuster is taking their recorded statement. Let me run you through those five critical pieces of information that you need to confirm and lock down so that there’s no gray area later and you’re trying to put the puzzle pieces together and figure out what the heck happened when you could have just confirmed this right away when the information was still clear in everyone’s mind.

 

 

5 Critical Pieces of Information to Confirm Following a Work-Related Injury

 

Let’s talk about what these things are.

 

  • You need to confirm the mechanism of injury
  • If there are any witnesses there at the scene that saw exactly what happened,
  • What body parts were involved
  • If that individual injured worker has previous injuries or not,
  • And then finally who the healthcare providers are, who their primary doctor is, etc.

 

Let me run you through those again. The mechanism of injury. What and how did the injury occur. The witnesses. The body parts. What exact body parts were involved. Was it the elbow only? Was it the knee as well? Was it the hip? They landed on their back. What was involved and what was not involved. If there were any previous injuries and then if there were healthcare providers, what healthcare providers have they seen in the past, so that you can locate those medical records and get a lot more information on what exactly has occurred with this individual and injured worker, so you can make the right decision, which is what we’re trying to do here in worker’s compensation.

 

 

How to Execute A Bulletproof Workers’ Comp Claim Investigation

 

For more information on this, for more in-depth training on this, I have a fantastic new course. It’s called how to execute a bulletproof work comp claim investigation. I walk through these five things with our special guest Stewart Colborn, who’s a defense attorney out of Texas. It’s great in-depth training in how to do this and how to do it right out of the gate. You could check that out on a link below. Again, my name is Michael Stack. I’m the CEO of Amaxx. 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.

What Is Likely The Problem With Your Work Comp Program


It was late one March evening and a taxicab going over 115 miles per hour smashes into the back of a police car. Instantly setting that car on fire, and the officer was trapped inside. Hello, my name is Michael Stack, I’m the CEO of AMAXX.

 

 

Burning Shield – Jason Schechterle

 

This past week I spent several days at the annual meeting of the settlement planning organization Ringler, he’s one of the partners on my website here at Reduce Your Worker’s Comp. Now it was a great couple of days spent networking and learning and sharing ideas, but one of the highlights of that conference or of that meeting was the keynote presentation given by Jason Schechterle, who was the officer who was inside of that car hit by the taxicab. Now Jason experienced severe burns on his face, his neck, his head, and over 40% of his body. He underwent over 50 surgeries to recover from that event. His message was powerful in his keynote presentation, and the book that he wrote called the Burning Shield. I recommend checking it out.

 

 

Accountability In This Life

 

Jason’s message had a lot to do with taking an honest look at our circumstances, and taking accountability for where we stood and what happened. There were so many powerful lessons and inspiring keynotes that he gave throughout the course of that presentation. The one that struck me the most went like this, he said good or bad, we have an accountability in this life. Why me is not a question is not a question we can ask. He said good or bad, we have an accountability in this life. Why me is not a question we can ask. Good or bad, we have an accountability in this life. Why me is not a question we can ask. That lesson and that sentiment is so applicable to so many areas of our life. Today we’re gonna talk about how that applies to your work comp program.

 

 

You Are Likely Looking At the Problem

 

What I see so often, particularly from employers, is that we want to blame everyone else. It’s the adjuster, they have too high of caseload. It’s that stinking doctor, he’ll never release my employee to work or that case manager’s not getting it together. Or my attorney, he’s a real pain in the butt or she’s a pain in the butt. Or that investigator, if that investigator would just have done their job we wouldn’t be in this mess that we’re in right now. It’s such a common sentiment that we feel in our work comp programs, and generally within our own lives. Per Jason’s lesson, we need to think about how that applies to our lives, and how that applies to our work comp programs as well. Because when you wake up in the morning and you’re looking in the mirror, you need to realize that you’re likely looking at the problem.

 

Again my name is Michael Stack, I’m the CEO of AMAXX. 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.

 

Evaluating Medical Evidence to Make Better Workers’ Comp Decisions

medical evidenceMembers of the claim management team are called upon to evaluate the medical evidence and determine issues of reasonableness and necessity of medical care and treatment, along with determinations of causation and primary liability.  These decisions have a significant impact on an individual claim and the effectiveness of a workers’ compensation program.

 

 

 

Evaluating the Medical Evidence from a Physiological Standpoint

 

Imagine the next claim that lands on your desk involves a meat production worker.  The employee is a 62-year-old man who’s work activities requires him to process meat on a bench that is no higher than their waist.  During this process, the employee will turn in one direction to place the finished product for further processing and sale, and turn in the other direction to place the undesirable portions of the product for disposal.  None of their work activities require the employee to lift objects above chest level or over his head.  The employee is now claiming a progression of symptoms that involve stiffness, which has now culminated in “frozen shoulder” syndrome.  Should the alleged injury be accepted?

 

While the cutting of meat and its processing are repetitive, not all claims of repetitive trauma are compensable.

 

 

Making the Right Assessment

 

Claim handlers deal with many barriers when reviewing matters and determining questions that have real consequences.  This includes rigid timelines that can result in sanction or penalty if not done right or within a timely manner.  Questions that must be considered include:

 

  • Did a work injury actually occur – even if it only aggravated or accelerated an underlying condition?

 

  • What role if any, did the work activity contribute to the injury, disability and/or need for medical care and treatment?

 

  • Even taking into consideration the employee’s age and possible prior injuries, did the work activity advance the underlying condition to the point of compensable injury?

 

  • Does the overall medical evidence as presented fit the alleged injury?

 

In terms of the above scenario, the claim handler worked with a medical expert to review the claimed mechanism of injury, prior medical records and other information to allow for a primary denial.  It was noted that the contemporaneous medical records and work history did not support a work injury and the claimed mechanism was inconsistent with the subsequent medical diagnosis.  In sum, because the physiological body mechanics in question did not fit injury, the proactive claim handler was effective and proactive in denying the claim.

 

 

Application in Claims Handling Practice

 

It is important for members of the claim management team to review their files and determine if the medical evidence fits in not only workplace exposure/repetitive injury claims, but also specific incident injuries.  Examples of how this can be used in specific injuries include:

 

  • How the employee fell or what they were doing when they fell;

 

  • Angles of fracture and the type of fracture following a slip/fall; and

 

  • The nature and extent of an injury based on pre-existing conditions such as degenerative disc disease for back and neck claims, and claims involving joints such as knees, shoulders, and

 

The list of possibilities is really endless.

 

 

Conclusions

 

Members of the claim management team face many challenges in their position on a daily basis.  It is of utmost importance that claims handlers make proper decisions after having investigated a claim in a timely manner and making evidence-based decisions.  This includes taking the time to obtain information on how the injury took place, they can save time and money for their program and clients.

 

 

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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