How To Ensure Your Adjuster Is Being All They Can Be

Workers comp adjusterIf you have ever felt an adjuster assigned to one of your workers’ compensation claims was not making a proper effort to investigate a questionable injury claim, you are not alone. Every large claims office has some really good adjusters, some acceptable adjusters and some unmotivated adjusters who are just going through the motions to make it to the next weekend.

 

If you contact an unmotivated adjuster about the status of their claims handling, the adjuster will tell you, that she is doing everything she can on the claim. The reason the adjuster will say that is because the adjuster knows that the employer most often does not know what can be done on the claim. If you want to really shake up the unmotivated adjuster and to get the adjuster moving forward full speed on the investigation of the claim, review the following list of investigation suggestions with the adjuster.

 

Check List of Investigation Tools:

 

  • Employer’s First Report of Injury form
  • Employee’s written report of claim form (in states where it is required)
  • Insurance Services Office filing (formerly known as the Central Index Bureau)
  • Contact with claim adjuster(s) on claimant’s prior work comp claims
  • Contact with prior employer(s) on claimant’s prior work comp claims
  • Medical records from claim files of prior work comp claims
  • Contact with work comp board/industrial commission for their records on prior claims (some states will not cooperate, other states do cooperate)
  • Employee’s detailed recorded statement
  • Recorded statement of any witnesses to the accident
  • Supervisor’s recorded statement
  • Police report on vehicle accidents
  • OSHA reports, whether federal OSHA or a state OSHA
  • Any other government agency records
  • Discussion of the claim with the employee’s attorney, if the employee is represented
  • Contact with any third party involved in the claim – driver of other vehicle in auto accidents, manufacturer of machinery that injured employee, manufacturer of defective product that caused employee’s injury, etc
  • Telephone contact with each medical provider to have the most recent medical report(s) faxed to the adjuster
  • Medical records for all medical appointments
  • Photographs of the accident scene
  • Diagram of the accident scene
  • Having the claimant call the adjuster after each doctor’s appointment to report on medical progress
  • Nurse case manager’s input on serious injury claims
  • Field case manager to meet with the employee and doctor, and to attend medical appointments with the employee
  • Review of claimant’s social media sites – Facebook, Twitter, LinkedIn, etc.
  • Employer’s personnel file on the employee, including job application, new employee forms, disciplinary records, etc.
  • Employer’s safety records for the accident location
  • Employer’s public notice of plant location closing, lay-offs, union issues, etc.
  • Referral of the claim to the Special Investigation Unit (the unmotivated adjuster may be quick to do this, as this passes the buck to someone else to do a complete investigation).
  • Outside Vendor Services (Investigation steps that can be taken, but not normally performed by the adjuster, but overseen by the adjuster).
  • Surveillance
  • Activity check
  • Neighborhood canvass
  • Background check
  • Credit check
  • Public records review / civil records searched
  • Criminal records check
  • Skip tracing
  • Clinic records sweep (checking for medical treatment at all clinics in the area of the employee’s address)
  • Hospital records sweep (checking for medical treatment at all hospitals in the area of the employee’s address)
  • Pharmacy records sweep (checking for prescriptions filled at all drug stores in the area of the employee’s address)
  • Video re-enactments of the accident
  • Examination under oath

 

Unfortunately, there is no central system where an adjuster can check to see if the employee is currently working another job. The use of a private investigator for surveillance can fill this void, but without knowing where an employee might be working, this is often a hit-and/or-miss approach.

 

It would be a very rare claim where it is necessary for the adjuster to take all of the investigation steps listed above. The key to an investigation is for the adjuster to take as many of the investigative steps as needed to verify the validity of the claim, or to disprove the claim.

 

We realize this checklist of the investigation steps your adjuster can take is incomplete. We welcome our readers to contact us with additional investigation techniques they would add to our investigation checklist.

 

 

 

Rebecca ShaferAuthor 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: http://blog.reduceyourworkerscomp.com/

 

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

 

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

Can You Spot the Workers Comp Fraud Red Flags?

Detecting Workers’ Compensation FraudCombating fraud in workers’ compensation claims is a skill that can prevent much frustration and save significant worker’ comp dollars.  While we can tell our readers the importance of fighting fraudulent claims and publish lists of red flag indicators of fraud, it is often difficult for the risk manager or workers’ compensation coordinator to separate the legitimate work comp claims from the bogus claims.

 

To assist you in recognizing the bogus claims, we are providing a sample claim, using the actual facts of a submitted workers’ compensation claim to see if you can recognize or spot ten red flags of a bogus claim (the name of the employee has been altered to protect the guilty).

 

 

The Claim:

 

John Doe works in an auto repair shop as a mechanic.  Upon arriving early for work on Monday morning, Mr. Doe went into the auto parts storeroom to get a part for the car he was going to work on.  While leaving the storeroom and using both hands to carry the heavy auto part in a box, he tripped over another box on the floor.  In an effort to keep from falling, he grabbed a storage shelf, twisting and injuring his shoulder as he fell to the floor.  No one saw him fall in the parts storage room as the other employees were just arriving for work.

 

Mr. Doe immediately reported the claim to the shop manager and explained to the manager how he fell over the box on the floor he did not see because of the box he was carrying with both hands.  The shop manager offered to take Mr. Doe to the nearest industrial medicine clinic, but Mr. Doe instead chose to take himself to his “family doctor”.  The family doctor took Mr. Doe off work and did not indicate when he would be able to return to work.

 

When the shop manager called Mr. Doe the next morning to see how he was doing, Mr. Doe’s wife stated he was sleeping and could be disturbed.  The shop manager waited and called Mr. Doe again that afternoon.  Per the wife, Mr. Doe had stepped out.  The shop manager asked for Mr. Doe’s cell phone number, but instead of providing the phone number, the wife promised to have Mr. Doe call the manager.  Mr. Doe almost immediately called the manager back to relay what the family doctor had said. The shop manager recorded the cell phone number of Mr. Doe.  When the shop manager called Mr. Doe’s cell phone the following week to see what the family doctor had to say after the second medical appointment, the background noises did not sound like the noise you would hear in a person’s home.

 

A second mechanic in the shop after being overworked for three weeks due to the absence of Mr. Doe advised the shop manager that he had heard through a mutual friend that Mr. Doe had injured his shoulder while rock climbing the weekend before the reported injury.

 

The claim has numerous red flags that could be a tip-off for workers’ comp fraud.  They are:

 

  1. Monday morning accident.  Almost twice as many accidents occur on Monday morning than any other morning of the week.  This is due to people claiming non-work related weekend injuries as work-related in order to not lose their source of income.

 

  1. Arriving early for work.  Unless the employee habitually arrives early for work, arrival for work early on the day of the alleged accident is an indicator the employee wanted to “have the accident” before other employees see he is injured.

 

  1. Not seeing a hazard he had just seen moments earlier. If boxes on the floor were a common occurrence, the employee would be careful about watching where he was going.  If a box on the floor was unusual, the employee would have made a mental note to avoid it.

 

  1. The mechanism of injury does not make sense.  If the employee was using both hands to carry a heavy box, how did he have a hand free to grab the storage shelf?

 

  1. The accident was not witnessed.  Bogus injury claims almost always occur where no one else will see the accident happen.

 

  1. The selection of a particular doctor over a more qualified doctor who specializes in treating injured employees.  This is normally a sign the employee wants a doctor who will accommodate his desire to be off work.

 

  1. A doctor who does not address return to work This is normally because the injured employee tells the doctor that he does not feel he will be able to meet his job requirements.

 

  1. The employee being asleep when he would normally be awake.  Unless the doctor has prescribed some very strong pain killers, the employee should be available to talk to the employer.

 

  1. The employee not being at home.  Occasionally not home is understandable, repeatedly not home/not available is usually a sign the employee has something better to do than being at home, i.e., possibly another job, either short-term or long-term.  Background noises that don’t sound like a spouse or a television often are an indicator the employee is working elsewhere.

 

  1.  Tips from co-workers.  This is probably the strongest evidence of fraud and should be investigated thoroughly.

 

None of these red flags by themselves are proof of fraud, nor is a combination of two red flags.  However, the more red flags the employer sees on a claim, the higher the probability the claim is fraudulent.  If you see multiple reasons to question the validity of a claim, the insurance adjuster and the special investigative unit of the insurer should be notified as to why you believe the claim to be questionable.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Shifting or Falling? A Look at Fall Rescue Plans and Safety Culture Shifts

Working at heightsBoth construction and general industry see too many fatal falls. Let’s look at the safety culture shifts that are needed at job sites to eliminate fall deaths.

 

 

Startling Statistics

 

In December last year, the Bureau of Labor Statistics issued some sobering statistics: Fatal falls accounted for 17% of total worker deaths in 2017 (887 deaths), which is the greatest number of fall-related deaths recorded in the 26 years of their census. Moreover, fatal falls are by far the leading cause of death in the construction industry (not including traffic collisions, which are counted in a different category), with nearly 40% of construction worker deaths.

 

 

Limitations of Fall Protection PPE

 

Fall-related deaths are preventable. And having a fall protection rescue plan isn’t just a smart idea- it’s the law.[1] Workers can survive falls from heights by using PPE fall arrest systems (OSHA specifies PPE must be used six feet above a lower level for construction, whether that be above a roof or a hole, and four feet in general industry), but fall protection PPE is not enough. Fall deaths can occur even after PPE does its job.

 

In some cases, workers can successfully self-rescue using their own PPE. In other instances, assisted self-rescue, that is, PPE plus a mechanical rope/hauling system, is possible. Both of these scenarios assume that the worker who fell is conscious and physically capable of aiding themselves. A third scenario envisions a fall where the worker is unconscious or has sustained injuries that would prevent them from aiding themselves; this means a fully assisted rescue is necessary.

 

In the scenario where the fall victim is unconscious, we can immediately see how the risk of death may be imminent. What may not be so obvious is the additional risk of suspension trauma (also called “harness hang syndrome”), which is fast-acting and can be lethal- even for a fall victim who is initially conscious and uninjured. The combination of a person’s suspended weight in a vertical position and limited ability to move (and thus maintain blood circulation) can result in serious injury or death. The Emergency Medicine Journal has noted that in harness design experiments, loss of consciousness occurred in seven to 30 minutes.[2]

 

The American National Standards Institute (ANSI) recommends fall rescue in six minutes or less. Six minutes is not enough time for most local 911 emergency medical services to respond and rescue. Additionally, 911 requires special resources for fall rescue (both in terms of equipment and trained personnel). Employers should not automatically assume that their local EMS has these resources available at the drop of a hat. Fall rescues, then, must be performed by trained onsite personnel who can react more quickly.

 

 

Fall Rescue Plans and Culture Shifts

 

But since job sites are often frequently changing environments, how can employers keep up with the demands of having an effective, up-to-date fall protection rescue plan? And what does this mean for workforces?

 

To begin with, employers must recognize and facilitate the safety culture shifts that are needed for fall protection rescue at their job site. Creating and maintaining an effective fall protection rescue plan causes a safety culture shift for both the employer and the workers. The frequency of these safety culture shifts will be as often as hazards, or potential hazards, change at a job site.

 

The first safety culture shift comes with the move from relying on 911 for a fall rescue plan to embracing an onsite, in-house rescue plan. This shift is foundational, and both employers and workers must embrace it together. If they are not on the same page in terms of safety outlook, little progress will be made.

 

Employers should remember that OSHA cites companies both on the basis of unabated workplace hazards and on the basis of unresolved potential workplace hazards. It’s good for employers to adopt OSHA’s recommendation and exercise their fall rescue plan, that is, have a “trial run” of an actual fall emergency;[3] this exercise is best conducted by outside qualified rescue experts.

 

Another safety culture shift comes with inviting qualified rescue experts to audit and evaluate a location’s existing fall protection rescue plan; these experts can help employers see where gaps and holes (literally and figuratively!) exist. From there, qualified rescue experts can create a site-specific fall rescue plan that incorporates that location’s SOPs and existing emergency action plan.

 

 

Amazing Things Happen When Workers’ Become Rescuers

 

More still, qualified rescue experts train workers to become authorized rescuers. This is also an important safety culture shift. When workers themselves become rescuers at their site, amazing things happen for morale and strength of workforce unity. Incentives and perks invite workers to become part of a rescue team, where they can take greater ownership of their work environment. This personal investment is a positive, active form of engagement for fall rescue plans (whereas waiting for 911 is passive).

 

Safety culture shifts are a reality for all job sites because hazard assessments, required by OSHA, must be comprehensive and continuous.[4] Whenever a new hazard is identified, policies, procedures, and programs must be updated. These updates necessitate shifts in the safety culture of a workplace. Fall protection rescue plans shouldn’t be viewed as an inconvenient “one more thing” to add to the list of updates, but rather should be viewed as part of an integrated whole that will protect workers and save lives.

 

 

 

Author Raymond Loch, Safety Training Services Leader, Medcor, is a certified safety professional with over 32 years of experience as an instructor, operator, and consultant in safety, emergency preparedness, and emergency response for general industry, construction and fire service.   He has developed and implemented training programs for OSHA compliance, technical rescue, and industrial fire suppression. Ray has worked with Fortune 100 firms and with small companies and government entities.  . http://medcor.com.  Contact: raymond.loch@medcor.com

 

Author Jason Funk, Worksite Safety Coordinator, Medcor helps employers reduce the costs of workers’ compensation and general health care by providing injury triage services and operating worksite health and wellness clinics. Medcor’s services are available 24/7 nationwide for worksites of any size in any industry. Headquartered in McHenry, Illinois, the company operates 174 clinics and provides triage services to over 90,000 worksites across all 50 states and US territories. Medcor’s triage methods are covered by U.S. & foreign patents, including U.S. No. 7,668,733; 7,716,070; & 7,720,692; other patents pending. Medcor is privately held. Learn more at www.medcor.com.

 

 

[1] See OSHA standard 1926.502(d)(20)

[2] Caroline Lee and Keith M. Porter, “Suspen­ sion Trauma,” Emergency Medicine Journal 24, no. 4 (2007): 237-238.

[3] OSHA Appendix E to Subpart M, “Non-Mandatory Guidelines for Complying with 1926.502(k),” Sample Fall Protection Plan.

[4] ‘See OSHA standard 1910.132(d)

Pro-Actively Stop Workers’ Comp Fraud Before It Starts

stop workers comp fraudLarge workers’ compensation insurers will have a special investigations unit (SIU) dedicated to fighting fraud and assisting the adjusters with various aspects of an in-depth investigation into work comp claims.  Self-insured employers and most medium and small size insurers do not have the claim volume or the expertise to have their own SIU.  The self-insured employers and the medium/small insurers know the importance of defeating fraudulent claims and the importance of in-depth investigations (intelligence data) beyond what the adjuster has the expertise (or time) to do.  When a need arises for SIU, these employers and insurers will outsource their questionable claims and specialized investigations to a company who can provide the SIU needed.

 

The SIU company will frequently provide the adjuster with an a la carte selection of services.  However, it has become common for SIU companies to partner with the self-insured employer or insurer with the SIU acting as if they were just another department within the self-insured’s or insurer’s company.

 

The service most often provided by the SIU is surveillance.  Unfortunately, the SIU investigator will not always be able to provide documentation the claimant’s disability is not as claimed.  The investigator can sometimes be looking for a needle in a haystack, all the while racking up large investigation fees.  The practice of ordering surveillance by default is all too common and unnecessarily spikes the cost of claims.

 

A recommended approach to limiting investigation costs is to pro-actively stop fraud before it starts.  The best SIU providers will offer a comprehensive approach by getting involved in the process early and showing significant workers compensation savings.  Two areas to work with your SIU provider on this comprehensive approach are in the hiring process and injury response.

 

 

Review Your Hiring Process:

 

  1. Are you using Integrity Testing?
  2. Are initial background checks being performed?
  3. Has the employee had any previous claims?
  4. Do they tend to carry out a claim over a long period of time?
  5. Do you require employment history and are you checking the references?
  6. Are you doing pre-employment physical examinations?
  7. Are you doing pre-employment drug testing?
  8. Are you checking social media for any red flag behavior?

 

 

Review Your Injury Response:

 

  1. Who is reporting the injury?
  2. How is it being reported?
  3. How much investigation, if any, has been performed at the time of injury?
  4. Is there an escalation process in place?
  5. When is your TPA/Carrier involved?

 

We recommend to not have surveillance set up unless it is certain that the employee will be moving. One of the best times for this is to coordinate with medical appointments. Another time is after bad weather that will cause the employee to move outside to fix damages from snowstorms, windstorms, ice storms, etc.

 

 

When an employee maintains they are unable to return to work due to the severity of their injury, the adjuster will request the SIU to do surveillance on the employee.  Surveillance is normally done covertly, that is without the employee knowing he/she is being watched.  The surveillance is usually done by one investigator, but if the location is complicated or the neighborhood is crowded, multiple investigators may be employed at the same time.  Both video surveillance and still photographs are taken whenever the claimant is visible.

 

 

Examples of Successful Surveillance:

 

  1. The claimant maintains he is unable to walk and must use a wheelchair.  The investigator obtains video of the claimant using a push lawnmower to mow the yard.
  2. The claimant maintains he is unable to lift more than five pounds.  The investigator obtains video of the claimant hand loading concrete blocks on his truck.
  3. The claimant maintains he is unable to work (for any number of reasons).  The investigator obtains video of the claimant working full duty for another employer while drawing disability benefits.

 

Unfortunately, the SIU investigator will not always be able to provide documentation the claimant’s disability is not as claimed. However, there are enough successfully completed surveillance cases that surveillance is standard procedure when there becomes a question in regards to the claimant’s need to be off work.

 

While surveillance is the most frequent service provided by SIU companies, there are numerous other services SIU companies provide, including:

  • On-site investigations of severe injuries
    • Injured employee’s statement
    • Employee’s supervisor statement
    • Co-worker’s statements
    • Witness’ statements
    • Pictures of the accident scene
  • Medical records searches
    • Identifying all medical providers within a specific radius of the claimant’s residence who have treated the claimant prior to the date of the alleged injury
  • Fraud
    • Developing a fraud prevention plan
    • Fraud procedures manual
    • Identification of “red flags”
  • New hire assistance
    • Integrity testing
    • Background checks including criminal records, liens, and judgments, social security number verification, licenses, assets check
    • Prior injury history
    • Social media checks – Facebook, LinkedIn, Twitter, etc.
    • Drug screening assistance
  • Locating people
    • Prior employees who are no longer employed
    • Independent witnesses
    • Skip tracing
  • Process Service
  • Alive and Well Verifications (confirming long term total disability claimants and spousal benefit claimants are still alive and entitled to the benefits they are receiving)

 

The proper use of SIU will reduce or eliminate leakage on many workers’ compensation claims.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

How Clear And Understood Is Your Return To Work Program?

return to workWhen an adjuster reserves a file, they focus on probable outcomes. The medical side of the file is usually pretty straightforward. An adjuster can tell based on risk drivers if a person will need surgery, extended rehab, or other procedures based on their medical history.

 

 

Return To Work Becomes Complicated When It’s Unclear

 

What is more difficult is whether or not this worker will return to work should light duty become available. What complicates the process is when the employer is just not sure if light duty work will open, when it will be available, or if they even want the worker to return at all.

 

Let me explain by using an example. Let’s say a worker needs a back surgery. The employer has light duty positions open, and tells the adjuster that once the worker has restrictions they will place them in work. So, the adjuster will plan to reserve for when the worker is off work post-operatively, and then target a range of when restrictions should be in place and the worker can get back to work.

 

What will complicate the file is a delay on the employer’s side in getting the worker into light duty. I have reviewed countless files where the employer has stated early on that work is open, but then delayed placing the worker into the light duty work program for weeks or months after restrictions were placed. This not only affects the indemnity costs on the file, but can inhibit the workers overall physical recovery.

 

Especially with a back surgery, the sooner you get the injured worker off the couch and back to work doing anything the quicker and easier their recovery will be. The last thing you want is the worker sitting around for weeks waiting for the phone to ring. Even worse is when the worker knows light duty in there, and cannot figure out why they can’t return to work.

 

 

Claimant Suspicion Can Lead to Higher Claim Dollars

 

Then the wheels start to turn in the head of the injured party. Maybe they are going to fire me? Why can’t I go back to light duty when I know other workers that returned to work after they had surgeries? Is my employer mad at me because I needed a surgery? Should I get an attorney just in case I get fired because of all of this?

 

Then when they talk to the adjuster, most adjusters will have no answers for them as to why they can’t return to work as well. After all, the employer told the adjuster that light duty work would be available. Why is this not happening for this claimant? Is the employer not being honest about something in regards to the employment future of said worker? Should I be reserving this file for vocational rehab and start posturing for a potential settlement?

 

 

Failure To Communicate

 

The culprit here, as in many work comp problems, is a failure to communicate. In this example, the employer laid the groundwork for a simple return to work post-op in the light duty work program they have up and running. If there were some political aspects as to why this worker should not or cannot return to work, the adjuster needs to know. Not only for reserve forecasting, but for general return to work forecasting.

 

Should light duty work not be open for the employee for whatever reason, the adjuster has options to get the worker off the couch and working. The main option is to use an employment vendor that can find transitional light duty work in their own community. This way the worker is still working in some capacity, until they are released to perform full duty work for their own employer. Other options could include work hardening programs, which can be intensive therapy that can help the worker aggressively rehab and get to full duty status faster than traditional therapy methods.

 

The result of failure to communicate a return to work will result in under-reserving the file. In the end this helps nobody, and the carrier/TPA in general hates to under-reserve anything. It also will make the carrier question the validity of a light duty program in general, and many questions will start to be asked about why this claimant was not able to work light duty when it was promised early-on in the file. Certain carriers will provide discounted premiums based on the existence and use of light duty return to work programs, and if the employer is not delivering on their end of the deal, expect premiums to increase.

 

It will also create a rift between the worker and their employer. Why was this person singled out to sit at home when others were allowed to return to light duty and make their normal wage? It is almost as if you are penalizing this worker, for whatever reason.

 

 

Implement Your Return to Work Program Consistently and Communicate, Communicate, Communicate

 

At the end of the day, the employer has the option to do what they want with each worker. But the program has to be clear, and applicable to all employees regardless of the injury or surgery that was performed. If you have a light duty program, use it for all of your injured workers fairly. If for whatever reason any particular worker will not be able to return to light duty, make sure the adjuster knows way ahead of time so they can plan other work options accordingly.

 

Per usual, it all comes down to communication.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Dealing With “Off-Work” Disability Doctor Notes

off work disability note“Off-Work” disability doctor notes from employees stipulate that employers allow injured workers to stay off work due to a work-related injury. These notes include such things a “work status note,” “off work slip,” “disability note,” or even a “functional capacity worksheet.”  While many disability notes are valid, sometimes these notes are vague and unclear why the employee still needs to be off work.

 

The purpose of disability slips is to advise the employer when the medical provider does not believe the injured employee can do any work in their current medical status or is able to work only in a restricted capacity.  Running an effective workers’ compensation program requires employers and other interested stakeholders have clarity, conform to the law, and help get that employee back to work promptly.

 

 

Demanding the Basics for Injured Employee Disability

 

The quality of the disability slips covers the spectrum from telling the employer everything about the injured employee’s injury and disability, to telling them nothing at all. The lack of uniformity can create issues for the employer in tracking the status of the injured employees.

 

Some jurisdictions have minimum requirements when it comes to disability slips following a work injury.  Florida’s Division of Workers Compensation mandates every medical provider use the same Medical Treatment Status Reporting Form, DWC-25.  This form serves two purposes.  It requires the health care provider to outline the functional status of an injured employee, and report their treatment plan.  Even if a jurisdiction does not require a form to be completed, the interested stakeholder can take proactive action to demand it.

 

 

Avoid Employee-Determined “Off-Work” Status

 

When the medical provider does not provide the “off-work” slip, and the employer does not ask, the employee becomes the person determining when the employee will return to work. This is not a good situation for all interested stakeholders and turns workers’ compensation into an entitlement program.  Proactive employers should require a disability slip be turned in by the employee after every medical appointment.  This information encourages timely return-to-work and holds everyone accountable.

 

In some jurisdictions, the state department overseeing the workers’ compensation program can help employers obtain this information.  In Minnesota, a Health Care Provider Report is required to be completed and returned within 10 days of receipt by a medical provider.  The Department of Labor and Industry will follow-up with medical providers when such form is submitted.  Failure to respond can result in a penalty being assessed against the medical provider.

 

 

Take Charge with the Medical Provider

 

If the medical provider treating the employee is sending an off-work slip that states “no work until seen by this office again,” with no further information, the employer needs to take charge and advise the medical provider’s office more information needs to be provided.   At a minimum, the off-work slip should provide the date of the next office visit and the employee’s current physical limitations.  Basic information that should always be included should have the following:

 

  • The employee’s name
  • The date of the office visit
  • Whether the office visit was work-related
  • Objective findings
  • Diagnosis and prognosis
  • The existence of a pre-existing condition
  • The specific nature of any functional limitations, for example:
    • No bending
    • No carrying over ____ pounds
    • No climbing
    • No kneeling
    • No lifting over _____ pounds
    • Standing limitation ________
    • Sitting limitation _________
    • Walking limitation _________
    • Other relevant limitations
  • Date of next office visit
  • Anticipated full duty date
  • Anticipated date of Maximum Medical Improvement (MMI)
  • Date of next appointment
  • Anticipated treatment plan
  • Doctor or health care providers signature

 

 

Help Me, Help You!

 

Medical providers are in the business of providing medical care, and often have no knowledge about the employer’s business.  It is important for employers to let medical providers know about their business and the employee’s pre-injury position.  Relevant information to send can include a job description or video of the work the employee will be expected to perform.  This will allow the doctor or health care provider to better understand the employee’s job and its physical requirements.

 

 

Conclusions

 

Employers need to take the lead when it comes to returning employees to work following a work injury.  One important step in this process is making sure health care providers are properly completing disability slips with specifies about the employee’s restrictions and/or limitations.  By demanding this information, employers can receive a more honest assessment of the employee’s ability to work rather than letting the employee drive their time off work.  It will also reduce workers’ compensation program costs in the long run.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

How to Identify EARLY Indicators of Expensive Workers’ Comp Claims


This video is a 12-Minute Preview of the 60-Minute WC Mastery Training Course How to Identify EARLY Indicators of Expensive Workers’ Comp Claims.  

 

 

Okay. Hello everyone and welcome to workers’ comp mastery training. My name is Michael Stack and this is going to be a fantastic session. This is an extremely interesting and important topic. It’s actually one that I find quite fascinating. So the title is how to identify early indicators of expensive and problematic claims. So these are the claims that really keep us up at night. These are the ones that you’re like, I can’t believe it got to this place. These are the most frustrating claims. Really. The headline type claims when you’re telling stories, you know by the campfire, you are not going to believe what happened in this one type of thing. And the idea here is to get in front of those, get in front of those claims so that those stories by the campfire never have to happen. Those doozies of claims we can get in front of prevent and get them going in the right direction.

 

 

Hindsight is 20-20; Foresight is Priceless

 

They say that hindsight is 20-20 you look back and you say, Oh man, I wish we would’ve done this if we would’ve done this. And it wouldn’t have caused that, hindsight is 20-20 but foresight, which is what we’re talking about today, is really priceless for the impact that we can have on the individual lives of the injured workers. Because each one of those stories has a person behind it as well as then the costs that are associated with those claims, which we know are significant and major, major drivers of the entire cost of our program. So looking forward to going through this information. We have a tremendous guest, Dr Jake Lazarovic, Dr Jake, welcome to you. Happy to have your expertise on this session.

 

Well hopefully we’ll, we got your audio going here in just a minute. So let me get through and let me go through our three major points and let me go through the three major topics that we’re going to be covering. So the first topic is going to be talking about the cost and cause of these claims. So what is the cost and what is the cause behind these claims? What does that underlying piece to understand what’s actually happening. Next piece is then we’re going to talking about accurate claim screening techniques, accurate claim screening techniques. And we’re talking 90 to 95% accuracy on getting in front of these claims. One in fact are those techniques. And then the last piece, the third major point is we’re going to talk about those interventions strategies and actually implementing them. So once we understand the drivers, what’s causing them, understanding the techniques and how to identify them, then third pieces is gonna be, then how do you go ahead and implement those as this should feel like a live interactive session.

 

So we’ve got my computer and the bright behind the big screen right behind the camera here. So go ahead and type in questions, type in comments. This should be interactive. You can get feedback from myself if feedback from Dr Jake as we’re able to do throughout the session. But I do want to encourage you to make this interactive. That’s one of the greatest things about being live here together. All right, so let’s get down into this first major point and actually, oh one more administrative point is the outline for today’s session is in the GotoWebinar interface, so two places you can get that in the final email that I just sent you that said we’re starting now. There’s a link in there that you can download it and it’s also in the GotoWebinar interface so you can follow along. There’s a lot of content we’re going to be talking about today.

 

 

Cost & Cause of Expensive Claims

 

You can download the word document, take notes, write on there as we’re following along. All right, so let’s get down to business and let’s get into this first major point, which is the cost and cause of these really expensive and problematic clans. So firstly you want to talk about is the cost, and I want to put some context kind of behind this and have this really start to resonate. As far as a picture, I don’t want to do as good of a job as they can sort of drawing this. It’s probably not going to be as good as I would like it to be, but it will give us an idea of what we’re talking about. And so if you look at this picture on the board here, it’s a reverse pyramid. So we all sort of know the idea of a pyramid and at the bottom is most of the stuff, and typically at the top is at least, and we’ve seen this a lot of sort of different contexts, you see this and the hierarchy of needs and sort of a lot of different sort of contexts.

 

 

5% of Claims Account for 80% of WC Costs

 

We see this and I want it to present this just kind of visually so we can understand these costs and the drivers of them. We’ve heard so many times that 5% of costs are 5% of claims anyway. I account for 80% of costs, so 5% of work comp claims, I account for 80% of costs. And I’ve seen various statistics on that. That’s not maybe exactly 100% accurate. I’ve seen a lot of different places say, oh, it’s 10% that’s causing 80 to 90% of costs. I see. It’s 10 to 15% I see various references in various different places talking about this. So the numbers, exact numbers don’t exactly matter, but we need to understand the concept that its very few claims, whatever the exact percentage is, five or seven or 10 very few claims are causing the vast majority of the costs. So these are the big ones.

 

These are the ones we’re talking about today. Now in the middle here or sort of on the bottom or the top of this pyramid, you’re going to see about 80% which is the opposite of this. 80% of claims are only causing about 5% of costs. So the exact opposite of the top of this reverse pyramid is that the vast majority of the clams are pretty simple. Medical only claims, no big deal. Get your stitched up, get you back to work, Bada Bing, Bada boom, you’re rocking and rolling. So most of the claims we’re cranking right through the system and they’re not causing a huge amount of financial burden or much burden on the individual’s life, which is fantastic. And then in the middle here you have, you know about 15% of claims causing 15% of costs. And these are the last time the indemnity claims. No, you guys, these are the ones that you’re out of work for.

 

Oh, maybe a week, two weeks, something like that. Uh, you get you fixed up and you’re back to work. So visually, again, don’t get too caught up on the actual numbers themselves. But what we need to understand, particularly as we’re going into today’s session and we’re talking about sort of this context of how to address these claims and the importance of addressing these claims and the impact of addressing these claims is that we’re talking about a really big bucket of claims costs in a really small amount of actual planes themselves. And so the trick and what we’re going to be talking about today is figuring out when a claim comes along, you’ve got all these claims on your loss runs, which one of these is going to end up here in which one of them is going to end up here. And so if you’re looking at this huge number of claims, you see him coming in all the time.

 

 

Which 1 Claim Out of 14 Will Become Catastrophic?

 

Which one of these, you know, I’ve got six seven, I’ve got 14 sort of little lines on here, which one is going to be up here? And the trick is finding out that early, we know that late, right? A year later, two years later, we know, oh man. Of those 14 claims, that one was a doozy. That was the doozy. That’s the one that really impacts you both financially and then the life of that and very injured worker. And the trick is finding out which one out of this major group early in this process. And as I said, we talk about hindsight being 2020 if you look at that little couple of lines, which represents your claims, if you knew it was that one in the beginning, you would have done it differently. You would have managed that claim differently. But the problem is oftentimes we don’t know.

 

We don’t know. And we’re just going along. And a lot of times we treat these claims the same and then all of a sudden we’re surprised when a claim that should’ve been down here escalates its way all the way to up here. So I want to have that visual sort of in your head of what it is we’re talking about and then the impact if we can in fact identify these early [inaudible] what a major, major, major benefit that is for that individual and then a huge, huge impact on our costs. So one more little quick illustration that I want to go over here just to continue to resonate. Sort of the importance of this point are two more quick illustrations to continue to get it to resonate. The importance of this point as far as the costs. And what I want you to do when you leave this session is have this process which we’re going to be talking about today, a part of your process.

 

 

Early Screening Needs To Be A Part of Your WC Program

 

So if it’s not a part of your process, some of these screening techniques, some of this awareness it needs to be, it needs to be part of your best practices in your claims management program. So that is going to be a major takeaway. And the importance of this as far as why this is as to why you want to kind of go over some of this context here. So if you think about that concept of one 5% of claims, and again it could be five, it could be 10 but I just think about this concept. Say it was five each percentage of claims represents a big percentage of dollars. So each percentage is small amount of playing represents a big percentage of dollars. Let’s just go run through this very quick. [inaudible] this is percentage of claims and this is cost. So each percentage is representing roughly 16% of your costs, 48 64 and then 80 so each percentage, and if you think about this sort of contextually, each percentage is representing 3% is representing 48% of your costs.

 

And just kind of let that sink in for a second as far as what that actually means for your program. So if you say, Hey, want to reduce our costs and you’re looking at your loss, running your total loss costs, and you’re saying, hey, we’d love to get a 30% reduction in our total work comp costs, you got 33% just by a very small amount of your claims. And so again, that major, major financial impact of what that can actually do for your program. In one other exercise that I want to recommend you do because when we talk about some of this concepts, we talk about sort of this conceptually and you’re looking at the reverse pyramid and you’re looking at these numbers and you’re like, God, okay. You know, I’m, maybe I’m with you, maybe you’re not with me, but you can kind of start to think about it.

 

 

Identify 5 Most Expensive Claims

 

But I want you to put this in context, and I’ve done this with several employers and it’s always very illuminating when we do this little exercise. I want you to look at your loss runs and I want you to pull out your five most expensive claims. So look at your loss run. Or if you’re a client service provider, if your insurance broker, you’re advising or consultant to customers, you’re advising your customers, take a look at their loss run, you do this together, you can pull it up on excel, grab your five most expensive, and then calculate what percentage of your total costs is that for you. So what percentage of those five most expensive claims is that for you? And so when you go through this exercise and you pull out these five most expensive claims, you’re like, whoa. Like that’s a big chunk of our costs.

 

When you start to recognize that, and you can put this into context for yourself and again, if you’re a service provider, tremendous way to introduce some of these concepts to them to get them to buy into this and you say, Hey, I want to look at your program. We want to look at our claims handling process, etc. Let’s put some context on that and when you do that now these 1% and 64% and the reverse pyramid and all that sort of theory that we just talked about becomes very real for that individual person. It’s a great little exercise to do very impactful thing. I’ve done that with several, several employers and every time we do it it’s very illuminating and sheds a lot of light on the importance of recognizing I drew out those little lines, which one or which two of those or in this case the five that we just mentioned are going to now be that impactful. And then the importance of us going through some of the things we’re gonna be talking about today as far as these screening techniques.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

September 11th Remembered – Tribute To Marsh And AON

Article republished from a previous post.

 

Everyone remembers where they were the when they learned the World Trade Center crumbled to the ground. I was scooping ice cream at the Mansfield Center General Store. Having recently retired from the risk management and insurance industry, I had moved back to the area, built a house in Mansfield Center and worked from my home office. I was helping my family restore and run the General Store.

 

I had an exciting career in risk management and insurance working for two of the best insurance brokers in the industry. BOTH companies had sizeable offices located in the World Trade Center. So, when Bill called and asked me if I was watching TV, did I know a plane flew into the World Trade Center, I was alarmed. Initially I thought he meant it was a small plane, but when I turned on the TV, I could see it was a huge plane and the building was on fire. And then another plane had flown into the other tower.

 

 

We Never Knew How 9/11 Could Affect An Entire Industry

 

Everyone in the risk management field “plans”… we plan for every eventuality, thinking things through. That’s what we do. We help our clients, which are large companies such as The New York Times, Universal Orlando, and USAir, etc. plan how to provide safer workplaces, safer products and safer environments. But we never planned for Sept 11. We never knew how it could affect an entire industry.

 

AON and Marsh are the two largest insurance brokers in the world and I – with a loyal team of consultants – was responsible for development of the workers’ compensation practices at those companies. Workers’ comp insurance is the largest line of insurance coverage – a huge cost to most employers – and I had found the solution to reduce those costs significantly. Helping a wide-variety of types of organizations was gratifying, and there was a new challenge every day. I had written, published, traveled, and worked hard for 25 years, so I looked forward to scaling back.

 

When a retirement opportunity presented itself, I left the workforce to enjoy being a mom. My daughter was 17 and Glastonbury High School had not gone well. Against her will, we had moved her to a private school, and she and I were getting reacquainted during the long drive to and from school in Farmington, CT. Life was good.

 

 

Many Former Employees Went Back To Work

 

It wasn’t part of the plan to go back to work, but two weeks after Sept 11, I went back to AON, filling in for Lisa Ehrlich. Lisa was an outsourced risk manager who worked on-site at a company in Stamford, CT. On 9/11, she had gone into the NY office for a meeting and was killed that day. I was honored to be able to help in some small way. Many former employees went back to work in the intervening years to help the brokers rebuilt their practices. Here is a remembrance of my colleagues.

 

In the 18 years since Sept 11, a new generation has taken over. Some hardly know our industry lost so many that day, key leaders and pioneers in the field of workers’ compensation cost containment. In the intervening years, my nephew, Michael Stack, has taken over a leadership role in my company and become an industry leader in his own right. I am very proud of him for carrying on the legacy and memory of our beloved colleagues lost on that fateful day.

 

 

 

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:RShafer@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.

 

 

 

Look to Your Data for Opportunities to Improve Your Workers’ Compensation Program

This Content is Sponsored by the National Workers’ Comp & Disability Conference

 

data in workers compensationWith mounds of data at their disposal, workers’ compensation managers and financial executives might find it difficult to know exactly which metrics can help them create programs that both improve financial performance and keep employees safe.

 

The amount of available data can be so overwhelming that, according to Marsh’s 2019 Excellence in Risk Management survey, only 29% of companies reported using data for strategic planning.

 

“There’s a huge opportunity curve for organizations to better leverage data for improved outcomes,” said Luke Harrison, senior vice president and central claim consulting practice leader at Marsh.

 

Digging through all of the different metrics is valuable. It can help companies spot cost drivers early by allowing them to recognize historical trends.

 

“The best predictor of the future is the past,” Harrison said. “Not understanding your own data and what historically has driven your costs creates gaps in your ability to measure areas of excess leakage or various inflection points during a claim where intervention might be beneficial.”

 

 

Data in Action

 

Using data to understand a company’s past experiences with injuries certainly helped 2017 Teddy Award winner Rochester Regional Health.

 

They were able to make safety improvements in patient handling — one of the leading causes of injury in the health care industry — because they took the time to understand what “story” their data on safety metrics was telling them, according to Rochester’s senior manager of workers’ compensation Monica Manske.

 

“Our data confirmed what we already knew about our own organization,” said Manske.

 

“But with that data, being able to tell the story of how much money and lost work days and possibility of, you know, patient error occurs with how to handle patients. We were able to set the wheels in motion and dramatically reduce our claims reported due to patient handling injuries, and we’ve had up to a 60% reduction in our claims.”

 

Part of the reason Manske believes their program was so successful is due to their use of internal data, which allowed them to track their progress.

 

“With the improvement in technology, we really have so much more information available to us to perform a full evaluation of a program. And the data itself can really tell us where we had been over time. So not only benchmark against industry like with OSHA [metrics], but benchmark against yourself,” she said.

 

“We know what our drivers are over time. We know that cost, lost work days and even the department in shift if necessary. And that provides us a framework for our program development.”

 

 

Data Cuts Down Costs

 

Just as Manske’s company was able to reduce claims and save money by using the data available to them, companies that avoid jumping in and analyzing their data to drive program improvement can face serious financial consequences, too.

 

Luke Harrison, senior vice president, central zone claim consulting practice leader, Marsh Risk Consulting

In fact, large actuarial adjustments are something that Marsh’s Harrison sees frequently when companies don’t use data and analytics to evaluate and improve their programs.

 

“As a consultant, I can’t count the number of times I’ve heard from a claims manager that they found out from someone in finance in their company that they recently had a large actuarial adjustment out of nowhere,” Harrison said.

 

Manske said there are two major reasons why companies struggle to make the best use of their data: The sheer amount of data available and finding the time to analyze it all.

 

She believes collaboration can help solve these problems.

 

“I really recommend anybody collaborate with their TPA or churns carrier, because they can really be a great asset in this arena. And really helping you identify what are the best metrics that you should focus on,” she said.

 

Improvements in data gathering and technology have also made it easier for companies to turn to their data to find actionable solutions in real time.

 

“If you go back ten years ago we were really looking at Excel loss runs,” Harrison said.

 

“If you fast forward into 2019, I can say within Marsh we’ve created a new claims platform that provides real time analytic data feed out of your third party administrator or insurer.

 

“So rather than waiting six months or a year to look at your data for that year in a PowerPoint or in a printed document format, now our clients are able to leverage data on a real time basis,” he said.

 

At the end of the day, using data to improve workers’ compensation programs is well worth the effort because it provides companies with a way to both help their employees while also saving money and improving company culture.

 

“The data helps give you a tangible way to make a difference in peoples’ lives. Making things better for the organization and the employee together is a win-win,” Manske said. &

 

This November, NWCDC will feature two different sessions on using data to improve your workers’ compensation programs. The first is the pre-conference session “The Key Metrics for Understanding Your Workers’ Comp Program” led by Beth Dupre and Luke Harrison both of Marsh. The second session, “Improving Your Culture of Safety Through Analytics & Engagement,” will be led by Monica Manske. Check out the rest of the NWCDC line up here.

 

 

About the National Workers’ Compensation and Disability Conference® & Expo:

 

As the largest National Workers’ Comp and Disability Conference for more than 25 years, NWCDC offers endless opportunities that will propel your workers’ comp and disability management programs forward.  With the biggest Expo in the industry, you’ll be able to touch, compare and contrast the newest solutions from leading vendors in every category, and gain knowledge on-the-go at in-depth sponsored sessions on the show floor. Additionally, NWCDC offers valuable networking opportunities so you can make important contacts and share strategies with your peers.

 

You can also customize your learning experience with breakout sessions in six distinct program tracks: Claims Management, Medical Management, Program Management, Disability Management, Legal/Regulatory, and Technology.

 

Learn more about NWCDC and special savings for Amaxx, Inc. readers here.

 

Courtney DuChene is a staff writer at Risk & Insurance. She can be reached at cduchene@lrp.com.

Spot Over-Treatment from Medical Providers

medical over-treatmentMembers of the claim management team need to take control of their files to reduce workers’ compensation costs by spot unscrupulous practices by medical providers.  While a vast majority of providers are ethical, never let down your guard, and be proactive in identifying red flags when it comes to over-treatment by medical providers.

 

 

  1. The medical records are “template” style or barely exist at all.

 

A careful review is required when medical records all look the same.  It is important to note “template” style records that repeat does not mean you are dealing with a shady doctor.  It could just be that the doctor is very poor at note-taking.  Great doctors do great analysis and back up opinions with objective medical facts.  They arrive at this point by walking through the medical records and creating a great conclusive medical report.

 

 

  1. Missing dates of service, or no date labels on the medical notes

 

Missing dates of services are often paired with “template “style medical records.  The doctor uses a fill-in-the-blank system.  Typical examples include: Patient came in with complaints of _______ which they attribute to work causing them _____ pain out of 10, with 10 being the worst pain imaginable.

 

Pay attention to medical records generated by health care providers.  If anyone is watching, a physician will not get far by doing this.  On the other hand, if nobody is paying attention, thousands of dollars could be paid for unnecessary medical care and treatment.  Make sure the notes are clearly labeled, dated, and legible.  If not, you need to contact that physician’s office immediately.

 

 

  1. Different handwriting or inks on the same dates of service.

 

Some medical providers are not fully digital when it comes to the preparation of medical records.  A nurse or the medical assistant may make notes in a medical record before the doctor attends to the injured employee.  However, in some instances, this could mean notes are being manufactured.  Carefully review these records.

 

 

  1. The medical provider will not send medical records or state that they do not keep medical “records.”

 

All legitimate medical providers should keep records of patient interactions, including telephone calls and messages.  Even the most trivial of companies store records of some sort.  As a matter of best practice, refuse to pay any bill ever without a medical record.

 

 

  1. The medical notes showed continued high levels of pain.

 

All legitimate medical care and treatment should provide some relief to an injured employee.  If it is two months post-injury and the employee reports a pain level of “10 out of 10,” questions need to be raised as to what care is being provided, and why the injured employee is still suffering from the effects of the injury.  If the physician is not doing anything about it, or the person is no better, then you must find out what is going on medically and get that person to a specialist or set up an Independent Medical Exam(IME) to address these ongoing complaints.

 

 

  1. Conflicting medical reports or conflicting subjective complaints.

 

Take the following example:  You are reviewing a stack of medical records on a claim.  The injured employee states they are in very bad pain, 8/10.  It is hard to bend and walk.  The next day they show up for therapy, and they tell the therapist they are doing great, and they think treatment is really helping them.  Two days later they go back to the doctor and say they feel the same, about 7-8/10 pain. Then the same day they have therapy and tell the therapist they feel great, and are looking back to getting back to work.

 

Therapy can flare pain up a bit, but over a few weeks, the pain should be gradually lessened.  If you start to notice inconsistent pain complaints, and pain out of proportion to the injury, think about getting an IME to better understand what is going on.

 

 

Conclusions

 

All health care providers should have consistent billing practices.  They should be using standard billing forms such as a CMS/HCFA-1500 form so the bill can be processed and paid in a timely manner.  All medical bills should conform to the medical record that is often required to be attached to the bill.  If not, ask immediate questions. It is also important to ask questions if red flags are raised when reviewing medical records.  Failure to do so can result in excessive money being spent.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

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