4 Quick Tips to Get Adjusters to Follow Account Handling Instructions

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HOW TO SCRIPT WINNING ACCOUNT HANDLING INSTRUCTIONS

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A well-done set of account handling instructions can be the very foundation on which a highly successful employer and claims handling organization can work together as a partnership to drive positive injured worker outcomes and drive down workers’ compensation costs. Hello, my name is Michael Stack and I’m the CEO of AMAXX. While that statement is true about the account handling instructions, if they’re not followed, they’re not worth the paper they are printed on. If they’re not followed, they are not worth the paper they are printed on. So, the question then becomes, if you put in the time to create this great set of beautiful account instructions that no one is following, what good are they?

 

 

Adjusters Need to Follow Account Instructions

 

And then the second question is, how do you actually get adjusters to follow those account instructions? I’m going to give you a couple of quick tips here. To dial into some of this mindset of how to approach this and how to make them just that more effective so they can, in fact, be that foundation which we talked about earlier.

 

So I want to give you three quick tips here about how to design these and then how to get cooperation from those adjusters. Three things you want to make them clear, you want to make them concise. And number three, you want to make them easily understood, clear, concise and easily understood.

 

Many companies will have 10, 20, 30, 50, or 60 pages worth of account instructions. And when you are the one that wrote them and participated in writing them and you look at them and you’re overwhelmed and have a difficult sometimes understanding what the heck is in those, the chance of your adjuster team, being able to pick them up and understand and be able to execute on them effectively is very, very low.

 

 

Clear, Concise, and Easily Understood

 

So make them clear, make them concise and make them easily understood. When you’re designing those, take a look at what you have. If it’s this thick, you’re not going to be effective and you need to dial that in to sharpen it up and you need to take another look at it with these three things in mind.

 

And then the other question on this is if you are wanting to get participation from your adjuster team when you’re designing this, ask for their input, ask for their input. When you are designing these and finalizing them, if you can get some cooperation in the beginning of this partnership from that claims handling team, when you’re designing them, clear and concise and trying to make them understood, maybe there’s stuff that you think, Oh, that’s obvious as can be. But to them it just doesn’t, it just doesn’t make a lot of sense in how we would actually function.

 

 

Work Successfully Together

 

Get that input from your claims handling team, dial these things in together, and then you can build that partnership together and work successfully together. And again, my name is Michael stack. I’m the CEO of AMAX. And remember your work today in workers’ compensation can have a dramatic impact on your company’s bottom line, but it will have a dramatic impact on someone’s life. So be great.

 

 

 

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.

First Report of Injury Accuracy Critical for Workers Comp Success

first report of injuryRisk managers and workers’ compensation managers normally delegate the job of filling out the First Report of Injury form (also known in some states as the Employer’s First Report). Delegation of the First Report of Injury to someone who is not extremely careful creates numerous problems. All the information on the First Report of Injury needs to be checked carefully before it is submitted to the claim’s office and the state Workers’ Compensation Commission / Department of Labor / Industrial Commission / etc. For this article we will use Workers’ Compensation Commission (WCC) for all the states.

 

The First Report of Injury form is usually given the number 1 in most states, whether it is known as the WC-1, DWC-1, or other nomenclature. The reason the form is given numeral 1 is that normally it is the first form for both the WCC and the claims office. The information and data used by both the WCC and the claims office in setting up their files is taken from the First Report of Injury. Little errors on the First Report of Injury are copied and can create havoc.

 

 

Ensure Important Details are Correct

 

  • Name Spelled Correctly

The spelling of the employee’s name should be checked. If the last name is misspelled by the employer’s representative completing the First Report of Injury, the WCC will copy it verbatim. When the WCC receives medical information or other state forms which they are unable to match to an existing claim, the WCC will inquire as to why the claim has not been reported, as they could not find the work comp claim in their database.

 

 

  • Correct Social Security Number

An employer should never submit a First Report of Injury without the correct social security number (SS#). Too often, when the SS# is not readily available, the employer’s representative will use a fake SS# such as 123-45-6789 or 000-00-0000 or 999-99-9999. This may get the First Report of Injury off the desk of the employer’s representative, but it creates issues for the employer, the WCC and the claims office. For the employer, it can mess up your loss run accuracy. The WCC will need to call the employer and/or the claims office for the correct SS#. The claims office can submit the Insurance Services Office (ISO) inquiry with the fake SS#, but the likelihood of identifying previous insurance claims by the injured employee is greatly reduced when the SS# is not accurate.

 

 

  • Correct Date of Injury

When the date of injury is incorrect, problems occur. In most workers’ compensation claims, the date of injury is also the date of the first medical treatment. Most claim management computer systems are programmed to kick out medical bills that occur before the date of injury. For example, an incorrect date of injury of 3/3/19 is entered on the First Report of Injury while the correct date of injury is 3/2/19. The medical bills from 3/2/19 will get denied because, to the computer system, they occurred before the date of injury. This results in phone calls from the medical provider(s) and the claims office trying to determine the correct date of injury.

 

 

  • Proper Wage Information

When the wage information on the First Report of Injury is incorrect, it will create problems, especially if the employee is represented by an attorney. Too often, the employer’s representative will take the easy way out rather than contacting the payroll department for the correct wage information. When the employer’s representative completes the First Report of Injury reflecting the employee works 5 days a week, 8 hours per day, at the standard hourly rate for the work the employee normally does, without verifying with the payroll department, problems arise. For example, on a 40 hour week with a position that pays $15.00 per hour, $600.00 is entered as the weekly wage. But in reality, work has been slow; the employee has been absent a lot and has only averaged 32 hours per week. In this situation, the employee’s attorney often will request a hearing trying to compel the payment of disability benefits based on the higher payroll information entered on the First Report of Injury. This will force the claims adjuster to spent time and legal fees proving the correct earnings information.

 

 

  • Proper Type of Injury & Body Part Affected

The importance of properly entering the type of injury and the body part affected on the First Report of Injury cannot be overstated. One of the first things an attorney for the employee will do is check the First Report of Injury for the type of injury and the body part. If this information is missing, your represented employee’s injuries will expand dramatically. Neck and back injuries that you did not know the employee had on the date of injury will suddenly appear. The employee’s pre-existing medical problems will be severely aggravated. The additional medical treatment and extended time off work can be very costly when the type of injury and body part is not completed properly.

 

 

  • Double Check First Report of Injury Prior to Submission

Any incorrect or incomplete information on the First Report of Injury can result in problems. A lot of the problems created by wrong information can be corrected with a few phone calls or the resubmission of the First Report of Injury with the correct information. However, this is a waste of time for all the parties involved. Plus, when the First Report of Injury is inaccurate or incomplete, it can often be exploited by the employee’s attorney. To make the job easier for everyone related to the workers’ compensation claim, be sure your representative who completes the First Report of Injury checks it twice to be sure it is totally accurate.

 

 

 

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.

 

 

 

Two Key Tactics to Avoid “Creeping Catastrophic” Workers’ Comp Claims

creeping catastrophicWe know that aside from traumatic injuries, the vast majority of workplace injuries heal as expected. However, we also know that roughly 20 percent of seemingly minor injuries turn into major problems, leading to complex medical treatments, long-term recoveries, and major expenses. These claims are often referred to as ‘Creeping Catastrophic’ Claims. The question is why do these types of claims occur?

 

There is no single answer since every injured worker is different. But we know that biological, psychological and social factors — or a combination of all three, are often to blame. Uncovering and intervening on those issues early in the claim cycle can pay dividends in the long run. Using the right approach at the right time can keep the claim on track for a favorable outcome.

 

  

Biological, Psychological & Social Factors

 

Factors that may have nothing to do with the injury itself may impede the recovery process and be a significant cause of Creeping Catastrophic claims. Biological factors, such as the person’s genetics, age or gender, may impact recovery. There may be mental or emotional health issues, beliefs, expectations or other psychological elements that have a bearing on the healing process. Social issues, such as financial strain, support systems and relationships can easily derail a claim.

 

Let’s say an injured worker takes a bus to and from work; however, no bus is available to him to the location of, or at the appropriate times for medical appointments. An injured worker in this situation won’t be able to get the treatment he needs and, therefore, cannot be expected to have a smooth recovery. Having this knowledge at the beginning of a claim allows claims managers and others to work with the injured worker and figure out some available options — rather than finding out this information weeks or months into the claim.

 

Another injured worker may have cultural issues that render her unable to work with particular medical providers. Again, knowing this early on can allow stakeholders to direct care or steer the worker to someone more appropriate, saving time, money and unnecessary suffering.

 

There are also injured workers who must care for an elderly parent, which may prevent them from going to physicians at certain times or strictly adhering to their medical regimens.

 

These issues are not the responsibility of the payer, yet ignoring them or failing to recognize them can turn a minor injury into a complicated nightmare. It is incumbent upon payers to do everything possible to find out and address any issues that could harm recovery.

 

 

Trust and Engagement

 

Injured workers are typically scared, confused, and possibly angry. Since they probably have no first-hand knowledge of the workers’ compensation process, they may feel out of control and powerless over the situation. Add to that the fact they are likely in pain, and it’s no wonder they may be less than forthcoming with their life issues that may impact a claim.

 

On the other hand, an injured employee who trusts the payer — or a representative of the payer, understands the process and feels that he is at the center of his recovery is much more likely to discuss non-injury factors that could significantly affect a claim. A biopsychosocial approach to managing claims can truly engage the injured worker, so he feels comfortable sharing certain aspects of his life outside of work or his injury.

 

Key to the approach is:

 

 

 

1) Timing. The first available opportunity for someone to speak with the injured worker is the right time, whether that is within the first two days, the first day, or the first hour of the injury. That is when the injured worker is trying to make sense of what has happened to her and what she can expect — before she has had days or longer to get ‘advice’ from family members, well-meaning friends or attorneys on TV. It is when she is most likely to listen to and if done correctly, trust the person speaking with her.

 

That first conversation with the injured worker should not be viewed as an unemotional session where the claims manager is firing questions, but instead should be an empathetic, interactive dialogue. The main focus should be explaining the process and the injured worker’s options, listening to and addressing her concerns and fears, and expressing genuine care and concern — and emphasizing that the goal is to help her heal and return to her job. It is the first step in building a relationship with the injured worker, not just a one-off, quick chat.

 

 

2) Genuine Communication. Often the best person to initiate this first conversation is the nurse case manager. He may have insight into the injured worker’s medical issues that can be discussed.

 

His approach should be easy, to try and establish trust with the injured worker. In discussing the workers’ compensation process, he may set expectations; for example, saying he expects the injured worker to call him after her medical visits. It lets her know that he is going to be with her for the long haul.

 

The initial and subsequent conversations should be just that — conversations. In addition to discussing the injury and the process the injured worker will go through, the discussion should also center around other things important to the person. Is there a spouse and/or children who may be experiencing some of the same fears and concerns as the injured worker? What are some outside activities that may be affected by the injury?

 

Learning about the injured worker’s life outside of work can also help in the recovery process. Once the nurse and/or claims manager has a better understanding of what is important to the injured worker, that information can be used as motivation to help with her recovery. For example, if she plays in a golf league once a week, the nurse or claims manager can share that information with other stakeholders and incorporated into the treatment regimen.

 

 

 

Conclusion

 

Injured workers are far too often left feeling out of the loop in their own recoveries. Including and engaging them early on and using a holistic approach empowers and motivates them to have a positive experience, and avoid the life-altering impact of a creeping catastrophic claim.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: 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.

Use Orebro Pain Questionnaire to Prevent Creeping Catastrophic Claims

 

Do you know that up to 80% of workers compensation costs are caused by only 5% of workers’ compensation claims. Hello, my name is Michael stack and I’m the CEO of AMAXX. Those exact figures, the 80% of costs are driven by 5% of claims, the exact numbers of 80% and 5% don’t really matter. I’ve heard a lot of different estimates could be 10% driving, 90% of cost or 15% driving 85% doesn’t really matter, so don’t get caught up too much in those numbers. The point is that a small percentage of claims drive a very, very large percentage of workers’ compensation costs and the other real wrinkle in that and the point of today’s video is to recognize that up to 50% of those costs, that huge bucket that we’re talking about are preventable, are preventable.

 

 

Small Injuries Become Big Problems

 

It’s those cases that end up with a really small shoulder injury. It should be pretty standard run of the mill type issue. The person gets fixed up, get them back to work, couple of weeks, they’re back in business. But it’s those claims where it’s this regular run of the mill type injuries that end up putting that person out of work for the rest of their life, causing a very major negative impact on that person’s personal life and of course, driving significant workers’ compensation dollars.

 

So how do we prevent that? How do we get in front of that? How do we identify those claims early on in that process so that we can prevent that very negative impact on that person’s life and of course, dramatically reduced the worker’s compensation costs. Now there’s several ways for us to do this. There are some informal techniques as far as just measuring that person’s resiliency at work. How resilient have they been are when they’re dealing with a regular run of the mill problem in their daily work life?

 

Are they really great at handling that problem or really poorly at handling that problem? How they deal with that as a great indication of how they’re going to deal with the challenge of an injury. So those little informal screening techniques and those work very well, and we just need to pay attention and tune into that a little bit better.

 

 

Formal Screening Technique – Orebro Musculoskeletal Pain Questionnaire

 

And then there’s formal screening techniques. And then what I want to talk with you about today is a really great formal screening technique called the Orebro Musculoskeletal Pain Questionnaire. So the Orebro Musculoskeletal Pain Questionnaire. Now this was invented by a psychologist in Sweden and the nice thing that you need to know about this is that it’s actually free to use, it’s free to use, it’s in the public domain. You can Google the Orebro Musculoskeletal Pain Questionnaire and you can find the test, you could find how to rate it and you can implement this yourself at your claims organization if you’re an employer working with your adjuster or case managers on how to implement this.

 

So that’s what you need to know first, highly effective when they’ve done studies on this, and this has been proven and validated over years and years and they’ve actually sharpened it up and shortened up the form now. Now there’s only 12 questions. There used to be I believe 23 or 27 when they first started it. Now it’s down and it’s called a short form 12 or the SF 12. You administer this and it could be administered by a nurse case manager, it could be administered by the adjuster or could be a third party outside vendor that’s just administering and specializes in this type of thing. But it’s administered two to four weeks into the claim. So, there’s, you know, the person’s hasn’t gotten back to work yet. It’s not really going or getting off the ground or going the way that it’s supposed to, or they’ve been back to work, but they’re on modified duty and they’re not progressing as well as you would like to see them.

 

 

Gain Information to Get In-Front of High-Risk Claims

 

Or there’s just some other red flag indicators that you think, let’s get a little more info on this one because we want to get in front of this and we want to prevent that major creeping catastrophic impact on the personal life and cost. So a Orebro Pain Screening Questionnaire administered by the case manager adjuster, or third party vendor two to four weeks into the claim, gives us those early indicators that there may be some additional intervention that is needed on John Smith’s particular claim to help John get over whatever hurdle it is that’s preventing him from recovery. Look it up, use it, it’s free to use, and it’s highly effective.

 

Again my name is Michael stack. I’m the CEO of AMAX, and remember your work today in workers’ compensation can have a dramatic effect on your company’s bottom line as we’ve demonstrated today in this pain screening questionnaire, but it will have a dramatic impact on someone’s life. So be great.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Dealing with Idiopathic Injuries

Dealing with Idiopathic InjuriesMembers of the claim management team are called upon to make important decisions at the inception of a claim.  One of these decisions includes the investigation of idiopathic injuries and making determinations regarding primary liability.  While this may take more time, failure to understand the mechanism of injury can result in extra time and money being spent.

 

 

 

Idiopathic Injuries Result From Unknown Origins

 

Simply put, idiopathic injuries are those that result from unknown origins that more likely than not are the result of workplace exposure, or related to a workplace injury.  In its basic form, it is an injury resulting from a condition or disease an individual has that has nothing to do with their place of employment and is not easily explained.

 

A common example of an idiopathic injury includes an employee walking down a hallway free of imperfection – suddenly, their knee gives out.  Was it work-related?  Is it compensable under workers’ compensation?  These types of injuries present several challenges for all interested stakeholders in the workers’ compensation system.

 

  • Employee: Proving up their case – receiving compensation for their work injury;

 

  • Employer: Preserving evidence that will be used in determining primary liability, and zealous defense of the workers’ compensation claim; and

 

  • Insurer: Diligent and proper claim investigation, and if necessary, making a legally defensible determination regarding liability.

 

 

 

Investigating Idiopathic Work Injuries

 

Investigating idiopathic injuries starts with a timely and accurate report of the work injury.  For members of the claim management team, the following needs to occur to make the right decisions:

 

  • Encourage employers to have an open line of communication with their workforce. Make sure injuries are reported in a timely manner can help preserve evidence;

 

  • Accurate reporting is essential. Do not guess the weights of various objects or distances involved.  Make sure everything is documented correctly; and

 

  • Preserve all evidence. This includes taking a photograph of conditions as they excited at the time of the incident in case they could change.  Examples of this include a hallway that has carpeting, uneven surfaces, slippery surfaces that might be covered in ice; and stairwells.

 

 

 

Determine Exact Mechanism of Injury

 

The devil is in the details – attention to details is required.  It is important to determine the exact alleged mechanism of injury.  Document the best you can in terms of movements and motions made by the employee at the time of the injury.  When you are able, make a contemptuous recording to “lockdown” someone’s version of events.  Pre-existing conditions are also important to uncover.  Other important factors to consider include:

 

  • Did an injury occur because of a work activity?

 

  • Was the employee performing work activity consistent with the claimed injury?

 

  • If there was, in fact, a work injury, what body parts are involved? Defining an injury by ICD-10 codes may also be important given the reporting requirements for Medicare and Medicaid coordination of benefit issues.

 

  • How long did the employee engage in the work activity for it to result in a work injury? Was it a substantial contributing factor in the disability and/or need for medical care and treatment/disability?

 

  • If not a specific incident-type injury, when did the injury culminate?

 

It is essential to provide this information to an independent medical examiner.  Questions regarding these issues may involve a medical director, nurse case manager, or someone with an advanced understanding of medicine.

 

 

Other Considerations

 

Other idiopathic injuries in workers’ compensation can include workplace exposure to dusts, allergens, asbestos, and idiopathic pulmonary fibrosis.  These claims can be difficult to defend as some jurisdictions have a statutory presumption, albeit rebuttable, which puts insured on the defensive – literally.  These complex cases require the use of experts to successfully defend.

 

 

Conclusions

 

Idiopathic injuries create a series of challenges for members of the claim management team.  Defense of these claims involves proactive actions from the defense interests to preserve evidence, determine with accuracy the circumstances surrounding the events leading up to the injury, and the injury itself.  Failure to take these important steps can increase program costs and lead to excessive litigation.

 

 

 

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.

Dispute Questionable Workers Comp Claims

Dispute Questionable Workers Comp ClaimsNotwithstanding conventional wisdom, 80-90% of all workers’ compensation claims are initially accepted.  While claims can be later denied, questions arise as to how to properly dispute a claim.  It is important for members of the claim management team to take several factors into consideration and avoid making costly mistakes.

 

 

  1. All questionable claims need to be reported to a claim handler so a proper investigation can occur

 

Employers are on the front line of the claims process and generally report workers’ compensation claims to their insurance carriers, or third-party administrators.  They know more about the matter and anyone else and can assist the claim handler in obtaining medical records and starting a proper investigation.

 

Members of the claim management team need to be responsive to the concerns of an employer and flag it for special consideration.  Issues to consider include making a timely determination as to compensability, and direction of inquiry.  Leakage occurs when this does not take place.

 

Steps to consider include taking an employee statement, obtaining medical records, prior medical records, and background checks.  Taking these steps ensures the claim handler completes the investigation and makes the correct decision in good faith.

 

 

  1. Retroactive denials of primary liability and other considerations

 

Retroactive denials of primary liability can be troublesome.  Take for example the admitted low back injury.  During the course of investigation, medical records indicate the employee told a doctor they hurt their back over the weekend doing yard work.  The claim handler has no way of knowing how bad this injury was based on the timing.

 

Using nurse triage can reduce the likelihood of this type of claim because the employees speak to a nurse immediately at the time of injury, so there is less room to change a story.

 

 

  1. Dealing with injuries that are not proportionate to the work injury

 

Members of the claim management team should always review medical records and determinate the mechanism of injury. If an injured employee claims a lumbar strain while lifting a 20-pound tote, and the doctor finds objective evidence on exam of severe, and disabling back pain, then something is not right.  The lifting of 20 pounds should not have such excessive force that it will herniate multiple lumbar discs.   The claim handler should set an IME, and let that IME physician comment on the severity of the symptoms in relation to the stated work injury.

 

A proactive claim handler should also be on the look-out for false positives.  It is likely an average aged individual has degenerative changes in discs without experience symptoms.  IN some instances, these changes are not necessarily related to a work injury or activity.

 

 

  1. Dealing with the “illegitimate” claim

 

Members of the claim management team should have an ethical obligation to investigate all claims – even if there is clear evidence from the onset it is not legitimate.  In the same manner, employers are required to report all injury claims to their workers’ compensation insurance carrier no matter the circumstances.  The claim handler has training and certification, and they are qualified to deny a claim that is alleged to be work-related.

 

Some jurisdictions can carry heavy penalties for failure to report a work injury to the insurance carrier.  The employer pays a premium to the insurance carrier to protect the insured.   The employer should gather all the pertinent details, and report the claim promptly.  Indicate on the First Report of Injury that the claim is questionable, and then go from there. Follow up with the adjuster, and chances are it will be denied as you suspected.

 

 

Conclusions

 

There are several ways to dispute a questionable claim. But the most important thing to do, as an employer, is to gather all the information you can on the claim, then report it promptly to your carrier and follow it up with a phone call to the adjuster. The more you work together with your Carrier, the better the chance that questionable claims will be denied and not paid.

 

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.

Ensuring TPA Quality Control of Adjusters

Ensuring Quality Control Quality control does not just apply to files; it can also apply to the personnel handling files. When you make that choice for an insurance carrier or third-party administrator (TPA), you want to be confident the claim handlers and other members of the team working your claims are qualified.  During the selection process, there are items interested stakeholders should consider before finalizing a decision.  This includes a review of screening tactics an insurance carrier or TPA uses when building their claim teams.

 

 

Multi-level Screening and Training Requirements

 

Most insurance carriers/TPAs prefer to hire entry-level candidates with little to no experience. This happens because HR departments look for new candidates to enter their company.  While it is generally a requirement a claim handler has a college degree, important considerations should include:

 

  • Requiring a candidate to have a degree in an area that applies to insurance. Examples of this include economics, accounting, finance, human resources, and criminal justice.

 

  • Training for new members of a claim management team is essential. The best insurance carriers/TPAs provide career path training so trainees know what they must do to move to the next level. Training can also include training that is onsite so they will know and understand the company culture.

 

  • Forms of advanced training are key to a claim handlers’ success. Proactive stakeholders should require new claim handlers to take steps to receive their AIC (Associate in Claims) designation from the AICPCU (The Institutes).  Other training should include annual compliance training, which includes insurance fraud awareness training.

 

 

Other Quality Control Requirements

 

Interested stakeholders need to go beyond the basics when hiring members for a claim management team.  To ensure the best people are selected, other criteria need to be taken into consideration.  Items to consider may include:

 

  • Reviewing a candidate’s credit history;

 

  • Criminal background check; and

 

  • Be verified to be considered a “fiduciary agent” since they will be making payments for your carrier/TPA on behalf of another party.

 

State and federal laws may apply to this process.

 

 

Commitment to Continuing Education Required

 

All members of a claim management team are required by state law to complete continuing education in some form.  Once hired, a claim handler will be sent to an extensive claims school, or formal training program – normally these are in-house training facilities.  They will learn the skills from veterans of the insurance industry.  They will handle fake claims to go through the motions

 

What happens after this initial training is key.  A claim handler is required to obtain a certain amount of extra training and education every year. This is obtained by attending legal/medical seminars, taking online courses, or obtaining an insurance designation.

 

The management of individual claim handlers is also essential to the success of a workers’ compensation program.  Unless it is a minor claim or a “report-only” claim with no medical treatment, the claim manager will review the file at or around the two-week mark. This will ensure contacts have been made, and a medical diagnosis obtained.  Additional status reporting will also take place at various points in the future:

 

  • 60-Day Status Report: This is the first formal report on a claim. It summarizes the contacts made, the medical records obtained, and provide an outlook on the claim. It also will address the reserve amounts.

 

  • 120-150 Day Status Report: This report will assign the current and future exposure on the claim. By 150 days, it will be clear if this will be a long-term large exposure claim. By this time, an injured worker may have had surgery, or has surgery pending. The injured employee may also be released from medical care and the file will be set to close.

 

 

 

Conclusions

 

Insurance carriers or TPAs have several tools they use to maintain that the work product they put out is of top-notch quality, no matter what the exposure.  There are many items to consider when selecting a team to handle workers’ compensation claims.  Making the right selection includes examining who will be working a claim, and what that company does to prepare their team.  The more you know, and the more involved you can be, the better outcome your claims will have.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: 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.

Honesty In Work Comp Claim Reporting – A Claim Handler’s Point of View

Note: The following article was written by an experienced claim handler who wishes to remain anonymous. This will point out a disturbing issue in the world of insurance, where the employer is not being honest about injury.

 

 

Step into My World – The Life of a Claim Handler

 

Over the years, I have investigated workers’ compensation losses and have heard bizarre stories of personal injury and the circumstances surrounding accidents.  If someone asks me if I have seen everything in workers’ compensation, I have to answer an emphatic “NO!”  Chances are a bigger and more unbelievable instance has yet to cross my desk, and it will be my job as the claim handler to determine what happened. For those employers without the luxury of video surveillance, I go by witness accounts and attempt to piece the circumstances of the injury.

 

 

What do you know about the injury details?

 

Every employer has a designated person to report claims.  The first phone call I make after getting the claim is to this person. Today, we will call her Sally. I call Sally and ask her if this is all that is known about the injury.  She says, “yes,” and that all details are included in the injury report.

 

That may be correct, but I know the report is missing information.  I rephrase the question about the exact timeline of events:

 

  • Who was injured?

 

  • Did the worker tell someone?

 

  • Did the worker go to the clinic alone or did someone drive?

 

  • Do you know about any prior injuries to the claimant’s knee?

 

If you the employer, do not know the particulars about the injury, then be clear on that at the outset.

 

 

Just the Facts Ma’am

 

I can name countless times where an employer reports to me there are no witnesses to an injury. Then I interview the injured employee who provides several names as witnesses.  I then talk to those individuals and ask about their account of events, and more times than not they witnessed the incident or arrived shortly thereafter.

 

Perhaps the employer did not ask about witnesses at the time of reporting and was not aware of any. Maybe the internal injury questionnaire does not have the space to write witness names.  In some cases, the employer may intend for the claim to sound less substantial.

 

 

The Clock is Ticking – Failing to Make a Timely Injury Report

 

I sometimes get a claim with an injury date of a month earlier, or even a year.  Maybe this is an error, but if someone approaches you as an employer and reports being hurt, a claim should be filed immediately.  Do not wait and see if they are actually injured.

 

The employer needs to call it in because I will question the injured employee about dates.   Maybe the report was completed on the injury date and was sent to your agent or broker.  Agents receive a lot of paperwork from their clients.  Just call it in, and if it is sent to your agent, follow up with them.  The sooner the claim reaches the carrier, the better.

 

 

The Devil is in the Details

 

Do you know of any outside activities the claimant is involved in?  I like to ask employers this question to see how much they know about their employees. This kind of tip proves very helpful in a case and investigation.  However, if you as an employer cannot be sure about a tip, then tell us.

 

 

Avoiding Spoliation of Evidence – Saving Money through Subrogation

 

For those employers with moving machinery, admit if the safety guards were off at the time of injury.  The employee is going to tell us either way.  The guard is there to protect workers, so the worker is fully aware if it is missing.  Maybe this leads to a design flaw that our subrogation department can investigate so we can recoup claims dollars spent on this injury.  Modifying safety guards can lead to very serious injury, and the costs associated with that loss are far more than any profit you can attain by changing the functionality of machinery.

 

 

Conducting a Complete and Accurate Investigation

 

If you have internal reporting or accident investigations, then I commend you.  You are on the way to becoming more proactive at handling losses.  We frequently discuss reporting, trends, and identifying injury areas.  If you are not internally reporting, then that is okay also.

 

 

Conclusions

 

In the world of workplace injuries, a lot of people on the outside think that the carrier must worry only about the injured employee’s honesty, but the integrity of the employer is paramount.  In any case, the truth will prevail.  If all parties are honest in the beginning, it makes handling the claim that much easier for everyone involved.

 

 

 

Amaxx LLC is a workers’ comp educational company focusing on cost containment systems to help employers reduce their workers’ comp costs by 20% to 50%.  Amaxx offers 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 Certified Master of Workers’ Compensation designation through the Amaxx Workers’ Comp Training Center.

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

Amaxx WC Training Center: https://workerscomptraining.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 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.

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