The Executive Director of a governmental pool could not understand why the cost of the pool’s workers’ compensation claims was significantly higher than the workers’ comp claim cost of a second governmental pool operating in the same state. The Executive Director had an inkling the claims handling was not as good, but a claims file audit two years earlier found the claim handling to be good with few exceptions.

Due to the high cost of premiums, pool members were withdrawing from the pool and joining the other pool in the state.   The decline in membership in the pool was jeopardizing the existence of the pool. In desperation, the Executive Director sent out a Request for Proposal to various claim file auditors. The claim auditor from two years ago responded with a proposal with the lowest price, significantly lower than the other audit proposals. The Executive Director did something he had never done before; he excluded the low bid proposal.

Total Lack of Compliance with Guidelines

After interviewing several of the claim file auditors, the Executive Director selected an auditor who demonstrated a keen understanding of the cost of workers’ compensation. The claims auditor compared the claim handling guidelines of the third-party administrator (TPA) with the claim files. The auditor was dismayed by the total lack of compliance by the TPA with their own claim handling guidelines.

During the course of the claim file audit, the auditor interviewed the Executive Director, the claims manager at the TPA and several of the workers’ comp adjusters. The reasons the governmental pool had higher than average cost for workers’ compensation became clear to the auditor. The high cost of claims related directly to decisions the Executive Director had made.

Provider Was Chosen Solely on Price

Three years earlier, when the pool was looking to replace the prior TPA, the Executive Director had selected the current TPA because their claims handling proposal had been nearly $250,000 per year lower than the average bid from other TPAs bidding for the business. (The prior TPA had also been chosen based solely on having the lowest price). The claim auditor from two years earlier who had been chosen solely on the price quoted had not done an in-depth review of the files and had overlooked various mistakes in the claim file handling.

The TPA, who had bid the job at a flat price for the program, had each workers comp adjuster handling from 175 to 225 files at any one time, a workload the adjusters could not properly handle. If the TPA hired additional adjusters to handle the claims, the TPA would lose money on the program. The low price proposal the Executive Director had accepted did not have any provisions in regards to the number of claims each adjuster would be assigned. (The executed claims handling contract was also silent in regards to the overall claims handling service standards).

Most WC Claims Were Out of Control

The workers’ comp adjusters had low morale due to their overworked situation. The adjusters did not have time to properly investigate the claims, the adjusters were too busy to assist the pool members on early return to work for the employees, and the adjusters were not working with nurse case managers to control the medical treatment. Most of the workers’ comp claims were out of control.

The end result of the Executive Director’s short term thinking of price only in selecting the TPA was much higher payments on the workers’ comp claims and a loss of pool members due to the overpayment of claims (resulting in increased pool premiums). The Executive Director saved nearly $250,000 per year by selecting the lowest cost TPA over the average bid of other TPAs. An actuarial study using National Council on Compensation Insurance data estimated that the workers’ comp claims payments for claims occurring during the year 2007 were nearly $1.7 million higher than the average for other workers in the same NCCI job classification codes. The cost for short term thinking of price only in selecting the TPA? Nearly $1.5 million a year.

The second claims auditor included in his proposal not only a review of the claim files but also a review of the claims management process. As a result of the claims audit, the following recommendations were made to the Executive Director:

1. The Executive Director should meet with the current TPA, advise the workload of the adjusters was unacceptable and renegotiate the remaining year of the three-year contract to provide for proper staffing by the TPA at a profitable level

2. The Executive Director should put out for bid the claims handling before the current contract is up by utilizing “21 Questions to Ask in Your RFP for a TPA.”

3. The next TPA should have experience handling governmental pools and be willing to provide contact information for all their governmental pools.

4. When the final 3, 4 or 5 TPA candidates are chosen for the next claims handling contract, comparisons should be made of:

• the average value of closed indemnity claims;
• the average number of days open for the closed indemnity claims;
• the percentage of claims that went into litigation;
• the average settlement cost of litigated claims;
• the amount spent on expenses and the ratio of expense cost to claim cost.

5. The nurse case management should be selected as carefully as the TPA whether provided by the TPA or handled as a separate contract.

Short-Term Price Savings, Much Higher Total Cost In Long Run

The Executive Director selected the easy way of making a choice of a TPA using only the price for the TPA services. This resulted in an immediate, short term price savings, but a much higher total cost in the long run. When selecting any service provider, an in-depth investigation into the services that will be provided should be made prior to making a decision. A balance between price and quality of service should be reached prior to the start of the service contract.

When you speak with Senior Management, try to sell them on selecting the “best” service, with the most cost-effective outcome, refer to it as “value.” The Total Loss Costs will ultimately be lower if you choose the service that provides the best “value.”

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

Contact: RShafer@ReduceYourWorkersComp.com.

Workers’ Comp Roundup Blog: 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.

While implementing injury management best practices in workers’ compensation is the most effective way to reduce costs and improve injured worker outcomes significantly, the only challenge is tangible results from improvements takes time.  Self-insured or high-deductible programs can see tangible results in a matter of months, but an employer in a guaranteed cost program can sometimes wait years to see results in an improved experience mod and lower premium.

The oversimplified basic formula for calculating the total cost of workers’ compensation is:

Payroll x Rate x Experience Modification Factor x Adjustments = Premium

Premium + Claim Costs (in a loss-sensitive plan) = Total Cost of Workers’ Compensation

Double-check to make sure you Job Classification Codes are Accurate

Job codes are a huge component of the premium you pay for workers’ compensation.  Therefore, it’s critical codes be applied correctly. The reality of our fast-paced world is businesses change constantly.  As a business evolves, the type of worker needed changes to fit the new business model, and as the type of worker changes, so do the job codes.  Save your business premium dollars by reviewing your job codes periodically –  whether the business has changed or not.  Either way, you save money!

Where does an employer find these job codes?

Most states have adopted a job classification system devised by the National Council on Compensation Insurance (NCCI), consisting of 600+ job codes.  Since workers’ compensation is a state-driven system, applying the correct codes is not always an easy task.  A few states have adopted the NCCI classifications system, but have unique classifications for certain workforce exposures.  Other states have adopted their own classification systems. To make this even more complicated, NCCI doesn’t publish its complete list of codes on the Internet.  You can buy the list from NCCI, but it is not practical for most businesses to do so.

Why are there so many job codes?

Jobs having low-risk exposure carry a low rate; high-risk jobs carry a higher rate.  As an example, the rate for clerical workers is much lower than workers who handle chemicals because the potential workplace injury exposure associated with the two jobs is quite different. No matter what system your state uses, each job code has an associated rate used to calculate your worker’s compensation premium.  A business may also have multiple classifications.  A chemical manufacturer is further classified by the types of chemicals it produces.  Once the business classification is properly identified, classifications drill down to the type of work performed (such as chemical material handler, clerical, sales, etc.).

So, where do you turn? 

Your insurance carrier and broker have a list of job codes by state and will work with you to identify the correct codes for your business.  As this review may save premium dollars for you, it also benefits the carrier by ensuring the risk they cover is a known risk.  For corporations with multiple sites in several states and thousands of employees, reviewing job codes involves several stakeholders and takes time, perhaps many months.  At the table should be the insurance risk manager, insurance carrier, and broker.  You also want to invite division representatives who are well acquainted with site operations and the actual work performed there.  You may want to include a payroll representative who actually assigns job codes to individuals within your payroll system.  Once the stakeholders are identified, begin a systematic review of the operations and its jobs.  As a possible approach, first identify those job titles that are can be grouped into large classifications, such as clerical and sales, which are most easily assigned to a job code.  Then, move into the more specialized areas such as the chemical material handler mentioned above.

Repeat! Repeat!

Enough cannot be said of the importance of reviewing your job codes periodically, particularly if your operation has changed in recent years.  A thorough review ensures all codes are correctly applied for all workers and will likely result in a lower workers’ comp premium for the company.

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

Many insurers are great providers, however, it is naïve to think every insurer has your best interests in mind. Sometimes you need to remind them, and be very specific about your needs.

Here are six tips to get the most from your insurer:

1. Get Regular Reports

It is essential for companies to request brief, narrative reports from their insurers for all open claims at regular intervals of 30, 60 or 90 days. The frequency of reporting requirements is, of course, dependent on claims volume and availability of internal company staff.

A company with 1,000 lost-time claims annually may want less frequent or less-detailed reports every 90 days, for example, but, a company with only 100 lost-time claims annually may want full narrative reports every 30 days.

The adjuster should provide sufficient detail in describing “action items” planned for each 30-day period that indicates steps to be taken to resolve the claim.

Many companies requested information solely about reserve practices in the past, however, the focus of reporting requirements should be on claims resolution strategies.

2. Ask About Recovery Potential – Get it in Writing

Additional items often incorporated in your Account Servicing Instructions (ASI) include requirements that “all claims should be evaluated for state second injury fund and subrogation potential.” The company should receive a report identifying recovery potential within 90 days after the claim is received by the carrier. The carrier files liens in all actions brought by its employees against third parties and these liens should not be waived or compromised without the company’s prior written consent.

3. Benefit Checks Should Come to You First

In those states where permissible, benefits checks should be delivered to the company to distribute to employees. In lieu of this, copies of all checks should be forwarded to the company. Direct deposit can be a convenient way to distribute checks, but you will lose the ability to interact with your injured workers come payday.

All claims should be paid “without prejudice” in those states where possible, and the carrier should file for extensions of this status whenever possible.

4. Ask Your Carrier to Reference the CIB

Companies should also request their carriers reference the Central Index Bureau, an insurance industry-maintained database, on all claims to determine if a prior claim was filed.

5. Be Sure your Carrier and Insured Are On the Same Page with Denials

When the company requests a claim be discontinued, the carrier should be flexible enough to agree to take necessary steps to terminate benefits in a timely manner so long as the company’s position is legally supportable. The carrier should take an aggressive posture in denying insupportable claims. Conversely, the insured should be consulted before any claim is denied to avoid human resource and morale problems.

6. Your Insurer Should Notify You In Advance Regarding Hearings

Furthermore, the company should be notified sufficiently in advance of all hearings and conciliations so its representative may attend the hearings. Also, the litigation manager should be consulted before appeals are filed and should retain the right to determine whether an appeal is warranted.

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

Contact: mstack@reduceyourworkerscomp.com.

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

©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.

Every employer buying workers compensation coverage knows it is an insurance policy for the costs associated with injured employees, but few employers ever read the actual policy. The primary reason most people do not read the insurance policy is because it is written in “insurance speak” or legalese. The following is an effort to translate a generic workers compensation insurance policy into everyday English so more people can understand it.

A workers compensation insurance policy is actually divided into two parts. The first half covers what most employers think of in workers compensation. The second part is the “Employers Liability Insurance.” Part two is designed to cover instances where workers compensation insurance does not apply and an employee brings a lawsuit against the employer. Part one’s coverage and workers compensation statutes are so broad that it is rare for an employee to be able to bring a claim under Part two. For the purposes of this article, we will only be addressing what is typically found in Part one of the policy coverage

Section A – What the Insurance Covers

Workers compensation insurance will pay for injuries caused by accidents, or for illness/disease caused by being exposed to an unfavorable environment. Accidents and illnesses also include death. This section limits the coverage to the policy period. The injuries or illness has to be caused by conditions associated with the employee’s employment. If the work comp claim brought by the employee is for work-related illness, the employee’s last day of exposure to the conditions causing the illness must occur within the policy period.

Section B – What the Insurance Company Pays

The insurance company agrees to pay for all benefits as defined by the workers’ compensation statutes of the state where the employer does business. The insurance company agrees to make timely payment of these benefits.

Section C – The Right to Defend Claims

The insurance company reserves the right to determine which claims it will pay willingly and which claims it will contest. In exchange for the insurance company making this decision, the insurance company agrees to pay the cost of defending the employer from any claim brought against the employer. This allows the insurer to investigate and settle claims as it deems appropriate. It also includes the insurer’s right to not to defend a claim if it is not covered by the policy.

Section D – Additional Things Paid By Insurance

The insurance company agrees to pay the cost associated with the claim in addition to benefits provided by the work comp laws. This includes such things as:

1. Attorney fees and expenses.
2. Surveillance and extraordinary investigative expenses.
3. Medical management expenses (triage, nurse case managers, etc).
4. Court cost.
5. Employer’s expenses incurred at the request of the insurer, excluding loss of earnings.
6. Appeal bonds.
7. Any other expenses incurred by the insurer.

Section E – When There Exists Other Insurance

If the employer has a self-insurance retention or large deductible, the insurer will not pay until the employer has met its financial responsibility under the policy. Also, (this rarely happens), if the employer has other workers compensation insurance that will pay for the employee’s injuries, the insurance company will not pay more than its share of the benefits.

Section F – What the Employer Must Pay

The insurance policy makes the employer responsible for payments when the employer:

1. Intentionally fails to comply with a safety law or regulation.
2. When the employer has serious and/or willful misconduct.
3. When the employer knowingly employs someone in violation of the law.
4. When the employee brings a claim against the employer for discharging, coercing or discriminating against the employee for bringing a work comp claim.

Also, if the insurance company is compelled to make a payment in one of these situations, the employer agrees to reimburse the insurance company for all cost associated with the situation.

Section G – The Right of Recovery

In exchange for the insurer paying the work comp claim, the employer and the employee agree the insurer will have the right to recover the cost of the claim from a third party who is at fault for the injury (think auto accident or equipment malfunction).(WCxKit)

Section H – Legal Stuff

This section includes several miscellaneous conditions including:

1. Most states consider notice to the employer of a work comp claim to be notice to the insurer.
2. An employer’s bankruptcy does not relieve the insurance company from paying the work comp claims.
3. The insurance company agrees it is primarily responsible for any benefits owed under the policy.
4. The legal jurisdiction is the state where the employer is located.
5. The insurance company agrees the policy conforms to the applicable law.
6. The insurance company agrees to pay any special taxes or assessments that arise due to the issuance of the insurance policy.
7. Anything in the policy that conflicts with the state law is modified to comply with the state law.

Not every workers’ compensation policy will follow this generic outline, but the above outline should assist you in understanding your workers’ compensation insurance policy.

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

Contact: mstack@reduceyourworkerscomp.com.

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

©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.

An annual premium audit is a great opportunity to review your workers’ comp class codes and included payroll for accuracy.  Employers that understand the process and prepare early should, at the very least, have no surprises from the audit. Unfortunately, far too many organizations view the audit as a necessary evil, don’t take the time to understand it, and are later presented with a bill they did not expect and may not even be able to pay.

The best way to face a premium audit is head on. That means knowing what to expect and preparing ahead of time, along with avoiding the most common errors.

The Audit

Insurance carriers conduct premium audits to verify a company’s payroll for the period during which it provided coverage. It occurs after the policy expires to determine the accuracy of the payrolls for that year to see if the premium must be adjusted. If the payroll exceeds the estimated projected payroll, the carrier will send a bill seeking more money. On the other hand, if the payroll is lower than projected, the employer may get money back.

Insurers conduct audits to ensure the premium paid to them accurately reflects the company’s risk. That includes making sure the business and employees are properly classified. It’s imperative to have the proper documents and information ready for the audit.

Here are common errors employers make — and how to avoid them.

1. Failing to include deductions. Everything in the payroll is not necessarily subject to the workers’ compensation premium. The allowable exclusions vary among states, but several are universal to all jurisdictions, such as

• Overtime (premium portion, or the half part of time and half)
• Double time (premium portion, or the double part of double time)
• Severance pay

Severance pay for someone who has not worked at the organization incurs no risk and, therefore does not need to be included in the workers’ compensation premium calculation. Overtime and double time pay may be excluded — to a certain extent.

For example, if ‘Joe’ makes $10 per hour, but you give him overtime, or time-and-a-half for working weekends, the extra portion of his pay can be excluded. So, if Joe works 8 hours on Saturday at a rate of $15 per hour, the extra $5 per hour, or $40 (8 hours x $5 per hour) can be excluded. The same exclusion applies for double time.

Depending on the jurisdiction, additional deductions may apply.

• Officer excess
• Uniform allowances
• Tips/gratuities
• Employer-provided perks
• Bonuses

2. Neglecting to inform the auditor. You will be charged for your $100,000 in overtime, double time and severance if you do not report them to the auditor!

3. Omitting the necessary paperwork. Once you’ve informed the auditor of the deductions you’ve found, you need to back it up with the proper paperwork. For example, if a portion of your payroll went for severance pay, you will need the proper documentation. Other documents you may need to have at the ready include:

• Payroll records
• Payroll tax returns
• Certificates of insurance
• Invoices for contracts that show a breakdown of labor and materials

4. Forgetting to consider state differences. In addition to the overtime, double time and severance pay exclusions, jurisdictions often have additional deductions. However, they are not the same in every state. A multi-state employer that assumes exclusions in one state apply to another may be sorely mistaken. You can check your state’s Basic Manual, ask your insurance broker, or ask your premium auditor to direct you to the allowable deductions for a particular jurisdiction.

5. Improperly classifying employees. Your business operation determines what your ‘governing class’ will be; i.e., the classification code in which the bulk of your employees will fall. Employees such as clerical workers who incur little risk may fall into a different category, but only if they NEVER do other work. For example, if ‘Sally’ is an administrative assistant but once or twice a year she is involved with inventory control on the manufacturing floor, she cannot be classified in the clerical class.

6. Failing to ask questions. If you’re not sure which classification applies to your company or you don’t know what paperwork is required to back up your deductions, ask. Resources are typically available through state insurance bureaus, NCCI, or your broker or insurer.

Conclusion

Premium audits don’t need to be a gut-wrenching ordeal. Document and prepare for the premium audit on an ongoing basis, so you don’t have to spend hours or days getting ready. Asking the right questions, understanding deductions that apply, and gathering the proper documentation will make the process smooth and painless.

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

Contact: mstack@reduceyourworkerscomp.com.

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

©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.

When used properly, transferring risk for workers compensation exposure and losses can be an excellent tool for cost control. One such tool is known as Waiver of Statutory Immunity.

A Waiver of Statutory Immunity is: the abandonment, relinquishment, rejection, renunciation, surrender, release, cancelation, or loss (by implied conduct) of any known statutory or contractual legal right.  There are dozens of legal phrases outlining the various types of waiver and additional definitions.

While most waivers of immunity are in the construction industry, any employer using Sub- Contractors, Professional Employee Contractors, Leased Employee Vendors, Volunteers, Individual Specialists, or Temporary Help Agencies can face similar exposures.  The purpose is these entities take over exposures from the entity using their services.

Governments generally have almost full Statutory Immunity for negligence by either constitutional or legislative act.  Yet, if the loss is egregious enough, has major impact, or is not properly asserted, this immunity can be lost.

Hold Harmless and indemnification contracts (with or without Statutory Waiver) not properly written and designed to meet normal public practices, can held null and void by the courts, and/or workers compensation judicial ruling.

For purposes of this discussion two descriptions will apply.  Indemnitee: is the person or organization wanting to transfer risk.  Indemnitor: is the person or organization assuming or taking the risk.

Example of Exposure:

Company A (the Indemnitee) hires company B (the Indemnitor) to perform some computer adjustments.  The work is done on A’s premises.  A and B entered into contract with a standard hold harmless and indemnification agreement.  B also furnishes insurance endorsements naming A as an also insured.

Company B’s employee is injured and alleges A to have been negligent and cause of the injury.   B’s employee is paid compensation benefits by B’s insurance carrier.

B’s employee then sues A for negligence.

A, relying on the hold harmless clause and endorsements for liability coverage turns the lawsuit over to B for defense and disposition.

A is astounded when B’s liability carrier uses employer immunity as defense since B’s workers’ compensation carrier paid benefits.  Because the hold harmless and indemnity clause did not have a Waiver of Statutory Immunity, A is left without defense or coverage under B’s liability policy.

A may be denied coverage under its insurance policies.  A’s carriers may assert that A made its own assumption of risk.

The situation can be progressively worse depending on the number and type of insurance carriers, and parties involved, but most of these cases are resolved without lengthy litigation.  Records show that Indemnitees generally lose the most in exposure and cost.

There are numerous situations where Statutory Immunity is lost.  A few are:

1. Violation of Public Practice.
2. Late Reporting.
3. Failure to properly assert.
4. Vague or Cross interpretation of contract wording.
5. Missing litigation time tables.
6. Judicial or Administrative Ruling
7. Indemnitor fails to Waive Immunity in proper written format.

Manuscript Policy

Standard insurance policies are seldom written to extend coverage for Waivers of Immunity, and State Insurance Departments may not have premium structures for the coverage.   Few carriers recognize waivers without specific endorsement, therefore, a manuscript policy may be necessary.

A Manuscript Policy is written to conform to tailored needs of the insured, or joint venture.  Policies can grant coverage for almost every legal operation.   Premiums may be negotiable, and shared among the various entities.  The policy generally defines every entity exposures and limits, and will define how the insured is to comply with the policy provisions. The policy is generally written for a single use and will expire or be cancelled when the use is completed.  An extending endorsement may be added to allow for injuries or claims incurred but not reported.

Most agents, brokers, and underwriters are not experienced enough to write a manuscript policy, therefore, a manuscript policy is usually prepared by the home office insurance carrier department. The same will apply to endorsements accepting Waivers of Immunity.

Manuscript policies are seldom offered to smaller organizations as premiums are generally expensive or have high retention limits.  Such retentions may be spread across all participants, therefore, it will be crucial that all participants are fiscally sound enough to absorb their share of retentions.

Summary:

Obtaining a Waiver of Immunity from another is a good way to transfer and protect against workers’ compensation claims and subrogation challenges by non-employees, or independent contractor relationships.  However, they must be prepared by properly experience lawyers, in conjunction with all entities and insurance carriers.

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is 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 of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

©2016 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.

Annual Premium Audits (aka payroll reviews) are required by insurance carriers. They can be challenging for the insured employer as they tend to be disruptive, annoying, time consuming, inconvenient, and reduce business operation productive time.  Incomplete or wrong information provided to the auditor can result in adverse premium adjustments.

Self-insured employers face audits and questions from the state insurance department auditors.

Both types of audits are done to ascertain that premiums are proper, and /or the employer can continue to properly fund their workers compensation claims.

Prepare

Proper preparation for the audit can make the entire process less cumbersome and properly document the data being given to the auditor.  Do not wait until notice of the impending audit arrives which could be as short as several weeks.   Being on short notice can cause disorganization of information, missing information, inadequate information, and create more questions from the auditor.

Most employers have gone through prior audits and are generally aware of what will transpire.  Go to the last audit report and study the information used, and look for errors that were made in working with the auditor.  If this is the first audit, write to the auditor and request a listing of documents and information that they will be seeking.

Review all job descriptions to ascertain that the job fits the proper NCCI Class code descriptions’.  Leaving descriptions that can be interpreted for two class codes will certainly allow the auditor to use a higher rated code value that favors the insurance carrier.

Review all payroll records.  Be sure the employee is on the proper corporate payroll. Employers using outside contract employees need to be certain that the contract employees are not mixed with corporate employees.  Document the contract and provide copies of other insurance provisions by way of hold harmless agreements and insurance certificates showing the employer as an also insured on the contractors’ insurance policy.

Be prepared to explain excess earnings due to unusual situations.   An unexpected sale that required extra over time is an example.

On the day before the audit place documents and physical evidence in chronological order.  Place the audit items in a private comfortable room.  Arrange for IT hook up so the auditor can review electronic data.

During the Audit

When the auditor arrives be friendly and professional.  Take the auditor on a housekeeping tour of the office, coffee, photo copying, rest rooms, lunch facilities if on premises.

Designate one or two senior management persons who are totally familiar with the corporate programs, audit procedures, and the materials gathered for the audit, to act as liaison between the company and the auditor.

Auditors may be trying at times with their questioning and interpretations.  Others may have attitude issues.   It is also natural to feel threatened by an audit.  This could lead to unpleasant situations.   Remember it is the auditor’s responsibility to ascertain that the premiums were properly established based on sound financial data.

Keep cool.  Do not lose your temper. Do not make snide remarks or comments. Do not become hostel.

Be cooperative.  Answer all questions accurately.  Do not embellish or furnish any information.  Keep answers short, direct, and on point.

It is best to leave auditors alone and in private.  However, a mid-morning or mid-afternoon break or stop by is suggested.  This gives opportunity to see how the audit is progressing and address any concerns or findings that may be adverse.  Keep the discussions only on the audit.

Auditors are obligated to professional conduct.  They are not allowed to divulge information to any unauthorized persons.  Their reports must be confidential. Normally only the insurance company and the insured are copied on their reports.  Auditors are not authorized to review copyrights, patents, business secrets, and confidential industry procedures.  An example is ingredients in a cookie recipe.

Inviting the auditor to lunch, dinner, or office parties is not recommended.  Supplying tickets to the theatre or sporting events should also be avoided.  These can be interpreted as bribes or tokens to seek special favor.

Wrap-up Meeting

Set a date, time, and private place to have a meeting before the auditor leaves the premises.   Invite only those who need to know.  It is suggested that a draft of the auditor’s report be available.  Go over all the findings.  Attempt to resolve or make any corrections where discrepancies or confusions occur. Be completely frank and honest as well as cordial.

Challenging the Audit Findings

Should the wrap up meeting fail in reaching agreements and the published report is not in keeping with all facts, prepare a written challenge at once and supply necessary documentation to sustain a defense position.  Also request that any adverse premium changes be held in abeyance until the challenge is resolved.  This may require legal assistance.

Summary

Premium audits are a fact of life. They are conducted for the benefit of the insurance carrier. It is necessary to properly prepare for the audit.  Supply all necessary information and be cooperative with the auditor.  Maintain business professionalism in all dealings, challenges and appeals. Use legal counsel where necessary.

Author Michael Stack, Principal of Amaxx Risk Solutions, Inc. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  As the senior editor of Amaxx’s publishing division, Michael is on the cutting edge of innovation and thought leadership in workers compensation cost containment. http://reduceyourworkerscomp.com/about/.  Contact: mstack@reduceyourworkerscomp.com.

©2015 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

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

Experience Modification premiums are developed from, gross payroll, losses reported to the state for the past three years, job classification codes, and application of credits discounts, assessments and penalties derived by the state insurance department.

Gross Payroll Figures Must Reflect True Wages

Gross payroll figures must reflect only the true wages for the employees of the organization.  Sort out leased employees, contractors, vendors, and sub-contractor persons working.  It is necessary for the employer to transfer risk back to these suppliers.  Obtain Certificates of Insurance from these suppliers naming the employer as an also insured.  Use contractual hold-harmless and indemnification clauses in all contracts with the supplying organization.

Proper Employee Job Classification

Proper employee Job classification coding is the next step. The National Council on Compensation Insurance (NCCI) has developed the codes used by most states. The states not using NCCI codes have developed their own lists. Most job codes reflect the overall business.  Hence multiple codes could apply for the same type job. Each could have a different rate. Furnish the agent, broker, risk manager, or underwriter with complete job descriptions.  Detail all tasks and hours.   A few NCCI job class code examples are: 3632 machine shop repair employees, 8810 clerical persons, and 5022 masonry workers.

North Carolina currently has the class code rates and group rates for:

– Machine Shop coded 3632 has a basic rate of $2.69

– Clerical coded 8810 have a basic rate of $0.21

– Masonry coded 5022 has a basic rate of $5.79

Experience Modification Rate

In  addition to the basic premium states assign the experience modification rate.  This is developed by the state insurance department using the loss experience of the employer.   A rate of 1.00 is considered average for the industry. A poor loss experience will lead to a experience modification factor of greater than 1.0 and a positive loss experience will lead to a mod of less than 1.  Each employer will have a minimum mod which would reflect a zero loss history.

Discounts, Penalties, And Assessments

The final step is the application of discounts, penalties and assessments.  Credits are determined based on many potential factors. A few are: employer safety programs, substance abuse programs, low loss experience.  Penalties or assessments can be due to poor loss experience, poor operational conditions, OSHA fines and many other causes.

Final Calculation Formula

(Gross Payroll) x (Job Classification code rate) X (MOD Rate) + or – (adjustments) = Premium.

Assuming the net Gross payroll is $100,000.00 and the employer qualifies for a 5% safety discount, the numbers for the Machine Shop premium would be:

$1,000,000 x 2.69% (class code rate) x 1.15 (experience modification rate) – $1,547 (5% safety credit) = $29,388 as final premium.

Carrier earnings cause impacts on premiums.  Good earning years from carrier investments or income, may allow them to deviate from the state rates.  They may grant premium reductions based on a percentage of those earnings.  During lean earning years, or years with lost profit, carriers more than likely will charge full premium value.

Unit Statistical Reporting:

All data used in the experience modification calculation must be reported to the state insurance department six months prior to policy renewal.  If a policy expires August 1 2014 the losses must be valued and reported by February 1, 2014.  Since the modification calculation runs for three policy years that means policies that expired 8/1/13 and 8/1/12 must also have the current values reported.

Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact: mstack@reduceyourworkerscomp.com.

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

SALES TO PAY FOR ACCIDENTS CALCULATOR:  http://reduceyourworkerscomp.com/sales-to-pay-for-accidents-calculator/

MODIFIED DUTY CALCULATOR:   http://reduceyourworkerscomp.com/transitional-duty-cost-calculators/

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SUBSCRIBE: Workers Comp Resource Center Newsletter

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

It is natural for employers to be overly concerned about serious injury losses.  They recognize that the large incurred values will have effect on the experience modification rates set by the state department of insurance.  At the same time little attention is paid to the multitude of smaller claims including medical only cases.

Need for Concern:

A claim worth $50,000.00 will garner everyone’s attention.  It generally has a better investigation.  Medical management will be a top priority. Much effort may go into rehabilitation and vocational programs.  Great attention is given to reserving. Benefit and medical payments are audited.  Employee compliance is strongly monitored.

At the same time 10 claims worth $5,000.00 each are given much less attention. The difference between just one claim and ten claims can be significant.  The following example will demonstrate this.  This assumption is based solely to demonstrate the impact how frequency and severity impacts experience modification calculations and its impact on premium.

Example:

The total three year cost of premium for the largest claim, Claim 6, is $32,445.  The total three year cost of premium for the 5 smaller claims, Claims 1-5, is $38,958.

Unit Statistical Filing:

Experience modification rates are determined from the incurred values of all claims in a policy period. These values are reported on Unit Statistical forms to the state insurance department.  They are due six months prior to policy renewal.

As an example a policy with renewal effective date of 4/1/2013 must have Unit Statistical reports filed by 10/1/12.

States use statistical data for three policy years to determine the experience modification.    This means our example for the 2013 policy also requires unit stat reports for the policies that expired on 4/1/11 and 4/1/10.

The insurance broker or risk manager, should begin a claim review 8/1/12.  This review must be based on loss runs for policy periods 2013, 2012, and 2011.

Conclusion:

The frequency of smaller claims can have as much influence, if not more, than large losses or a shock loss.  Experience modification rates are based on claim values reported during the past three policy years.  A claim review must deal with large or shock losses, but is should also focus on the underlying issues and management of the smaller, more frequent claims.  It is important for an employer to understand these points and their impact on workers compensation costs, particularly in a guaranteed cost program.

Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact: mstack@reduceyourworkerscomp.com.

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

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

In any workers’ compensation claim, one of the most important issues that needs to be determined upon the onset of an investigation is the employee’s average weekly wage.  The average weekly wage serves as the basis for the determination of a number of workers’ compensation benefits entitled to an injured worker in most jurisdictions, which include Temporary Total Disability, Temporary Partial Disability, Permanent Partial Disability and Permanent Total Disability benefits.  If an average weekly wage is not accurately calculated from the onset, it can lead to a number of issues, which may delay or impede settlement, serve as a basis for underpayment of claims, or penalties should the claim become contentious.

Never Rely Upon the First Report of Injury

One of the first documents received by a claims handler at the inception of a claim is typically a First Report of Injury or similar document.  Often times, this is a pleading completed by either the employee or the employer and almost without exception contains inaccurate information about the employee’s average weekly wage.  In other instances, the average weekly wage is left blank, which causes further question about what the average weekly wage is, and can result in incorrect benefits being paid.

Obtaining accurate information to calculate the average weekly wage can often be received as follows:

o   Collect payroll records from the employer(s);

o   Use a recorded statement or deposition to receive information directly from the employee regarding the number of hours per week they are working, the number of weeks they have worked prior to the injury, their method of payment, information concerning vacation time and paid time off; and

o   Remember that construction workers or employees who work outside may be subject to different rules regarding the calculation of the average weekly wage.

Understand the Difference Between “Regular” or “Irregular” Employment

Every jurisdiction has different rules concerning the calculation of the average weekly wage and their definitions of “regular” and “irregular” employment.  If this is the case, an initial analysis must be made to determine the employee’s classification.

o   “Regular” employment typically occurs in instances where the injured worker has worked the same amount of time in the 26 (or 52) weeks prior to the work injury.  If employment is regular, the calculation to determine an average weekly wage is quite simple.

o   “Irregular” employees have a variance in earnings from week to week, as well as the hours that they work.  This typically arises in instances where an employee has worked varying hours depending upon their job duties, or has had periods of excessive absenteeism.

There are also a number of other issues that come into play when calculating an accurate average weekly wage.  These issues include, but are not limited to, the following:

1. Bonuses: Courts have usually held that performance bonuses based upon attendance at work to be includable in the average weekly wage.
2. Part-time/Additional jobs: Due to tough economic times, it is becoming more common to find injured workers who work more than one job.  As a result, even though an employee did not sustain an injury while working for one employer, it does not necessarily exclude the wages he or she earns in the final average weekly wage calculation.  Courts will usually examine if the employee was (1) regularly employed by two or more employers; and (2) that employment was taking place “at the time of the injury.”  In order for someone to be “regularly employed” the courts have scrutinized whether there was a continuing engagement to serve an employer in their business at that time.
3. Winter lay-offs and construction seasons: Employment in construction, mining and seasonal work presents a whole host of problems for determining an accurate average weekly wage.  Most states have special rules when dealing with workers who have membership in specialized labor unions.  States have adapted their workers’ compensation laws that generally allow for these types of workers to have their average weekly wage computed under special terms and formulas.

Conclusions

Careful consideration must be taken during the initial investigation of the unique circumstances surrounding the injured worker’s employment in order to accurately calculate an average weekly wage.

Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact: mstack@reduceyourworkerscomp.com.

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:   http://www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

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