How To Ensure Your Adjuster Is Being All They Can Be

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

 

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

 

Check List of Investigation Tools:

 

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

 

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

 

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

 

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

 

 

 

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

Contact: RShafer@ReduceYourWorkersComp.com.

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

 

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

 

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

Can You Spot the Workers Comp Fraud Red Flags?

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

 

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

 

 

The Claim:

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Pro-Actively Stop Workers’ Comp Fraud Before It Starts

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

 

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

 

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

 

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

 

 

Review Your Hiring Process:

 

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

 

 

Review Your Injury Response:

 

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

 

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

 

 

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

 

 

Examples of Successful Surveillance:

 

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

 

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

 

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

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

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

How to Identify EARLY Indicators of Expensive Workers’ Comp Claims


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

 

 

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

 

 

Hindsight is 20-20; Foresight is Priceless

 

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

 

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

 

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

 

 

Cost & Cause of Expensive Claims

 

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

 

 

5% of Claims Account for 80% of WC Costs

 

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

 

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

 

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

 

 

Which 1 Claim Out of 14 Will Become Catastrophic?

 

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

 

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

 

 

Early Screening Needs To Be A Part of Your WC Program

 

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

 

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

 

 

Identify 5 Most Expensive Claims

 

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

 

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

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

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

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

 

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

 

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

 

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

 

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

 

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

 

 

Data in Action

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

 

Data Cuts Down Costs

 

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

 

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

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

 

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

 

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

 

She believes collaboration can help solve these problems.

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

 

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

 

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

 

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

 

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

 

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

4 Ways to Control Skyrocketing Workers Compensation Claim Costs

skyrocketing workers comp costsThe sky should never be the limit when it comes to workers’ compensation claims.  Instead, members of the claim management team and other interested stakeholders should be searching for ways to control program costs, while making sure injured employees receive all the benefits, they are entitlement to after an injury.

 

Average claim life continues to increase due to the injury severity and increasing medical treatment costs. While employers continue their involvement in processing claims to reduce costs, insurance companies/third-party administrators (TPA) also must do all they can to save on the costs of handling and controlling claims.

 

 

Immediate Steps to Reduce Increasing Costs

 

There are many steps interested stakeholders can take to reduce program costs.  Here are some immediate steps to implement to run a better program immediately.

 

 

  • Be aggressive with medical bill cost containment

 

There are several good service providers who do utilization review/cost containment at a reasonable cost. This includes a review of procedure codes depending on the TPA/insurance company’s participating medical network.  Often what is missed is some providers are open to agreeing to a lower fee.  If a popular physical therapy clinic in your area nets many, there is an opportunity to negotiate a fee-reduction price in exchange for “preferred provider” status.

 

 

  • Stay on top of your claims – Be proactive

 

Some claims remain open due to claim handler complacency.  By proactively handling the file and using negotiation skills, claims may be resolved months earlier instead of lingering.  Prioritize your files and stay on top of them and before you know it the claim is ready to be closed.

 

 

  • Use telephonic nurse case management

 

When an injured employee is off work, every day of lost wage is an expense.  You want to do everything possible to bring the injured employee back to work as quickly as possible. Telephonic nurse case management (TNCM), as opposed to on-site nurse case management (NCM), gets the same result, for a quarter of the price.  Cases needing a nurse usually demand more follow-up, easily done by phone.  The nurse calls the employer, the injured employee, talks to the treating doctor’s nurse, obtains medical records, and performs other functions that take time and money.  A TNCM frees the claim handler to work on other tasks the file needs, such as background checks, ISO searches, and vendor assignments.  It also allows the claim handler to focus on case management and strategy, which advances a claim toward settlement.

 

The Utilization Review Accreditation Commission (URAC) is an umbrella organization responsible for certifying Nurse Case Managers (NCM); Triage Nurses (TN); Telephonic Case Management (TCM); Field Case Management (FCM); Utilization Management/Utilization Review (UM/UR); and Peer-to-Peer Review. To maintain quality control all these entities need URAC certification. URAC has stringent protocols for education, credentials, and training for these services.

 

 

 

Leakage is the biggest animal in the “reducing claim cost” jungle.  Unnecessary costs, expenses, and errors in payments add up to astronomical amounts of money.  These are often expenses workers’ compensation program are unable to recover.  When reducing file leakage, it is important to audit your files and do so on a regular basis.  File reviews are also an important opportunity to identify fraud, waste, and abuse, or stop it from occurring in the first place.

 

 

Conclusions

 

There are many steps one can take when reducing workers’ compensation costs, while at the same time maintaining the structural integrity of a program.  It all starts with a willingness to review one’s program and look for opportunities to save money.  It also requires all members of the claim management team and employers to be engaged and ready to implement change.

 

 

 

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.

The Problem with Wellness Programs and 11 Ways to Make them Work

Wellness Programs in Workers CompContent for this article was derived from a webinar presented through Risk & Insurance by

 

  • Marcos Iglesias, Chief Medical Officer, Senior Vice President, Broadspire;
  • Monica Manske Sr. Manager of Workers’ Compensation and Employee Safety, Rochester Regional Health.

 

Access the On-Demand Webinar here

 

 

Over the past few years we have heard it claimed that wellness programs can generate a 3 – 1 return on investment for employers. But many organizations that implement them become frustrated by the lack of significant – if any – benefits and may feel their money has been wasted.

 

Wellness programs are not a panacea. Some elements of typical wellness programs are questionable or even harmful, from a medical standpoint. Faced with high healthcare and workers’ compensation costs, organizations are seeking ways to help their employees and improve their bottom lines. Experts say with proper design, effort, time, and realistic expectations, employers can see positive impacts from wellness programs.

 

 

The Facts

 

The overall health of the average America is not ideal; “deplorable,” is how some would describe it. Chronic health conditions, which comprise 7 of the top 10 causes of death, are common, deadly and disabling – yet preventable. The Centers for Disease Control and Prevention says if we eliminated poor nutrition, sedentary lifestyles, and use of tobacco products, we could eliminate 80 percent of heart disease, stroke and diabetes, and 40 percent of all cancers. Improving the health and wellbeing of the employee population is far beyond the abilities of any single employer and will require massive changes in society.

 

But employers can take steps to help their employees make incremental improvements in their overall health and wellbeing. More than half of small employers and the vast majority of large employers are trying.

 

The problem comes when companies that undertake these efforts see no gain. One year into the program, it’s not unusual for companies to see no improvement in health outcomes or productivity and no difference in the number of sick days employees take.

 

One recent study showed the only difference after 12 months was that employees who were included in the program were overall happier than others. There were no measurable health changes, however. Another recent well-publicized study of employees at BJ’s Wholesale Warehouse found no reductions in healthcare costs and no difference in clinical measures after 18 months.

 

Dr. Marcos Iglesias, the chief medical officer for Broadspire, said some wellness programs include recommendations that don’t follow evidence-based medical guidelines. One he cited from the Midwest encouraged all employees to undergo a colonoscopy, which is not medically recommended for everyone, is expensive and unpleasant. Another suggested self-breast exams and testicular exams, which he said are also not advised or recommended for everyone. Iglesias said the frequency of preventive screenings in most wellness programs on the market do not follow medical evidence, and in some cases may do more harm than good.

 

Weight management programs, while well-intentioned, frequently advocate crash-dieting principles. Also, they may cause emotional harm by constantly reinforcing the message that the employee needs to lose weight or stop smoking.

 

The penalties for non-participation in the program or failing to meet certain clinical measures may be seen as coercive or punitive, especially for workers who cannot participate – the disabled and single parents, for example. According to Iglesias, employees who do not participate in wellness programs forfeit an average $670 per year.

 

 

How to Impact Employee Health

 

All this begs the question, what can employers do to impact the health and wellbeing of their employees?

 

The first step is to understand what a wellness program is and what elements to include, based on the organization. There are myriad definitions of what actually constitutes a ‘wellness program.’ Generally, it is a benefit to employees that focuses on lifestyle and prevention to help employees improve their health and/or stay healthy. It may include a variety of elements such as fitness activities, smoking cessation and weight loss programs, health assessments, disease management, nutritional guidance, and lunch and learn educational sessions, for example.

 

No two wellness programs are necessarily alike and the most effective ones evolve with changes in the organization. The webinar outlined a series of ‘musts’ in designing or improving wellness programs that can make a difference for organizations.

 

  1. Seek input from inside and outside the organization.
    1. Unless an organization is comprised of wellness experts, it can benefit from consultants who are brought in to provide input.
    2. A wellness program should be a benefit to all employees – not just those who are already-fit and healthy. Their needs and desires may be different. Creating a cross-functional team comprised of various employees can serve as a guide to the elements that should be included. Surveys can also be used to identify their needs and satisfaction levels, once the program has been implemented.
  2. Clearly define the goals of the program.
  3. Explore and determine the amount needed to be budgeted and human resource commitment.
  4. Find the right space.
    1. If onsite fitness will be included, an area needs to be designated.
    2. Additionally, there should be an area for educational services and preventive programs. It should be welcoming and attractive to employees and their families.
  5. Show compassion, care, and foresight for employees in the design and approach of the program. Consider the specific needs of all employees, including those with outside obligations that may prevent them from participating in after-hours programs.
  6. Continuously evaluate the program. Again, seek engagement of a cross-section of employees to determine how effective the program is.
  7. Make it a carrot, not a stick. Center the program on employees. Offer a variety of activities that meet their needs. That may involve expanded hours for certain programs, or allowing workers to use work hours to participate.
  8. Have realistic expectations. Acknowledge that it may not be able to move the needle toward optimal health and wellbeing for all employees, but that some improvement is a benefit to workers and the organization and that it will take time.

 

For existing programs that appear to be ineffective,

 

  1. Conduct a SWOT analysis. Collaborate with a cross-sectional team of employees to determine what is and is not working, and if any new needs have evolved; what, if any external forces are impacting the program.
  2. Identify what to measure. Looking to workers’ compensation costs to determine the program’s effectiveness may not make sense because of its long tail.
  3. Determine if there is the appropriate amount of HR support for the program, since these are often add-ons and, therefore, not administered by a designated person.

 

 

Conclusion

 

The idea of a wellness program should not be to create wellness superstars but to impact workers’ overall health. Organizations that carefully consider the needs and desires of their workforces spend time properly developing the program, and continuously evaluate and tweak it may see some benefits to their workers and bottom lines.

 

Author:

 

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/

 

Contributor:

 

Dr. Marco IiglesiasDr. Marcos Iglesias is senior vice president and chief medical officer of Crawford & Company’s global TPA, Broadspire. He has more than 25 years of experience in workers compensation, disability evaluation and treatment, and insurance leadership. In addition to being a physician, executive, national speaker and author, Iglesias is known for his compassion for patients, progressive and inspirational leadership, and integrated approach to injured worker care. Iglesias has a special interest in the prevention and mitigation of delayed recovery and disability. He is driven to help ill and injured workers live active, productive and fulfilling lives, which has led him to develop innovative, comprehensive disability management solutions that focus on returning workers to pre-injury function.

 

 

Monica ManskeMonica Manske, Sr. Manager of Workers’ Compensation & Employee Safety; Rochester Regional Health. Rochester Regional Health is the leading provider of comprehensive care for Western New York and the Finger Lakes region. From harnessing research and technology, to helping patients redefine the odds—we are leading the evolution of healthcare. It’s a commitment to health that exceeds expectations, reaching beyond the present into what’s next. Formed in 2014 with the joining of Rochester General and Unity Health systems, now, as one organization, Rochester Regional Health brings to its mission a broad spectrum of resources, an ability to advocate for better care, a commitment to innovation and an abiding dedication to caring for the community.

 

 

 

©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: 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.

Ensure Your Workers’ Comp Files Are Properly Documented

Workers Comp Files Are Properly DocumentedIt is important for members of the workers’ compensation claim management team to document their files properly.  If you do not have access to the electronic claims file, now is the time to ask. If not, it should be a condition of claim handling agreement with your third-party administrator (TPA) or insurer.

 

 

What is in a Properly Documented File?

 

Several items need to be in a properly documented claim file.  Important issues concerning coverage should be addressed at every step of the claim.  This should include:

 

  • The policy number;

 

  • The policy coverage period;

 

  • The states or jurisdictions covered by the policy;

 

  • Endorsements to the policy; and

 

  • Exclusions from the policy coverage.

 

If you have questions, be sure to ask – and demand prompt answers before the adjuster proceeds with the contacts and with the investigation.

 

 

Points of Contact Following a Work Injury

 

Prompt contact with all parties should be initiated immediately after the report of the claim.  Demand action is being taken on the same day a claim is received, or within 24 hours of the loss.  Points of contact should include, but not be limited to the following:

 

  • The employee;

 

  • The employer;

 

  • Any witnesses to the injury. All contact information for witnesses should be included as people change jobs over time; and

 

  • The medical provider(s), including ambulance services and law enforcement responding to a work injury.

 

The clock is ticking.  Steps taken during the initial phase of a claim are important.  Other important notes from a claim handler should be noted.  Important information to obtain should include:

 

  • Accident details as stated by the employee in the recorded statement, the employer’s version of the accident, and any witnesses’ version of the accident;

 

 

 

  • The current disability status of the employee, and projected return to work date;

 

 

  • Length of time the employee has worked for the employer;

 

  • The availability of modified duty for the employee not yet back to work;

 

  • Information on the nature of the injury, the treatment plan, diagnosis, and the prognosis;

 

  • Subjective information such as the employee’s attitude toward the employer, returning to work, and the quality of the medical treatment;

 

  • The explanation of benefits provided to the employee and the action plan information provided to the employee;

 

  • If there is an attorney representing the employee, if so, obtain the representation agreement.

 

 

Moving the Work Comp Claim Toward Settlement

 

Any time is the right time to move a workers’ compensation claim toward settlement.  Steps toward resolving the claim can also be taken after a work injury.  Part of this process includes obtaining documentation that is required to evaluate the claim and set reserves.  Documentation the claim handler needs can include:

 

 

  • Recorded statements of the employee, the employer, and any witnesses;

 

  • Medical authorizations. These will be needed to obtain a complete set of medical records regarding other conditions possibility contributing to the employee’s disability;

 

  • Wage records from the employer to calculating the average weekly wage;

 

  • Complete set of medical records. This may include past records, records related to the work injury, and for other records created in the future;

 

  • Other required state workers; compensation forms;

 

  • Police reports, EMS reports, OSHA reports, other governmental reports on an accident;

 

  • Independent medical evaluations (IME) or peer review;

 

  • Vocational and rehabilitation reports;

 

  • Subrogation documentation;

 

  • Second injury fund correspondence and/or documentation;

 

  • Correspondence to/from employee’s attorney;

 

  • Correspondence to/from defense counsel;

 

  • Workers’ Compensation Board/Industrial Commission correspondence and records; and

 

  • File notes on every telephone call, e-mail, or any other activity related to the file.

 

 

The claim file may also contain other important information on the claim handler’s efforts to resolve the claim, including:

 

  • Case evaluations and status reports regarding causation, legal defenses, and settlement;

 

  • Exposure analysis and case valuation;

 

  • A synopsis of any legal questions and the efforts to resolve those questions;

 

  • Information concerning the disability rating or the potential disability rating;

 

  • Legal analysis regarding a litigation strategy;

 

  • The “action plan” to bring the claim to a conclusion; and

 

  • A history of the settlement negotiations.

 

 

Conclusions

 

The claim handler’s file notes contain the main details of all file documentation received regarding a workers’ compensation claim.  It is important for employers to play an active role in every workers’ compensation claim and be engaged.  Failure to do so can prove to be costly and increase program costs.  The file documentation itself, whether maintained in the computer or by paper, must be complete and answer any questions you have about the file.

 

 

 

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.

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