TPA Best Practices: Loss Reporting, Claim Assignment, Assignment Procedure, and Coverage Verification

TPA Best PracticesPicking the right third-party administrator (TPA) takes time.  Failure to pick the correct one can result in increased costs to a workers’ compensation program.  There are many important factors to consider beyond a TPA having the right price.   In the first part of this series, we looked at selecting a TPA on how they make initial contact with the injured employee and other parties following a work injury, and the methodology of their initial claim examination.  Additional factors that need to be considered also include a deeper dive into how losses are reported, claims are assigned, and coverage is verified.

 

 

Nothing Succeeds Like Success…

 

Leading TPA’s success comes from the division of labor into four areas:

 

  1. Loss Reporting: Prompt loss reporting is a key aspect when it comes to timely loss notification. Prompt reporting has three advantages:

 

  • Immediate contact with all parties involved in a workers’ compensation claim results in reduction of claimant representation, and litigation. Contact with all parties includes the employee, employer, witnesses, other interested stakeholders;

 

  • Prompt investigation: This includes several different items to consider immediately after a work injury.  This includes making sure the employee receives medical care and treatment, identifying witnesses, preserving physical evidence, and getting information about the injury from the employee; and

 

  • Reduction of overall cost per claim: This promotes efficiency in any program.

 

 

  1. Claim Assignment: An effective assignment process helps to ensure proper handling of claims at the appropriate technical level. The claim assignment process may include gathering additional information beyond what is available in the First Report of Injury.  It includes other aspects such as making sure the proper forms are filled with the state industrial commission and asking the right questions.  TPAs can practice a team approach by:

 

  • Distributing the work to the most appropriate level of technical expertise; and

 

  • Obtain the highest possible efficiency possible by effective internal communication, use of regular file reviews, and communication with the insured.

 

 

  1. The Assignment Procedure: Upon receipt of a First Report of Injury, a four-step process must be initiated to promote best in class services:

 

  • Supervisory evaluation of the First Report of Injury to ensure it is properly classified. Examples include “medical only claims,” claims involving lost time; and catastrophic injury claims;

 

  • Supervisory review and direction to the appropriate claim handler. Claim management teams should have specialized units for various claims and situations.  The examination of fraud can also take place in these units;

 

  • Creation of a Central Index Bureau referral for lost time claims and medical-only as required. It is important to know the claims history early in the process; and

 

  • Case management services should be utilized as appropriate. (It should also be noted the claim classification and technician assignment can change throughout the life of the claim if a significant change in complexity level occurs.

 

 

 

  1. Coverage Verification: This starts with confirmation of the client’s self-insured  It also must include verification of a client’s policy of insurance, limits of coverage, and effective dates.  Coverage issues are recognized, investigated, and addressed with the carrier before it becomes an issue after a work injury.

 

 

Conclusions

 

Best in class service starts with paying attention to details and ensuring all of the “i’s are dotted, and t’s are crossed.”  It also includes making sure that claim handlers work as a team and have the resources to success.  This results in claims that are handled in an effective manner.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: 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.

TPA Best Practices: Initial, Ongoing Contacts, and Investigation

TPA Best PracticesThird-party administrators (TPA) perform many important functions in workers’ compensation claims.  It is important to make a reasoned decision when selecting the right TPA.  Failure to do so can result in a chaotic program that does not serve the best interests of the client, nor does it ensure the injured employee receives best in class service.

 

 

Keys to Effective Contact

 

A three-point contact system results in establishing and maintaining effective communication with all key parties to the claim to facilitate the investigation, claim control, and explanation of benefits.  This includes the following:

 

  • The claim handler will verbally contact the injured employee or attorney, if represented, the employer and the treating physician by the end of the next business day following receipt of the loss to the TPA;

 

  • When unable to reach an injured employee within one business day, a letter will be sent asking the injured employee to call;

 

  • The claim handler should make at least two attempts to contact the applicable parties within 3 days following receipt of the loss. A letter will be sent if unable to reach the parties; and

 

  • If contact cannot be achieved due to circumstances beyond the control of the claim handler, the claim file should be appropriately documented.

 

The contact process should continue throughout the life of a claim.  The following steps should be taken during a claim until it reaches its conclusion:

 

  1. Ongoing contacts with the employer, the injured employee and the medical provider;

 

  1. All contact efforts should be detailed in the claim notes. It is not written down contemporaneously, it did not happen;

 

  1. The claim handler should vary calling times to increase the chance of a successful contact;

 

  1. Significant changes in the injured employee’s condition should be documented in the claim notes; and

 

  1. If the injured employee is off work or on transitional duty, contact should be maintained, at maximum, every 30 days by the claim handler and/or medical case manager.

 

 

Medical-Only Claims

 

Medical only claims require contact just like any other claim.  Important steps that need to occur to be effective include:

 

  1. The medical claim analyst verbally contacts the employer by the end of the next business day following receipt of the loss report;

 

  1. The medical claim analyst sends letters to the employee and medical provider by the end of the next business day following receipt of the loss report; and

 

  1. On transitional duty claims with lost wages or a reduction in hours worked, three-point contact is verbal for all three contacts areas.

 

 

Effective Claims Investigation

 

Prompt and thorough investigation provides the framework for timely analysis of coverage, compensability decision, effective claim management, pursuit of cost containment opportunities, and the timely issuance of claim benefits.

 

  1. The scope of the investigation considers the type of accident, complexity of injury, and compensability issues. Investigation applies to all claims other than those designated as medical-only claims through the assignment process;

 

  1. Initial investigation is completed within 14-calendar days of receipt of the loss report. This TPA utilizes a proprietary claim advantage system, an evidence-based decision tree software tool, to support investigation and prioritize claims. The claim-handling process continues to re-evaluate the exposure as the case progresses and allows for the development of a goal-centered strategic plan of action; and

 

  1. Identification and investigation of potential subrogation or second-injury fund maximize recovery potential and reduces client/carrier loss cost. All claims with potential subrogation are handled by a claim handler who teams with licensed subrogation partner to evaluate and pursue recovery opportunities.

 

The TPA, as a matter of sound business practice, and in recognition of its public policy obligations, has a duty to identify and resist all fraudulent claims. When the evidence supports withholding benefits, such claims are promptly rejected, and aggressively defended.  When the evidence is inconclusive, the claim is promptly adjusted.

 

 

Conclusions

 

TPAs play an important role in the claim management process.  It is important to understand how a TPA communicates with parties following a work injury and investigates claims.  Examining these factors allows the insured to run an effective workers’ compensation program and provide better services to the injured employee, and all interested stakeholders.

 

 

 

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.

12 Ways to Foster and Sustain Employee Engagement

Employee EngagementInjured workers who feel engaged with their companies typically recover faster, have lower-cost claims, and rarely – if ever – seek attorneys, compared to other workers. Instead of an adversarial relationship, these employees trust their employers and, in turn, the workers’ compensation system. Engaged employees who become injured at work go through the workers’ compensation process the way it was designed.

 

 

Getting employees to engage with their organizations is not a one- or two-step process. But it also doesn’t need to be unreasonably complex. Companies that think of their employees as team partners and valued customers from day one have an easier and less expensive time of it.

 

 

Pre-Hiring

 

Employee recruitment and hiring methods can set the right tone for employees to feel engaged with their companies.

 

  1. Employee referrals. Job applicants who are referred by current employees are among the most engaged workers. Building trust with new employees who already feel they have an ‘in’ with the company is much easier than starting from scratch with someone who is not familiar with the organization or its culture.
  2. Community outreach. Short of in-house referrals, partnering with local institutions, goes a long way to help job applicants feel an affinity with a company. More than just responding to a blind ad, those who seek employment through organizations they know and trust are more likely to have positive feelings about the company from the very beginning. Some companies are reaching out to local colleges and even high schools to recruit new talent, especially with the exodus of baby boomers.
  3. New technology. Using new technologies is another way employers can gain the trust of new, especially younger recruits, in several ways.
    1. Younger workers are comfortable with new technology, as they’ve grown up with it.
    2. Artificial intelligence, robotics, machine learning, and the like can be implemented to handle the more repetitive, mundane tasks of a job, leaving the new worker to undertake more important and challenging tasks.
    3. Educating recruits on the advantages of new technologies, including that these are there to help not replace workers, lets them know the company cares about them beyond just being a faceless job holder.

 

 

Once Hired

 

During the onboarding process and initial employment, employers can focus on making sure the new recruit feels connected. Having an inviting culture is key. Employees who truly believe the company cares about them are more inclined to be engaged, then those who do not.

 

Employers can demonstrate they have a caring, supportive culture in a variety of ways.

 

  1. Health and well-being. Whether it is physical, emotional, or financial health, organizations can demonstrate they are genuinely concerned about their workers, through employee assistance programs and other avenues.
  2. Resilience training. Employees on the front lines, especially customer service representatives, can be barraged by negativism day in and day out. This can take an emotional toll on even the most resilient person. Helping incoming employees improve their resilience skills also makes them feel more a part of the team.
  3. Fun environment. The work needs to get done. At the same time, however, the atmosphere does not need always to be strict and rigid. Allowing workers to experience lightness is OK. For example, allowing them to decorate their work areas for Halloween or holding the occasional pizza party during lunchtime can be great stress relievers and help workers feel connected and engaged.
  4. Mentoring. New workers typically feel alone and somewhat anxious about coming into the new environment. Pairing them with a more seasoned, non-managerial worker helps them acclimate not only to the job requirements but the overall workplace community.
  5. Personal growth. Organizations that prevent workers from exploring new opportunities may find their workers leaving. Instead, find out what goals and dreams workers have and allow them to experience other parts of the company that may fit their desires. Work rotation, for example, allows workers to learn about other parts of the organization and allows them to grow while feeling more engaged with the company.
  6. Transparency and Employees don’t live in a vacuum. They talk to other people, pay attention to the news and social media, and will likely know if something unusual is going on, whether it’s bad or good news. Instead of keeping employees in the dark, organizations are advised to stay ahead of any news about the company and communicate it with them. This also ensures whatever news an employee sees on social media doesn’t spiral out of control.
  7. Include remote workers. As more employees work from home or other remote locations, employers may struggle with ways to engage them. But these workers can feel connected to the company through virtual means. Mentorships programs, for example, can extend to remote workers. Highly-engaged small groups can be established online, where workers frequently communicate with one another. Virtual meetings via webcams can be held. Online company newsletters can keep remote workers informed, especially if they are also encouraged to contribute to them.
  8. Create a diverse and inclusive mindset. All employees should feel comfortable with their coworkers and unafraid to shares their views – even if they differ from those of their coworkers. Meetings should include workers from all parts of the company, from the mailroom to the C-Suite, and all workers should be allowed and encouraged to express their opinions.
  9. Seek employee feedback. Anonymous employee surveys that elicit honest opinions about the company can identify areas where changes can be made to improve engagement.

 

 

Conclusion

 

Employees who feel engaged with their companies and fellow workers are happier, more productive, and less likely to leave for greener pastures. When they become injured, they are more likely to adhere to their treatment plans and, therefore, recover and return to work more quickly. And they are far less likely to seek out legal counsel. Organizations that understand this and work to make their employees feel connected are more likely to see better bottom lines.

 

 

 

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.

Eliminate ‘MSA Fear’ In Upcoming WCI Session in Orlando

msa fearAmong the biggest fears of many people you may know are heights, snakes — and MSAs. Workers’ compensation stakeholders often want to avoid the very idea of Medicare Set-Asides.  Among their concerns are

 

  • Fees for MSA preparation
  • MSA professional administration
  • Cost of the MSA
  • Requirements to obtain additional medical documentation
  • Time involved
  • Submitting the MSA to the Centers for Medicare and Medicaid Services
  • Failed settlements due to rejected MSAs

 

For injured workers, their concerns about MSAs may be the biggest thing keeping them from settling their claims.  The fear of running out of money too soon is often stronger than their dislike of the workers’ compensation system. Knowing they will have to navigate their own healthcare with no support from adjusters and/or case managers can also generate concerns. Finally, there is the uncomfortable prospect of having to administer their own MSA funds, or turning that task over to someone else

 

With so many parties apprehensive about MSAs, it’s no wonder many workers’ compensation claims go unsettled for years.

 

On Aug. 14, a panel of experts will discuss the fear of MSAs and how to overcome them to allow settlements to move forward. The session, Allaying the MSA Fear at the Time of Settlement, takes place during the 74th annual Workers’ Compensation Educational Conference (WCI), Aug. 11 – 14 at the Orlando World Center Marriott.  I’ll have the pleasure of moderating the session.

 

With expertise in MSAs, structured settlements, and professional administration, the speakers include:

 

  • Kris Sallee, Claims Manager-Eastern Region, American Airlines
  • Daniel Anders, Chief Compliance Officer, Tower MSA Partners
  • Marques Torbert, Chief Executive Officer, Ametros
  • Joe Bornstein, Structured Settlement Consultant, Arcadia Settlements Group

 

Using real case studies, the panelists will demonstrate how to approach settlements logistically by using an intervention-driven method to develop MSA allocation, professional administration to protect MSA dollars and support the injured party after the settlement, and a structured settlement to extend the dollars over the person’s lifetime.

 

The speakers will provide practical solutions to ‘MSA fear,’ and show how using each type of expert creates a synergy that allows for a smooth settlement process when an MSA is involved. They will also address the risks of not submitting an MSA for CMS review. And they will take questions from attendees.

 

 

 

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 the 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.

Mediation to Successfully Settle Workers’ Comp Claims

mediation to settle workers' comp casesMediation is frequently used in workers’ compensation cases to settle claims and avoid the uncertainties of litigation.  This is because it allows all interested stakeholders to be involved in the process and allows for outcomes not otherwise attainable in court.  When preparing for a mediation session, it is important for those involved to prepare and assist the neutral third party in better understanding the case.  One tool to accomplish this goal is to prepare a confidential mediation statement.  It not only helps the mediator but allows those involved to reflect and understand their claim.

 

 

Getting the Process Started – Agreeing to Mediate

 

Mediation can be a formal or informal process to settle a workers’ compensation case.  The structure involves a neutral third party who understands the process and controlling statute to help the parties evaluate their position and move a case toward settlement.  Selection of a neutral third-party requires cooperation between the defense and employee interests.

 

In very few instances is mediation “required” as part of the workers’ compensation claims process.  However, this should never prevent parties to a workers’ compensation case to use it as a means to settle a dispute.

 

 

We’re Going to Mediate – Now What?

 

Mediating a workers’ compensation case must be taken seriously.  It requires preparation and evaluation by all parties.  In many instances, the selected mediator will request the parties to prepare a mediation statement.  This is a letter prepared by the respective parties and should be kept confidential.  It should be factual, so the third-party assisting in the settlement can help.  It can also contain other important documents relevant to the case that outline a party’s position.

 

There is no one right way to draft a mediation statement.  Important elements to consider should include the following:

 

  • Defining the claim: When both parties outline the claim, it will allow the mediator to ensure both sides are beginning from the same starting point.  A classic example of this is a determination of the average weekly wage (AWW).  Because most indemnity benefits are based on this number, the value of a claim can hinge on the AWW.  It is also important to outline defenses to a claim.  This has a huge impact on the potential recovery and future exposures.

 

  • Procedural posture and prior negotiations: Providing this background information allows the neutral third-party to understand a case’s starting point and what the ultimate objectives of the parties include.  It will also allow the mediator to understand other important case dynamics.

 

  • Honest assessment cases strengths/weaknesses: This is especially important in instances where there is a denial of primary liability or the reasonableness/necessity of medical care and treatment.  Honestly going through the process allows all attorneys and members of the claims management team to understand the claim better and set realistic expectations.

 

  • Pertinent medical and vocational reports: These documents include IMEs, IVEs, FCEs and narrative reports from the employee’s treating doctor.  These reports and documents typically provide a good summary of the claim and help the mediator better understand the case.  It also allows the parties to understand the strengths and weaknesses of a claim.

 

 

Other Things to Consider

 

A mediation statement is also a great tool to inform the mediator about the case intangibles and dynamics.  It is important for a mediator to know information such as the special needs of a client and issues that are a “must-have” in any settlement.  This often includes a global settlement and voluntary resignation of the employee as part of the settlement.

 

 

Get Help Planning & Preparing for Mediation – For No Cost

 

With many aspects involved in a successful settlement, interested stakeholders can benefit greatly from professional settlement assistance. A settlement consultant comes at no cost and is a settlement expert with knowledge and access to various settlement tools to address the most challenging workers’ compensation claim issues. These experts can be brought into the process early on, so the settlement is set up appropriately.

 

Rather than just running quotes, the settlement consultant should act as the general contractor in identifying, bringing and managing the best experts to the table to address the issues preventing a positive outcome for all parties in the case.

 

 

Conclusions

 

The use of mediation in workers’ compensation is growing in popularity given its practical uses in settlement.  When preparing for mediation, it is important for all parties to prepare.  Part of this includes the use of a confidential meditation statement to provide a background to the neutral third-party and help the parties better evaluate their case.  It also serves as a means to make efficient use of time and reduce costs.

 

 

 

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.

Four Techniques to Effectively Communicate Safety in the Workplace

effectively communicate safetyEffectively communicating safety is a topic all interested stakeholders need to increase awareness. Not only is it required by law, but is reduces workers’ compensation program costs and promotes a better workplace.  When communicating safety, proactive employers and other interested stakeholders often struggle to find an effective means of communication with employees.

 

 

Effective Safety Communication Methods

 

There are many things employers can do to promote workplace safety and communicate important concepts to employees.  Simple suggestions that are effective include:

 

  1. Safety Equipment & Required Signs: A safety coordinator should review and determine what safety equipment is required in each area.   This should include a review and determination of the location signs may be needed, and where they are needed.  This consists of a review of the primary workspaces, individual offices, computer rooms, stairwells, bathrooms, other common areas, and parking garages and lots. Signage should be ordered and installed promptly. A periodic review should also take place.  This is something that can be done at the beginning of each month, and include an annual audit to ensure full compliance.

 

  1. Safety Awareness Posters: Every safety program should ensure all employees are aware of safety concerns in each area or location. These can be thought-provoking or humorous signs to highlight safety issues. Never hide safety awareness signage. Make sure they are placed in high traffic areas and rotated regularly.  A diverse workforce demands signs should be in all languages that are used in the workplace. These posters can be ordered from several vendors specializing in non-English signage.

 

  1. Safe Days Posters: Employers seeking to implement an effective safety program must communicate it to their entire workforce – and continue to do so on an ongoing, and regular basis. It is important to communicate to the whole workforce how well (or poorly) the safety program is working.  Steps should be taken, such as recognizing, and rewarding the efforts of employees for making the workplace a safe environment. Standard tools used to promote a culture of safety can include a chart highlighting the number of consecutive workdays without an injury for the facility, and also by department. Competition between departments can add increased consciousness of safety.

 

  1. Safety Recognition & Incentive Programs: 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 safely. 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. Instead of the emphasis of the safety program being on the incentives, the attention should be on training the employee how to work safely. Educating the employee in the proper performance of their job will have a more significant 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.

 

 

Other Safety Considerations

 

Engagement and follow-through by all interested stakeholders, including a company president or CEO.  If employees see active engagement and participation by everyone, the message will be reinforced.  Failure to do so will result in a failed mission, and the objective will never be completed.  Leaders need to lead by example.

 

It is also important to understand that safety is a continual process.  Once an effective program is in place, it requires frequent maintenance and review.  Improvements can always be made with involvement from all employees.

 

 

Conclusions

 

The best way to reduce work injuries is to prevent them from occurring.  The implementation of a safety program can accomplish this, along with an effective means of communication.  Now is the time to engage your workplace and promote a safe working environment.

 

 

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 the 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.

Bringing Understanding of MSA Complexities at WCI in Orlando

Understanding of MSA CompliexityMedicare Set-Asides are a pain-in-the-neck nightmare for many workers’ compensation stakeholders. They are expensive, complicated, and seemingly fraught with landmines. One misstep could cost a bundle for you and anyone else involved.

 

Concerns over MSAs result in a plethora of workers’ compensation claims left open – often years after they could have and should have been closed. Payers end up spending far more for ongoing medical than would have been allocated in an MSA, had the case been settled long ago.

 

But there is good news! MSAs don’t have to be ridiculously expensive or complex. Yes, they need to be carefully managed, and they need to be overseen by someone with a deep understanding of the intricacies of the Medicare Secondary Payer Act and the Centers for Medicare and Medicaid Services’ processes. Employers, payers, and others who have a basic insight into MSAs can approach claims settlement realistically, getting long-term claims off their books and helping injured workers to be in the best position to move forward with their lives.

 

A major employer and an MSA expert will take a deep dive into the issue during the 74th annual Workers’ Compensation Educational Conference (WCI), Aug. 11 – 14 at the Orlando World Center Marriott. Their focus will be on ways to measure and manage MSA costs. The session, Optimizing Settlement Outcomes by Measuring and Managing MSA Costs takes place Wed., Aug. 14, at 10:00 a.m. I’ll have the pleasure of moderating the session.

 

 

Measuring

 

The first step in assuring accurate future medical costs is to know what is in them. For example, do you know:

 

  • How many of your MSAs contain prescription drugs, the most commonly cited reason for high MSA costs?
  • How many contain prescription medications?
  • Your average CMS approved MSA amount?
  • Your trend lines year over year for your MSA program?

 

Attorney Dan Anders, the chief compliance officer for Tower MSA Partners, and Kris Sallee, claims manager-Eastern Region for American Airlines will provide metrics that will help you determine your MSA program success. Anders will show national standards, while Sallee will offer her company’s metrics to better understand how to measure your own program. Most importantly, the speakers will explain what the metrics mean and how they can be used to improve your MSA program.

 

 

Cost Management

 

Once the metrics are understood, it’s time to get down to the business of actually managing the costs of an MSA. The same types of best practices used for handling claims also come into play when developing MSAs, such as clinical interventions. For example, reducing unnecessary treatments and medications during the claims handling process will reduce the cost of the MSA.

 

Certain treatments, such as spinal cord stimulators and revision surgeries are most likely to increase MSA costs – and are often unnecessary. Likewise, certain medications may no longer be needed for the injured worker. Or there may be instances where a generic medication can be substituted for a brand name, either currently or in the near-term future when a patent for a particular medication expires.

 

The speakers will show attendees how to draft an MSA with an eye toward cost and frequency, as well as identifying opportunities to limit the MSA before sending it to CMS. Submitting the MSA can be tricky, and the panelists will address the necessary steps, especially the re-review process, when a dispute can be raised.

 

Finally, the speakers will allocate time for questions about all things MSA.

 

 

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.

DOL Strength Levels – Does Oversimplifying Job Demands Increase Exposure To Injury Risk?

DOL Strength Levels

This article originally appeared on MyAbilities.com

 

Article Summary: The DOL strength levels classify jobs into 5 separate categories defined by force/weight, and frequency of exertion. The classification system leads to a broad oversimplification of the demands of work, which in the worst case can lead to over and underestimates of physical demands of over 500%. A much more granular system is needed to better understand the different physical demands of work, and how that can be used in return to work, and injury prevention.

 

 

The Department of Labor’s strength definitions are widely used when determining the physical demands of a job, or the capacity of a worker when it comes to post-offer of employment testing,  return to work, disability management, and functional capacity evaluations. These strength definitions aim to look at the material handling component of jobs, and state what is required of the worker to be able to successfully perform that aspect of the work. Strength demands of work are broken into 5 categories – sedentary, light, medium, heavy, and very heavy. Each of these demand levels have a force and frequency component – stating what weight a person can lift, push, pull, or carry at a given frequency (Table 1).

 

DOL Chart

Table 1. Force/Weight, and frequency characteristics for the DOL levels of Sedentary through Very Heavy.

 

 

Most Common Jobs in America Are In Medium Category

 

According to the Bureau of Labor Statistics, the most common jobs in America are in the medium category – but this varies greatly by industry. Management and technical jobs have more of the light jobs, whereas construction, trades, and manufacturing jobs have more of the heavy jobs (Figure 1).

 

 

 

5 Levels of Classification Lack Granularity

 

While these five levels of classification of strength are useful in providing an initial look at the demands of work, there is not a lot of granularity when it comes to establishing how a worker is capable of performing these tasks.

 

 

NIOSH Lifting Equation – Vast Majority of DOL Levels For Strength Would Be Unacceptable

 

Ergonomists have a wide variety of tools for assessing the demands of work, and many are specific to individual physical demand types. One of these tools is the NIOSH lifting equation (Waters et al., 1991) – a tool that looks at the start and end height of a lift, the frequency and duration of lifting, the twisting required, and how far the worker has to reach to perform the lift. This equation returns a recommended weight limit (RWL) – the amount of weight that could be lifted that would keep the worker’s back safe during work. If you divide the actual weight being lifted by the RWL, you will get a value indicating the overall risk level of that given lift. If that value is greater than 1.0, this lift is above the RWL and puts the worker at a higher risk of injury.

 

Looking at the DOL levels, and a simple lift from about knee height to waist height, I simulated what the RWL would be for the ranges of frequencies and lifting weights from the DOL strength levels (Figure 2). (For those who would like to replicate these calculations, the start height was 30 cm, travel distance was 45 cm, horizontal reach was 40 cm, there was no asymmetry, or coupling factors modification. For frequencies, I used the less than 1 hour factors, and V<30. Each lift was assumed to be 2 s in duration, and the corresponding FM factor was found).

 

Job Demands Table

 

Figure 2. Lifting Index for the minimum, average, and maximum frequency possible (in % of time) for each DOL strength level. Values of greater than 1 (above the black line), would be considered “unacceptable”, as they increase the risk of injury in the lifter.

 

According to the Lifting Index, and the NIOSH lifting equation, the vast majority of DOL levels for strength would be unacceptable and cause an elevated risk of injury for workers. In fact, no simulated task for the heavy or very heavy categories would be a safe lift, and only 2 of the 15 simulated lifts in the medium category would be safe lifts. What is very interesting, is these large ranges spanning the frequencies identified in the DOL strength levels, can produce a lifting index of as low as 0.87, and as high as 4.41, all within the same strength bin (in this case, Medium). That is a 507% increased risk of injury in one strength category – primarily because of the high force levels, and huge variety of frequencies defined in this methodology.

 

The NIOSH lifting equation examines risk during lifting as a factor of the amount of spine compression that is occurring. NIOSH recommends lifts should not exceed 3400 N of spine compression during lifting. The peak spine compression of a lift is an interesting variable to examine, but it doesn’t necessarily factor in frequency – which can be an important variable in assessing risk. Even without frequency, you can see the DOL levels and their corresponding peak spine compression levels (predicted using Potvin 1997’s method) often exceed what’s known to be safe (Figure 3).

 

Spine Compression

 

 

Figure 3. Predicted spine compression level from different lifts, classified by the DOL levels of strength, compared to the NIOSH safe lifting limit of 3400 N.

 

DOL levels that feature 50 lbs or higher as the acceptable lift are in the high risk category. That means, these types of jobs are only appropriate for very strong individuals, if you want someone to work there with a low risk of injury. Even then, over the long term, these individuals are more likely to sustain a back injury in the workplace.

 

 

DOL Levels Do Not Include Other Physical Demands

 

What isn’t included in the DOL levels  are the other physical demands that could lead to an increased risk of injury in these types of work, e.g. lifting at, or above, shoulder height; lifting with a flexed spine; or a poor point of contact for gripping significantly impact the risk of injury.

 

The Demand Score includes the physical demands included with strength, but also factors in reaching, gripping, handling, data entry, and many more (26 different physical demands),  compares these demands against known ergonomic standards, and develops a score from 1 to 100, helping you better understand a job, and how it compares to other jobs within the same industry.

 

In summary – job descriptions and physical demands analyses are very nuanced and detailed things. Boiling them down into one of 5 categories over-simplifies the different factors in return to work and injury prevention, which can lead to either prolonged absences, or exposure to higher levels of injury risk than previously considered.

 

 

Author: Dr. Michael Sonne, VP Innovations and Research at MyAbilities. A leading occupational biomechanics researcher, with a history of developing technologies to automate ineffective processes in the ergonomics industry. In 2010, Mike developed the Rapid Office Strain Assessment – a method for conducting self-guided, office ergonomics assessments, resulting in a reduction of musculoskeletal injuries. Mike has developed global standards for muscle fatigue assessment in repetitive work, particularly in assembly lines. Mike is an adjunct professor at Brock University, and the University of Ontario Institute of Technology, and continues to publish in peer-reviewed journals.

 

 

References:

  • Waters, T. R., Putz-Anderson, V., Garg, A., & Fine, L. J. (1993). Revised NIOSH equation for the design and evaluation of manual lifting tasks. Ergonomics36(7), 749-776
  • Potvin, J. R. (1997). Use of NIOSH equation inputs to calculate lumbosacral compression forces. Ergonomics40(7), 691-707

 

 

The Work Comp Tool Box: Employing Creative Strategies to Settle Cases

Employing Creative Strategies to Settle CasesSettling workers’ compensation cases is an important part of being a proactive and effective member of the claims management team.  It also allows interested stakeholders to concentrate their efforts on other more burdensome cases.  Most importantly, it reduces unnecessary costs to a program’s bottom line. Working with an experienced workers’ compensation attorney can ensure you get the best agreement for both the employer and the injured worker.

 

 

What is the Claims Management Toolbox?

 

Having a “toolbox” at one’s disposal is important to being a great claims handler.  Like a toolbox a mechanic uses to practice their trade, claim handlers need one as well to fix, accomplish or avoid a number of issues.  Caution – use these tools with care and only when necessary.

 

 

Limited Compromise Settlements

 

All members of the claims management team will agree, the only good file is a closed file.  In some instances, this is not possible given the interests of the claimant or on advice of their attorney.  In cases that cannot completely settle, a claims handler should examine whether the claim presents an opportunity for a limited compromise settlement.

 

Under this type of settlement, indemnity benefits such as TTD, TPD, PPD and PTD are closed out.  The only benefits available to the employee include past and/or future medical benefits.

 

Limited Compromise Settlements have some advantages:

 

  • Reduces costly exposures that may be present on a claim. This is especially the case when an employee is not incurring much in terms of ongoing medical benefits, but is struggling with return to work issues; and

 

  • Studies indicate claimants in workers’ compensation claims tend to reduce the frequency of their medical care and treatment after closing out indemnity benefits. Limited compromise settlements that leave open future medical benefits can also be helpful in instances where the parties may want to consider a Medicare Set-aside, but the cost and/or future medicals that are reasonable is astronomical.

 

 

Effective use of Hold Harmless Agreements

 

A “hold harmless” agreement is another tool members of the claims management team can use to settle cases.  When using such agreements, the parties to a settlement are creating a contract where one party agrees to release another from all legal claims.  In the context of workers’ compensation claims, this is mainly used when it comes to the reimbursement of past or future medical expenses and liens.

 

Such agreements can be used in many instances to expatiate settlements.  This includes:

 

  • Delay in the receipt of medical bills related to a claim where the amount is either known, or reasonably expected to be known; and

 

  • One party to a claim has the ability to extinguish the interests or potential intervention rights of a known third-party.

 

Hold harmless agreements should be used with caution.  While such agreements “require” cooperation from the party receiving protection, it might not necessarily be the case if litigation occurs.  In fact, the indemnified party (the party receiving protection) may need to engage in litigation in order to secure cooperation.

 

Hold harmless agreements should also be avoided in instances where Medicare and Medicaid have an interest in a claim.  The statutory framework establishing these federal programs does not prevent the applicable government agency from enforcing their rights against any party to a workers’ compensation claim.  This rationale has been affirmed by a long line of case law interpretations.

 

 

Other Tools for Effective Claim Resolution

 

Settling workers’ compensation claims requires members of the claims management team to take affirmative steps to remove barriers to settlement by using their toolbox.

 

  • Develop strategies on their teams to identify cases ripe for settlement and take steps to close files. This sometimes includes picking up the telephone and making a settlement inquiry or offer. Once identified, these cases can be submitted to a competent structured settlement consultant who may be in the best position to determine the likelihood and course for settlement;

 

  • Using mediation and promoting the use of settlement conferences to move claims toward a timely resolution. Be prepared for these events.  One may also want to consider bringing a laptop computer and printer to these sessions.  This allows for the drafting of the settlement agreement on the spot and avoid delays in final execution; and

 

  • Implement effective medical management programs to lower prescription drug costs on all files.

 

 

Conclusions

 

The development of a claims “toolbox” is one step interested stakeholders can use to reduce workers’ compensation costs.  This is accomplished by promoting the closure of files, or at a minimum resolving some issues on a file to narrow the issues in dispute.

 

 

 

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 the 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.

Sit Up and Take Note: The Truth about Ergonomics

Sit Up and Take Note: The Truth about Ergonomics

Article originally published on Medcor Health Blog

 

Does your back hurt? Are you experiencing neck pain? Do you find yourself complaining of hand, arm, knee, or muscle aches? If so, you may be suffering from a musculoskeletal disorder (MSD). Discomfort/pain, numbness, tingling, stiffness, burning, cramping, and swelling of bones, joints, muscles, tendons, and ligaments can be symptoms of MSDs. If work or leisure activities are causing discomfort – it is time to become more ergonomically aware.

 

MSDs are conditions of muscles (sprains/strains), tendons (inflammation), ligaments, joints (arthritis), and nerves that are often associated with exposures to ergonomic risk factors, including: awkward postures, repetition, force, contact stress, and vibration.1 Age, sex, obesity, and health conditions (i.e., diabetes, rheumatoid arthritis, and hypothyroidism) can also play a factor.

 

 

Truth: Being Aware Of Ergonomic Risk Factors Can Significantly Reduce Your Chance Of Developing MSDs

 

Being aware of ergonomic risk factors can significantly reduce your chance of developing MSDs which have costly and disabling effects for many Americans. An estimated 126.6 million Americans aged 18 and older suffer from MSDs – that is one in two adults.2 Costs related to MSDs involve treatment (medical visits, prescriptions), lost wages, and work-related injuries, estimated to exceed $200 billion annually.3

 

MSDs often result in chronic complaints, disability, issues with mobility and decreased quality of life and are the second largest contributor to disability worldwide. Frequently, MSDs result in work-related injuries impacting worker’s compensation costs, absenteeism, and productivity.

 

 

Truth: One-Third Of Million Nonfatal Workplace Injuries/Illnesses Result In Days Away From Work

 

The U.S. Bureau of Labor Statistics reported that approximately 2.8 million nonfatal workplace injuries/illnesses occurred in 2017, one third of those resulted in days away from work. MSDs represented 32% of those injuries.4

 

Employers and workers share in the responsibility to help reduce risk factors by understanding ergonomics, taking actions to decrease those risks, and promoting best work practices throughout the organization. Ergonomics involves everyone.

 

 

Truth: Ergonomics Help The Job Fit The Worker

 

Ergonomics includes engineering, administrative, and personal controls to help the job fit the worker, rather than trying to have the worker fit the job.5

 

Engineering controls include: workspace design, reducing the weight of loads or applying lift-assist devices, automating processes, and re-designing tools to promote neutral postures.6

 

Administrative controls focus on establishing work practices to reduce the risk of injury and encompass actions such as job rotation, managing over-time, providing adequate staffing, reviewing injury logs, performing accident investigations, promoting near-miss reporting, providing employee education on MSDs/risk factors, encouraging early reporting of work-related injuries/illnesses, implementing break and stretching schedules, discussing work load and job satisfaction with employees, and maintaining equipment and tools.7 Providing ergonomic friendly accessories, such as: adjustable table/chairs, lumbar supports, footrests, arm supports, document holders, sit/stand work stations can each promote the job fitting the worker.

 

 

Personal Controls

 

Lastly, personal controls include the appropriate use of personal protective equipment (PPE), being mindful of posturing, alternating between sitting and standing, reporting of work injuries at the first sign of discomfort, participating in ergonomic stretches/micro-breaks and safety committees.8 Everyone should be mindful of posturing (feet flat on the floor or footrest, back supported, elbows close to body, avoid slouching, keep neutral postures), avoid awkward positions (bending the neck, static postures, placing wrists at extreme angles, working above shoulder height, stooping/crouching), reduce unnecessary movements, limit carrying heavy loads, avoid excessive bending and twisting, avoid over reaching, and keep frequently used items within a safe reach zone.9

 

Implementing ergonomic awareness and promoting a culture of safety and overall total worker health will reduce the risk of work-related injuries, increase productivity and job satisfaction, decrease costs associated with worker’s compensation and health premiums. The truth is, awareness goes a long way in preventing injury.

 

This article is not meant to diagnose or treat any condition. Always consult your primary care provider for healthcare instructions.

 

 

Author Ashley Clay, MSPAS, PA-C, Medcor Provider. 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. Occupational Safety and Health Administration, “Ergonomics: Overview,” accessed March 15, 2019, https://www.osha.gov/SLTC/ergonomics/index.html.
  2. Bone and Joint Initiative USA, “The Impact of Musculoskeletal Disorders on Americans—Opportunities for Action,” Executive Summary of The Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal and Economic Cost, third edition.
  3. Ibid.
  4. United States Bureau of Labor Statistics, “2017 Survey of Occupational Injuries and Illnesses Charts Package,” https://www.bls.gov/iif/osch0062.pdf.
  5. Occupational Safety and Health Administration, “Ergonomics: Overview,” accessed March 15, 2019, https://www.osha.gov/SLTC/ergonomics/index.html.
  6. Occupational Safety and Health Administration, “Ergonomics: Solutions to Control Hazards,” accessed March 15, 2019, https://www.osha.gov/SLTC/ergonomics/controlhazards.html.
  7. Ibid.
  8. Ibid.
  9. Washington State Department of Labor and Industries, “Ergonomics Principles for Reducing Awkward Postures,” accessed March 15, 2019, http://www.lni.wa.gov/Safety/SprainsStrains/AwkwardPostures/ReducingAwkwardPostures.pdf.

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