Course and Scope of Employment: Questions of Compensability

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

 

 

Case Study:  The Workplace Fall

 

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

 

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

 

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

 

 

Questions of “Risk” and “Position”

 

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

 

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

 

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

 

 

Applying the Standards – Differing Results

 

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

 

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

 

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

 

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

 

 

Investigating Troublesome “Course and Scope of” Claims

 

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

 

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

 

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

 

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

 

  • Instructions on workplace attire such as footwear, etc.

 

 

Conclusions

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

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

 

Hey there, Michael Stack here with Amaxx.

 

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

 

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

 

 

Injured Workers’ Often Cut Off From Work Friendships

 

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

 

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

 

 

Friendships Can Be Positive Support For Injured Workers’ Recovery

 

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

 

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

 

 

Visit Injured Workers at Hospital

 

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

 

 

Meet With Injured Worker Weekly at Company

 

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

 

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

 

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

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

5 Considerations For Effective Safety Program Incentives

Safety Program IncentivesSafety program incentives are a popular tactic as all good risk managers understand the importance of preventing injuries. From the employers perspective, the buy-in of the employees into the safety program should be a given, as the employer sees the safety program as protecting the employees from injury. However, the employees, especially the ones who have never been hurt on the job, may view the safety program requirements as hindrances in their performance of their work.

 

 

Unintended Consequences of Safety Program Incentives

 

To encourage employee participation in their safety programs, employers often add what they see as incentives for the employee’s to participate. For example, the employer may offer gift cards to local businesses with the size of the gift cards tied to the number of days the employer has gone without a report of a work comp claim. While some employees will view the gift cards as bonus compensation, it may have the unintended consequence of causing an employee with an injury to not report the injury due to peer pressure. If the injury develops complications due to the lack of timely medical care, the injury gets reported late and the cost of the medical benefits is higher than it would have otherwise been.

 

 

Safety program incentives can be used to create employee interest in the safety program and motivate employees (and managers and supervisors) to act and work in a safe manner. But, if the incentives become the focus of the safety program and actual safety is not the focus, then the incentives become interference in obtaining a true safe working environment.

 

 

Train Employees to Work Safely

 

Instead of the emphasis of the safety program being on the incentives, the emphasis should be on training the employee how to work safely. Educating the employee in the proper performance of their job will have a bigger impact on the overall safety record of the employer than an incentive program. If the employees do not know how to work safely, the incentive program will fail.

 

 

A tactic taken by some employers is to tie performance bonuses for managers and supervisors to the number of injuries reported at a work site. If the managers and supervisors are more interested in the bonus then they are their actual safety performance, they can go outside the lines of propriety by pressuring employees to not report claims or by delaying the reporting of claims until their bonus is paid. Any incentive program from managers and supervisors must have built-in safeguards to be sure all claims, big and small, are reported timely.

 

 

The safety program needs to be constructed where the employees are motivated to act in a safe manner and to promote safety with their fellow employees without anyone feeling there will be retribution for reporting an injury. If the employees feel there is retribution or retaliation for reporting an injury, the number of reported injuries may declined slightly, but the actual number of injuries does not decline.

 

 

When safety programs are tied to return to work programs, with only lost time claims being counted by the employer in awarding safety incentives or bonuses, there can be an abuse of the return to work program. There are situations where the employee following an injury is unable to perform any meaningful work for the employer. If the employee is returned to work anyway and sets in the cafeteria or break room all day doing nothing, it will have the unintended consequence of demoralizing other employees who see the injured employee as receiving preferential treatment.

 

 

Progressive Discipline Can Create Morale Problem

 

Some employers have tried tying safety programs to progressive discipline where injured workers are reprimanded for unsafe acts that result in an injury to themselves or others.   The problem of using progressive discipline is it usually has three or four steps including a written warning, probation, suspension and termination. Only the most careless of employees will have three or four safety violations or at-fault injury claims where they can be terminated for repeated violations of the safety program. While the progressive discipline approach can reduce safety violations, it can also create a morale problem, especially if the employee does not feel he/she acted in an unsafe manner.

 

 

For safety programs to be effective there needs to be:

 

  1. A screening program to prevent the hiring of people who are prone to accidents or who have a lax attitude toward safety
  2. A drug testing program that includes pre-hire testing, post-accident testing, random testing and for just-cause testing
  3. A culture of safety before profits or production within the company
  4. An integration of the safety program into the company’s quality control program
  5. A way to quantify risk and measure the results of changes with the work process

 

To prevent problems within the safety program, employers need to keep the focus of the safety program on training the employees, not on incentives for either the employees or the supervisors/managers. Safety program incentives should be used only as a way of obtaining the employee’s interest in the safety program. Properly educating the employees on how to work safely will have a much greater impact on worker safety than any incentive program.

 

 

 

Rebecca Shafer

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/

 

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

 

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

 

 

 

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

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

 

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

 

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

 

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

 

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

 

 

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

 

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

 

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

 

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

 

Total MSA Exposure — $326,925.

 

 

Solution:

 

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

 

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

 

 

Results:

 

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

 

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

 

 

Conclusion:

 

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

 

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

 

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

 

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Video Kinematics Produces Physical Job Demand Descriptions on Steroids

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

 

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

 

 

Why It’s Important

 

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

 

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

 

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

 

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

 

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

 

 

Physical Job Demand Descriptions

 

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

 

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

 

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

 

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

 

 

Study

 

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

 

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

 

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

 

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

 

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

 

 

Conclusion

 

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

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

3 Elements Needed In Workers’ Comp Medical Networks

 

How to Select the Right Workers' Comp Doctor

 

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

 

 

Getting Injured Employees Proper Treatment Is Core of Workers’ Comp

 

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

 

 

Broad vs Narrow Networks

 

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

 

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

 

 

Network Coverage

 

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

 

 

Network Access

 

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

 

 

Credentialing

 

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

 

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

3 Criteria Determine If A Workers Comp Claim is Covered

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

 

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

 

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

 

 

There must be an injury or an illness:

 

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

 

 

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

 

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

 

 

The injury or illness must be caused by the employment

 

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

 

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

 

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.

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