Making the Most of Work Comp Mediation

Making the Most of Work Comp MediationUsing mediation as a tool to reduce workers’ compensation program costs is a growing trend across the country.  There are a number of reasons for its increased use.  This includes the fact it involves all parties, allows the employer and employee to have a voice in claim settlement and for creative remedies that would otherwise not be available in a judicial setting.

 

 

How Does Mediation Work?

 

There is no set formula for a successful mediation.  It will typically involve an agreed upon neutral third-party who evaluates the case and moves the adverse parties toward settlement.  More successful mediations are held in-person and can include a mix of joint sessions or when the parties are separated into different private rooms.  Whenever a mediation is conducted, it is important for all interested parties to be present and free from distractions.

 

 

Preparing for Successful Mediation

 

There are a number of steps that parties interested in settlement should take in order to prepare for mediation.  Important steps should include:

 

  • Accurately review the claim to determine exposures and properly set reserves. Obtaining proper settlement authority and discussing settlement options is a must for defense counsel;

 

  • Determine if the case is ready for mediation and whether settlement could include bigger issues such as the closure of all future medicals;

 

  • Identify all potential intervention interests and place them on notice, if necessary. Failure to include a necessary party may be fatal to an otherwise great settlement;

 

  • Have realistic settlement expectations – and also understand what the expectations of the other party might be.

 

 

Securing the expertise of a settlement consultant can be a valuable tool prior to mediation. Prior to settlement, they can work closely with the injured worker to gain deep insight into his needs and desires and help all parties attain a successful settlement.

 

It is also important to prepare a confidential case analysis letter for the mediator.  This is an opportunity to help the neutral third-party understand not only the strengths and weaknesses of your case, but how you view the claims of the employee.  This correspondence should also include expert medical and vocational reports.  By providing this information to the mediator in advance, you can spend less time providing background information while actually at the mediation and more time moving the case toward settlement.

 

Information provided to the mediator directly related to the mediation and settlement of a claim is generally considered confidential and not admissible in court at a later date.  Be sure to fully understand the confidentially rules applicable to your jurisdiction before submitting information.

 

 

Getting to Yes: Tips for Settlements

 

It is important to keep an open mind when preparing for a workers’ compensation mediation.  Failing to do so will only lead to further frustration and lack of settlement.  Here are some tips to reach a settlement at mediation:

 

  • Prepare a Strategy: This includes playing “devil’s advocate” and discussing the pros and cons of various defenses.  A complete case evaluation should also take place and have a firm understanding of what the opening offer should be, likely counter-offers and the bottom line.

 

  • Keep Interested Parties Posted: In many instances, cases fail to settle at mediation because the parties have not placed interested medical providers on notice of their potential intervention claims.

 

  • Come Prepared for Settlement: Cases often settle at mediation and then languish as defense counsel and the attorney for the injured party exchange multiple drafts of settlement agreements. Proactive stakeholders should bring a laptop computer and portable printer, if available.  This allows the attorneys to have a copy of the settlement documents in hand, ready to review and reach a true final settlement.

 

 

Conclusions

 

Stakeholders interested in reducing workers’ compensation costs should examine the use of mediation as an opportunity to make their programs effective and efficient.  This can include the use of mediation as a tool to streamline the settlement process.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©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.

Quality Job Profiles Are Critical to Optimally Manage Workers’ Compensation

Quality Job Profiles Are Critical to Optimally Manage Workers’ CompensationFirst, let’s get our terminology straight. The terms “job profile” or “job description” are often used synonymously. These two terms refer to a more-or-less complete depiction of the tasks, physical and perhaps cognitive demands, and environmental characteristics of a particular position at a particular employer.

 

A well-designed job profile has great potential value, but the truth is that many employers have not expended the resources and time to develop comprehensive and quantitative databases of all their company’s positions.

 

In my experience, many jobs have no available profiles whatsoever, and when they do exist they are often incomplete, qualitative, sketchy documents on paper that provide little useful, actionable information.

 

 

Why is a Good Job Profile Important?

 

A good job profile describes every task and function of the job with detailed physical demands for each task.  A good job profile can:

 

  • set out the requirements of the job which can optionally be used for post-offer testing
  • identify ergonomic risks that can be modified to avoid injuries in high-intensity job tasks
  • explicitly document the body regions most susceptible to injury for each job, allowing for targeted fitness programs that can proactively reduce injuries. Preventing injuries is preferable to treating them!

 

Job profiles need to be presented in a “user-friendly” digital format, using accessible graphic displays and even annotated videos of the job being performed. Users need to be able to manipulate the data to find exactly the level of detailed information they require.

 

 

Easily Share Roadmap For Recovery

 

If and when an occupational injury occurs, the job profile should be electronically shared with the employer’s claim and medical managers, whether the employer self-manages claims, or these services are performed by an external TPA, carrier, or by other managed care entities. This is invaluable as the claim/medical team now has a “roadmap” for the recovery and rehabilitation process, aiming to achieve the specific physical demand goals depicted in the job profile.

 

 

The job profile can and should be securely shared electronically with treating clinicians (physicians, therapists, etc.) who now have accurate information to rely on for treatment planning purposes.

 

  • Progress can be easily monitored against job demands, enabling timely decisions about restrictions/limitations and return-to-work capabilities, as well as an assessment of the efficacy of the current treatment regimen.
  • Should the claimant achieve maximal medical improvement short of his/her present job demands, the residual capabilities can be automatically compared to all other available jobs in the employer’s database to match the claimant to other suitable employment available at his/her company (or elsewhere ).

 

 

Job Profiles Are Critical To Optimally Manage Human Capital

 

In summary, job profiles are critical for employers to optimally manage their valuable human capital proactively to maintain fitness, safety, and productivity, as well as for the cost-effective management of medical recovery, rehabilitation and return to work when occupational injury or illness occurs.

 

 

Jacob Lazarovic MD, Medical Advisor at Amaxx LLC, has considerable experience in managed care, including 18 years as chief medical officer at Broadspire , a leading TPA. His department produced clinical guidelines and criteria to support sound medical claim and case management practices; participated in analysis, reporting and benchmarking of outcomes and quality improvement initiatives; developed educational and training programs that updated the clinical knowledge and skills of claim professionals and nurses; provided expertise to enhances the medical bill review process; and operated a comprehensive and unique in-house physician review (peer review) service. He has been published extensively in industry journals and has held several senior medical management positions at companies including HealthAmerica, Blue Cross/Blue Shield of Florida and Vivra Specialty Partners

How to Use HIPAA to Obtain Timely Medical Records

Members of the claims management team obtain medical records on a frequent basis when investigating workers’ compensation claims.  It is important they do this promptly given the many constraints of workers’ compensation laws.  Given the nature of these requests, state and federal privacy laws come into play.  Failure to understand these laws and their requirements can lead to delay and problems down the road.  Now is the time to better understand these laws and how to incorporate them into your team’s best practices.

 

 

It All Starts with HIPAA

 

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) serves as the basis for healthcare privacy and the dissemination of medical records in the United States.  The law was enacted in 1996 to address the many issues medical providers were facing and to protect the privacy of all individuals.  In essence, it serves as the baseline for standards enacted at the state level for all covered entities.

 

 

Understanding the Basics of HIPAA

 

To understand the law, it is important to understand when it applies and whom it protects.  HIPAA applies to all “covered entities,” which are defined under 45 C.F.R. §160.103, as:

 

  • Health care providers who transmit “protected health information;”

 

  • Entities that process personal health information (healthcare clearinghouses);

 

  • Health plans such as Group Health Plans; and

 

  • Any business partner of a “covered entity.”

 

It is also important to note that the federal law applies to “protected health information,” otherwise known as PHI.  This is information defined under 45 C.F.R. §164.501, which is individually identifiable health information maintained or transmitted in any form, whether electronically, on paper or orally.

 

 

Exceptions to HIPAA in Work Comp

 

Employees at healthcare providers are required to know and understand HIPAA and have a duty to protect a patient’s PHI.  Training is required for these entities as part of their ability to do business.  Problems arise when employees at these facilities do not understand the nuances of HIPAA and how a state workers’ compensation act allows members of the claims management team to obtain PHI without properly executed authorizations.  One such exemption is found under 45 C.F.R. §164.512(l), which states, “A covered entity may disclose protected health information as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.”

 

 

Effectively Using the “Work Comp” Exception

 

Although this exception to HIPAA allows for easier access to a patient’s PHI, there are important limitations and requirements one must first understand.  Failure to understand these issues can result is frustration, delay, and sanction.

 

  • The permissible release of PHI is limited to only medical records directly related to the work injury in question. It does not provide for the cart blanche release of “any and all medical records;”

 

  • State workers’ compensation and other privacy laws often require the requesting party to notify the injured worker in writing they are making a request. Additional requirements sometimes require the requesting party also to disclose the medical records obtained from a provider to the injured party; and

 

  • Failure to make the necessary request disclosures may result in a sanction against the requesting entity.

 

It is also important to note that medical providers releasing documents under this exception may charge the requestor reasonable copy and retrieval fees.

 

 

Conclusions

 

It is important for members of the claims management team to obtain medical records in a timely manner.  Part of this can include the request of medical records related to a workers’ compensation claim under HIPAA without obtaining written authorization.  Before making these requests, it is important for claim handlers to know the necessary rules and follow them to avoid problems down the road.

 

 

 

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 Started Reducing Workers’ Compensation Risk

5 Ways to Get Started Reducing Workers’ Compensation RiskA lot of employers strive to be a safer, more productive workplace for their employees. Every business would love to reduce costs and increase profit margins. The cost of workers’ compensation claims can have a significant impact on the company bottom line, particularly if you are self-insured or self-administered.

 

So how do you get started? Where do you start, or better yet when do you start? The answer is RIGHT NOW, and here is how:
 

  1. Know Where Your Risk Lies

 

Observe your workplace. Go through department statistics and see how they all compare to each other regarding losses. Perhaps 75 percent of your injuries occur in the shipping department. Go down there and talk with the supervisor. Find out what their issues are and why they think injuries are happening. Then, work together to solve the problem.

 

Another helpful thing to look at is your loss run. Talk to your carrier or adjuster and see if they notice any trends in injuries, or which people are getting injured. Maybe the newer hires account for a lot of the injuries. This may show that a focus needs to be directed towards training and safety right from day one of their employment.

 

Look at your business. What do you do? What are the risks involved? You could have risk in several areas, stretching from workers comp to automotive issues with your fleet and the drivers, to liability risk from customers in your store. Break it all down, and start to track your statistics. Identify issues, and work on thinking of ways you can reduce your injuries or occurrences from happening in the first place.

 

 

  1. Plan Your Attack

 

If you have identified a few areas in which you could improve by reducing injuries or claims reports, what do you do to fix it?

 

The answer lies in the resources you have all around you. The first step is to talk to your carrier. Chances are they have the loss-prevention specialists ready to help you work with what needs to be fixed, and how to fix it. Ergonomic professionals can be brought in to address your workstations, and suggest possible solutions to reduce exposure.

 

Utilize your medical clinic contacts to see if occupational physicians can watch employees doing their work to identify potential issues with certain movements or repetitive motion injuries. Or, maybe it’s time to consider having your own in-house occupational clinic for a proactive strategy. Utilize your local council, and have them come in to explain the risks and costs associated with potentially serious injuries, automotive accidents, failure to drug test your employees, etc. Any or all of these will help you get to your goal of reducing your exposure.

 

 

  1. Implement Your Solution Plan

 

Once you have identified what needs to be fixed, and how it should be fixed, now it is time to fix it. Get rid of that old equipment and bring in new equipment that has better safety features. They cost less to maintain and repair, and they are quicker to operate. Most new machines use less energy than the old ones, reducing your utility bills and creating worker ease of operation. Get some padding on the floor for workers to stand on during work at their workstations (also known as “fatigue mats”). This reduces strain on their feet and legs, and reduces body fatigue, potentially making them more productive after long hours at the workplace.

 

Whatever the fix may be, get it done — out with the old, in with the new.

 

 

  1. Measure Your Success Statistics

 

Once new equipment is installed, and in place, it is time to measure your reductions. Measure your numbers in a two, four, and six-month stretch. Did you see any drop in claim activity? Did claims increase, making your plan backfire? You have to see how you did, and most importantly, you have to give it time. Change is disruptive to employees, but they will get used to it. Give it time, and measure your numbers post-change against the ones you first noticed back when you were figuring out where your risk was coming from.

 

 

  1. Get feedback from your workers

 

After all, you have done, you left out the most important thing: To talk to your staff of workers about the changes. How do they feel it impacted their workday? Were the changes helpful, or did they hurt production? How do they feel at the end of the day? Do they feel less sore or are the new workstations worse than the old ones?

 

Ask as many questions as you can. This makes your staff feel that their input is important, and taken into account. After all who better to talk to about the changes that were implemented than those who were directly affected day after day?

 

 

Summary

 

It is hard to break old habits and accept change. Even though it is hard work to find out what your risks are, how to attack them, implementing your changes, measuring your success, and getting worker feedback, in the end, it will be worth it. Lean into the task; don’t try to tackle it all at once.

 

 

 

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.

Proper Claim Reporting Parameters for Self-Insured Employers

Proper Claim Reporting Parameters for Self-Insured EmployersSelf-insured employers (SIE) for workers compensation take on the role of claims management in exchange for the cost savings of self-insurance. Whether you elect to self-handle all of your workers’ compensation claims or to hire an independent third party administrator (TPA), you need to be able to verify claims are handled properly. Rather than reviewing the adjuster’s every activity and item of documentation, it is more time efficient if the SIE claims manager requires the adjuster to submit written reports on all efforts to move the claim forward.

 

 

First Report of Injury

 

The initial report, (First Report) and subsequent reports, (Status Reports) are submitted on a predetermined frequency schedule. Most self-insured employers opt for the First Report submission within 14-15 days of the report of the claim to the claims office. Sometimes a SIE elects to have the First Report submitted by the 30th day of the claim. Status reports are routinely placed on a 30-day reporting cycle, with older claims moved to a 60-day or even a 90-day reporting cycle, depending on the amount of activity on the claim.

 

 

For consistency in reporting and ease in reading the reports, the establishment of a reporting format is standard protocol. The First Report is all inclusive covering all aspects of the claim. In the initial report, the adjuster discusses each of these areas:

 

  1. Coverage– policy number where applicable, policy dates, applicable deductible for loss location.
  2. Accident description– date and time of accident, location within the insured’s premise or if away from the premise, where and why away from the premise.
  3. Insured location– includes the department or unit, the street address and the type of work performed at the location.
  4. Employee – name, age, social security number (edited if required by state law), how long employed, years experience in the current job, number of dependents (if the number of dependents might impact the indemnity rate), prior injuries including both workers comp and non-workers comp injuries, summary or recorded statement when appropriate.
  5. Jurisdiction– the state where the injury occurred or federal benefits.
  6. Investigation – a discussion of the investigation and all the applicable information learned about the accident.
  7. Compensability– why the claim is compensable or why it is being controverted.
  8. Reserves– the expected cost of the claim divided into indemnity benefits, medical benefits, and expenses for the anticipated life of the claim.
  9. Nature of injury– the treating physician’s diagnosis.
  10. Medical care – the treating physician’s prognosis, the expected recovery time, plus any information on surgeries, hospitalization, and projected length of recovery.
  11. Indemnity benefits– the average weekly wage, the indemnity benefit rate, the availability of light duty work, the estimated return-to-work date.
  12. Rehabilitation and Physical Therapy – the reasons for rehabilitation, whether it is physical or vocational, the length of rehabilitation and the facility or provider of the rehabilitation service.
  13. Subsequent injury fund – in states where available, the anticipated amount that can be recovered from the state fund.
  14. Subrogation – whether or not there is a third party from whom the cost of the claim can be recovered, and if so, the identity of the responsible third party, the theory of negligence, the preservation of evidence, the employee’s right of recovery vs. the employer’s right of recovery.
  15. Action Plan– steps to be taken to move the claim forward and the potential barriers to resolving the claim. These are often called Specific Plans of Action (SPOA). An SPOA is a “real” plan, not just the adjuster saying they are trying to close the claim…
  16. Litigation– if the claim is being contested, the name and address of the defense attorney, the issues in contention, the probable outcome of the claim, and the anticipated legal budget.
  17. Future report date – when the claim will be reported again.
  18. Attachments– any pertinent information to the claim the adjuster believes the claims manager may wish to review or all documents to the claim if the reporting guidelines dictate same.

Note: If Nurse Triage is employed, a report from the triage nurse will be sent to the carrier automatically before the claim is even made. This type of immediate medical advise often obviates the need for medical care at a clinic or prescription medication, and the injury may never turn into a “claim.” This is especially true if the injury is treated with “self care” by the employee .e.g. ice your lower back, etc.

 

Status Reports

Status Reports normally do not repeat all the information covered in First Reports. It is standard protocol for status reports to be limited to the topics that have changed or are the subject of change. For instance, the status reports would not repeat the information on coverage, accident description (unless new information becomes known), insured location, employee, jurisdiction, compensability, or the nature of injury. ASK for the “grades” of your adjusters. Yes, “grades,” some TPAs score or grade the adjusters files each month and post the grades on the bulletin board! You want the adjusters with high grades!  If the adjusters do not have grades above 80, they are sent for remedial training; if their score is > 85 they receive a cash bonus and if higher than 95 they receive a larger cash bonus in their paycheck that month.

 

However, the status reports usually restates the reserves and explains any changes in the reserves, the status of the indemnity benefits, the status of the medical care, the progress in rehabilitation (when applicable), the status of the subrogation claim or second injury fund claim (when applicable), the status of the litigation (when applicable), the action plan and the next report date.

 

In essence, proper claim reporting is designed to provide the claims management of the self-insured employer with all the information needed to properly oversee the workers comp claims, without the claims manager having to actually handle the claims

 

5 Steps To Implement a Safety Action Plan

A Safety Action Plan to identify and eliminate physical, ergonomic, biological and chemical exposures will assist the employer in the reduction of the number of work-related injuries and occupational diseases.  By having a Safety Action Plan, the employer is taking a proactive approach to providing the employees with a safe place to work.

 

This article is too limited in space to provide you with a fully operational Safety Program, but we will give you the broad outlines of a Safety Action Plan to assist you in creating or improving your Safety Program.

 

 

The 5 Steps of a Safety Action Plan   

 

 

  1. Identify all the hazards

 

  1. Establish who is responsible for eliminating each hazard

 

  1. Plan a course of action to remove the hazards

 

  1. Take the necessary corrective actions to eliminate the hazards

 

  1. Establish a system to prevent the hazard from returning

 

 

Step 1: Identify all the hazards:

 

If you have not already compiled a list of potential job hazards that could cause injury or damage to equipment, you should do so.  Incorporate the employees into identifying the job hazards.  Ask each employee to list the 5 biggest safety hazards in their job.  Not only will you see most of the job hazards you have already identified, but you will also learn of potential job hazards of which you were not aware.

 

 

Step 2: Establish who is responsible for eliminating each hazard:

 

Once you have compiled your list of job hazards, place the name of the unit supervisor or department manager, or senior executive who is responsible for the eliminating the hazard.  Lower management can correct simple hazards like improper storage of supplies.  More complex hazards requiring a revision of the work process or a change in the physical facility structure will necessitate the involvement of senior management.

 

 

Step 3: Plan a course of action to remove the hazards:

 

Once the hazard has been identified, and the person responsible for eliminating or correcting the hazard has been identified, a course of action to accomplish the hazard elimination must be determined.  Identifying the hazard will not accomplish anything for the employer if the steps to remove the hazard are not established.  By knowing what needs to be done, the process to achieve the elimination of the hazard can move forward.  The plan of action should include the completion date to facilitate its timely accomplishment.

 

 

Step 4: Take the necessary corrective actions to eliminate the hazards:

 

Implementation of the plan of action is critical to the success of the Safety Action Plan.  Identifying the hazard and determining how to correct it will not matter if the necessary corrective actions are not taken.  The employees who have assisted you in identifying the hazards will judge everything in the Safety Program by whether or not management was serious about removing the hazards.  When the corrective actions are taken, and the hazards are eliminated, the employees will be more safety conscious as they understand management is serious about their safety.

 

 

Step 5: Establish a system to prevent the hazard from returning:

 

Some safety issues, like cluttered storerooms or spills, have a happy of returning if steps are not taken to prevent the hazard from reoccurring.  Management can best address these safety hazards by continuous emphasizing the importance of safety.  Each employee should understand safety is not a one-time correction, but a continuous, on-going process.

 

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the co-author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:.

Contact: RShafer@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.

 

 

 

 

Overcome Catastrophic Claim Settlement Resistance With Support

Overcome Catastrophic Claim Settlement Resistance With SupportAs much as some injured workers’ complain about workers’ compensation, the system has some perks like a nurse case manager and adjuster to help coordinate appointments, deal with the administrative burden, and check in to ensure everything is going smoothly on the claim. Giving up this support can be a paralyzing fear and prevent a claim settlement.  This challenge is particularly true in complex catastrophic cases.

 

The good news is professional administrators are becoming increasingly popular — even Medicare “highly recommends” using them. Some of these organizations are going the extra mile to provide true one-on-one help for injured workers with complicated needs.

 

 

Professional Administrators

 

Professional administrators handle many of the administrative tasks on behalf of the injured worker once they’ve settled their Workers’ Compensation claim.

 

Managing the settlement money, paying medical bills, and complying with government regulations such as Medicare reporting requirements can be a nightmare. The professional administrator acts as an advocate for the injured worker to ensure they successfully navigate the health care system post-settlement.

 

Additional tasks include:

 

  • Finding and setting appointments with appropriate physicians and specialists
  • Taking care of all durable medical equipment needs
  • Ensuring that, at the very least, any payments for medical care don’t exceed the state’s medical fee schedule
  • Deciding whether recommended medical procedures should be undertaken

 

The role of the professional is to guide the injured worker through this process, by

 

  1. Coordinating medical care
  2. Processing medical payments
  3. Applying discounts to medical office visits, medications, and procedures
  4. Performing annual prescription reviews to assess medications that are prescribed
  5. Complying with government requirements
  6. Answering any questions of the injured worker

 

 

Post Settlement Help for Catastrophic Cases

 

While the services of professional administration are a tremendous benefit and offer peace of mind for the majority of injured workers who settle their claims, some need additional help and support. For them, a new service is appropriate.

 

Some professional administrators have developed teams of nurse care partners that specifically focus on injured workers with particularly complex medical situations; those who are brain injured, wheelchair bound, suffering from limb loss and depression and have difficulty with activities of daily living. Despite the shortcomings of the workers’ comp system, many in this situation are hesitant to settle their workers’ compensation claim for fear of losing the system’s support.

 

This innovative solution of providing nurse care partners provides a holistic focus on the injured worker. These partners will engage in conversations with injured workers, providing guidance and support about their treatment plan, medications, upcoming surgeries and any other concerns they have. This discussion allows the injured worker to make informed decisions about their healthcare, empowering them to take control of their lives. Additional benefits they provide include:

 

  1. Ensure monthly supplies of medications are provided on time
  2. Discuss potential post-surgical complications and recovery
  3. Provide insights into the long-term effects of medications and treatments related to the injured worker’s condition
  4. Assist injured worker in understanding their health care options, empowering them to make their own healthcare decisions
  5. Coordinate treatments for any unexpected complications that may arise
  6. Finding solutions to durable medical equipment needs
  7. Identify and discuss potential savings opportunities with the injured worker so they can make their own informed decisions
  8. Provide one-on-one support

 

 

Case Study: Henry* (case study provided by Ametros)

 

Henry* had lost both legs after a severe motor vehicle injury over two decades ago. In addition to his medical issues, he also suffers from depression, anxiety, and Post-Traumatic Stress Disorder.

 

Roadblock to Settlement

 

  • The only thing stronger than Henry’s desire to settle his claim was his concern over losing the support of the nurse case manager with whom he had developed a close relationship throughout the years.
  • He learned of the post-settlement assistance he could receive through a professional administrator and was encouraged to settle, though not fully convinced.
  • He knew he required an extra level of support.

 

Catalyst to Settlement

 

  • What ultimately changed Henry’s mind was learning about Ametros’ Health Navigator service and how its post-settlement care could impact his life.

 

Post-Settlement Care

 

  • As promised, Ametros sent a nurse, Melody, to meet Henry and conduct a wellness assessment in-person to understand all of his wants and needs. She established a direct line with Henry, built a rapport and let him know she would be available to help him navigate the complex healthcare system.
  • Before Henry settled his claim, Melody gathered all the medical information needed to make sure the transition would be smooth.
  • Henry settled his claim last December and Melody continued to act as Henry’s dedicated Care Partner.
  • Since then, Melody has been working with Henry closely. Initially, Henry contacted Melody multiple times each day with questions and concerns she could help address. His contacts are less frequent now, but he has come to trust and rely on her to be his advocate.

 

*name changed for privacy

 

 

Conclusion

 

Knowing that someone will be available to help navigate the complicated healthcare system leads many injured workers with long-standing claims to agree to settle. Now there is an extra layer of advocacy to help the most seriously injured take charge of their lives.

 

 

 

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.

How To Get the Most From A Workers Compensation Claim File Audit

How To Get the Most From A Workers Compensation Claim File AuditSelf-insured employers, insurers, third party administrators, and government entities all use workers’ compensation claim quality audits to measure the performance of the claim adjusters, supervisors, and over-all claim staff. Common uses of claim file audits include measuring compliance with Best Practices, verifying the accuracy of reserves, identifying leakage, preventing fraud, and improving subrogation recoveries. As self-auditing often results in the inability to see the forest due to all the trees, claims management frequently turns to an outside independent claim file auditor to ensure unbiased and objective opinions in the claim audit.

 

 

Both Closed and Open Claims Files Should be Audited

 

Critics of claim file audits often complain that audits are retrospective, as the Best Practices have already been missed or the leakage has already occurred. The critics are correct if only closed files are being reviewed. However, when open claim files are audited, and the audit results are acted on promptly, substantial savings can be had.

 

When open workers’ compensation claims are reviewed, issues that have been missed can often can still be corrected. This is true because once the claim is paid and closed, it is too late to investigate compensability, arrange for an earlier return to work, provide proper medical management, adjust incorrect reserves or negotiate a better settlement.

 

A complete claim file audit not only provides a report on the correct or incorrectness of individual files, but also includes an aggregate report of the various claim handling procedures that have been reviewed. The most common way of tabulating or scoring an audit category is based on 100%. Usually, a score of 90% or higher is considered acceptable, and a score of 95% or higher is considered good. Hence, a score of 96% in the category of medical management would be good, but a score of 76% would indicate a lack of quality in medical management and the need for the adjuster to improve in this area.

 

When the claim file audit is limited to open files, the adjuster/supervisor/claims manager has the opportunity to correct files where an important part of proper claims handling has been missed. In the above theoretical example where the claims office scored 76% in the medical management category, the aspects of the medical management that have been missed could be completed. This would positively impact the overall medical cost of the claim and possibly also reducing the indemnity portion of the claim by getting the injured employee back to work faster.

 

 

Management Benefits By Identifying Weak Spots In Claims Handling

 

By identifying both individual files where claim handling errors occurred and by identifying claim handling categories where either an adjuster is weak or the entire claims office is weak, management benefits in several ways, including:

 

  • Management can focus training resources on specific issues, whether with a single claims adjuster or the entire claims office
  • Data provided can be used by claims management to support the need for procedural changes, additional personnel, or personnel restructuring
  • Reserving data can be used to verify the accuracy of, or the need to adjust coverage underwriting

 

By having an independent claim file audit, the self-insured employer, insurer, third-party administrator or government entity can use the information gathered to improve the overall quality of the claims handling, and in doing so, significantly impact the cost of workers’ compensation claims. For more information on how an independent claim file audit can improve claim quality and reduce the cost of claims, please contact us.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©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.

Proper Claim Management Requires a Strategic Plan of Action

Proper Claim Management Requires a Strategic Plan of ActionKeeping track of everything the workers’ compensation adjuster needs to do is not easy!  Every adjuster will have numerous claims, and each claim will have many things that need to be accomplished to move the claim forward.  Proper claim management recognizes the difficulty and the enormity of the task of trying to move all the claims forward at the same time.  There are often conflicting demands on the adjuster’s time and resources.

 

 

Best Practices Call for a Strategic Plan of Action

 

To alleviate the burden of keeping track of everything that needs to be done, the insurer’s/ self-insured’s Best Practices provide the adjuster with a roadmap to what needs to be completed.  Even then, it is still a challenge to accomplish everything that needs to be done on each claim file.  To prioritize the adjuster’s work on each file and to obtain the proper resolution of the claim, Best Practices call for a strategic plan of action.

 

When an adjuster receives a new claim, Best Practices will require the adjuster to verify coverage; contact the employer, employee and medical provider; and set the initial file reserve all within the first 24 hours of the claim.  Once these must-do items are completed on the new claim, the adjuster will review the facts developed and create the initial strategic action plan for the future actions to be completed on the file.

 

 

Initial Strategic Action Plan

 

The initial strategic action plan should contain both the activity to be accomplished and the date it will be accomplished.  The action plan can be included in the adjuster’s file notes, or it can be a stand-alone document.  The activities to be included in the initial strategic action plan can include:

 

  • The next contact with the employee to learn the employee’s medical status, work restrictions and return to work status and a date for completion of this activity

 

  • Verification of the receipt of the initial medical report and work restrictions, if any, and a date to complete this activity

 

  • The next contact with the employer to establish the availability of modified light duty within the employee’s work restrictions and date to complete this activity

 

  • Verification of the receipt of the documentation of the average weekly wage and the date it is to be completed

 

  • Completion of any remaining investigation (Best Practices normally dictate the completion of the investigation within 14 days of the claim being reported) and the date the investigation is to be completed

 

  • A determination to accept compensability or to deny the claim, and the date the decision must be made

 

  • Issuance of the first temporary total disability benefits check and the date it must be completed

 

  • Placing a third party on notice of subrogation and the expected completion date

 

  • The ISO filing and the date it is to be completed.

 

  • The filing of all state forms and the date(s) each form is due

 

  • If the claim is reportable to an insurer, excess insurer or any other party, the completion of the report and the date the report is due

 

  • The date for the next strategic plan of action (normally 30 days after the first strategic action plan, but the time frame can be longer or shorter depending on the facts and circumstances of the claim)

 

The strategic plan of action is not static, but constantly evolving.  As activities are completed, and additional information is obtained, a new strategic action plan is developed.  Over the course of the claim, the one claim file can include numerous strategic action plans.   Normally, by the time the second strategic action plan is created, the activities in the initial strategic action plan have been concluded.  If there are activities in the first strategic action plan that the adjuster could not accomplish, for any reason, the activities are carried over to the second strategic action plan.  This is true for all future strategic action plans with any incomplete activity being carried over to the next strategic action plan.  This prevents needed activities from being missed.

 

 

Subsequent Strategic Action Plans

 

Subsequent strategic plans of action after the first action plan will include new steps/activities that need to be taken to move the file forward.  These activities and their due dates can include:

 

  • Reevaluation of the file reserves

 

  • Evaluation of the need for a nurse case manager on the claim, if one is not already assigned

 

  • Coordination of return to work full duty or restricted duty

 

  • Obtaining and evaluating medical reports of the on-going medical treatment

 

  • Regular and on-going follow-ups with the employee, employer and medical provider

 

  • Obtaining and evaluating the disability rating

 

  • Subsequent reports to insurers, self-insurers or other parties

 

  • Subsequent ISO filings

 

  • Completion of any additional state forms

 

  • Scheduling and obtaining a peer review or independent medical examination

 

  • A litigation plan and litigation budget if defense counsel have to be involved

 

  • Settlement evaluation, including both the strengths and weaknesses of the proposed settlement

 

  • Notification to Centers for Medicare and Medicaid Services if a Medicare Set-Aside Arrangement is needed

 

  • Settlement of the claim

 

  • Obtaining all required waivers and/or releases

 

The strategic plans of action keep the adjuster focused on moving the claim to a conclusion.  By using the strategic action plan to accomplish all needed activities on the file in a timely manner, the adjuster obtains the best possible outcome for both the injured employee and the employer.

 

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the co-author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:.

Contact: RShafer@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.

 

 

 

4 Ways to Stay Vigilant On Specialty Medication Costs

The latest trend in medications for injured workers is good news indeed — for the most part. But one tiny area can add up to major dollars. Spending on specialty medications increased 3.8 percent in 2017, according to the latest Drug Trend Report from myMatrixx, an Express Scripts company.

 

The fact that these drugs represent less than 1 percent of all medications used by injured workers is by no means a reason to overlook them. Because of the high costs associated with specialty medications, payers need to stay vigilant in understanding and addressing this small but growing segment of pharmacy spend.

 

 

The Issue

 

HIV, osteoarthritis, high cholesterol, and hepatitis C are among the comorbidities that require prescriptions for specialty medications. Just over 2 percent of injured workers used one of these drugs last year, accounting for 0.6 percent of all prescriptions filled and 6.3 percent of total pharmacy spend.

 

The most used specialty drug for injured workers in 2017 based on per-user-per-year spend according to myMatrixx, was Truvada®, used to treat pre-exposure to HIV. The cost per Rx was $1,019.11. The overall use of medications to treat HIV increased by 17.6 percent — not too surprising considering the need for them to treat workers with occupational exposure to needle sticks.

 

However, the use of medications to treat osteoarthritis rose 21.6 percent, while the cost per prescription increased 1.1 percent. The medication Synvisc had increased utilization of more than 58 percent. Driving the increase was likely the fact that workers may use the drug for repetitive stress injuries caused by activities that stress the knee joint — squatting, kneeling or lifting heavy objects.

 

The most expensive medication on the top 10 list is Epclusa®, with a price tag per Rx of $24,510. However, the drug has been hailed as curing the disease.

 

 

Affected Workers

 

Workers in a variety of occupations may need specialty drugs.

 

  • Medical workers may contract HIV and hepatitis C from blood-borne pathogens due to exposures to needlesticks.
  • Coal miners are at risk of black lung disease
  • Outdoor workers are vulnerable to Lyme disease.

 

Other reasons workers may need specialty drugs include postoperative blood clots and organ failure.

 

 

The Drugs

 

The top 10 specialty medications for 2017 according to myMatrixx were:

 

Drug                           Therapy Class

Truvada®                    HIV

Isentress®                   HIV

Synvisc-One®            Osteoarthritis

Xolair®                       Asthma

Enbrel SureClick®     Inflammatory conditions

Enoxaparin                  Anticoagulant

Repatha SureClick®   High cholesterol

Enbrel ®                     Inflammatory conditions

Xyrem®                      Anti-cataplectic agents

Epclusa®                    Hepatitis C

 

 

What to Do

 

It’s important for claims handlers and injured workers to have a clear understanding of how and why they are using these medications. They often require special handling instructions, for example. While denying a specialty medication to an injured worker in need would not be prudent, organizations can rein in costs and prevent overutilization by ensuring the drugs are used appropriately and judiciously.

 

  1. Train. Injured workers and those involved with the claim should know what side effects may be present with each specialty medication. Injured workers should be well informed about self-administering the medications.

 

  1. Monitor. These injured workers often need ongoing clinical monitoring and more intensive help from pharmacists and other caregivers to ensure they are taking the medications as prescribed, as patient adherence is crucial.

 

  1. Use specialists. Specialty pharmacies are better equipped and should be utilized for handling these medications, as they typically offer services not available at retail pharmacies. For example, on-staff nurses and physicians who are experts in the conditions and treatment are likely to be available only in specialty pharmacies.

 

  1. Engage physicians. Nurse case managers and other caregivers should work with treating physicians to make sure the injured worker is getting the proper medications and treatment. Some medications, including Repatha for high cholesterol, are appropriate only for a small number of patients and must be appropriately managed for patient safety and costs. Cancer medications are not usually included in workers’ compensation formularies and therefore may require prior authorization.

 

 

Conclusion

 

Specialty medications represent just a fractional component of prescriptions filled by injured workers, yet their costs can be nearly prohibitive. Since they offer an important lifeline for injured workers who truly need them, it’s important to see they are prescribed only where appropriate and are taken as prescribed.

 

 

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.

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