Record and Document Even Minor Work Injuries

The majority of workers at some point in a career sustain a minor injury at work. Sometimes it does not need to be treated and the worker prefers to deal with it privately at home. Or maybe the employee takes a few sick days to rest and then returns with no other issues.

 

 

Why Document Minor Injuries

 

No matter how minor the injury, it should always be documented. Adjusters receive countless workers comp claims, where a new claim is received in one month but the injury date is 6 to 8 months earlier. Why was this claim not reported back when the injury occurred? The answer from the employer is usually “Since the employee said it was not a major injury, and did not want to go to the clinic, I did not call a claim in at that time. No time was lost from work, so we did not think it was important .”

 

True, it may not have been important at the time. But if the injury details are not documented, then the adjuster has too little information. The employee may report telling the supervisor after the injury happened. And maybe the supervisor failed to make the necessary injury report, so no supporting documents exists. In addition, the supervisor does not remember any details of the injury. However minor the incident, it is important to have floor supervisors and managers document every incident. And the decision to call or not call in the “incident-only” claim to the carrier can be left up to whoever is responsible for calling in claims.

 

 

Put A Copy in Personnel File

 

The important thing is to document everything and put a copy in the worker’s personnel file. Then when a worker comes back about this injury a year later, there is documentation to support that an incident did actually occur and someone in management was informed. This helps the adjuster legitimize the claim and continue on with an investigation. If an employer chooses not to document an injury, then no supporting documentation is available for defense of a potential law suit.

 

A workers comp claim may seem “bad” to some, but it’s not as bad as a liability suit against the owner. A minor injury can morph into a bigger issue at any time. It is better to be on the safe side by documenting every seemingly insignificant little thing, as there is no way of knowing when  a little injury or issue may turn into a nightmare.

 

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

Contact: RShafer@ReduceYourWorkersComp.com.

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

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

 

Dealing with Chronic Pain in Workers’ Compensation

chronic-pain in workers compensationIssues concerning chronic pain continue to dominate workers’ compensation claims across the United States.  These issues include recognizing it, efficiently dealing with it and finding creative solutions to drive an effective program.

Understanding Chronic Pain

There are different types of chronic pain.  When investigating a workers’ compensation claim, it is important for claim handlers to determine a potential diagnosis early on in the process, which includes a recognition of symptomology and familiarity of potential treatment protocols.

 

  • Chronic Pain Syndrome: This is pain that continues for more than a month following an injury.  It is characterized by persistent symptomology that interferes with daily life activities and the quality of life of an employee.  Associated conditions can include numbness and tingling in the lower and upper extremities, psychological disorders (anxiety, insomnia, and other dysfunctions), and the inability to perform even light duty work activities;

 

  • Fibromyalgia and other Myofascial Pain Syndromes: Persons suffering from this condition have complaints of hypersensitive reactions to touch on various areas of one’s body. Other symptoms include muscle spasms and weakness in the upper and lower extremities.  Studies indicate a person’s suffering from these conditions may have underlying psychological and/or psychiatric conditions.

 

  • Pain Syndromes: These conditions are often referred to as Complex Regional Pain Syndrome (CPRS) or Reflex Sympathetic Dystrophy (RSD).  Symptoms of these conditions include: burning or throbbing pain in the extremities (including hands and feet); hot/cold sensitivities; swelling and stiffness in joints; and changes in skin color, which include a reddish or bluish discoloration.  It remains a mystery as to how these conditions develop and the effectiveness of various care plans.

 

State law or administrative rules are often used as a guide to help compensation judges or industrial commissions approve claims for these conditions.  Careful research that includes case law should always be conducted by a claim handler to know the correct standard.

 

 

Reasonableness and Necessity of Care in Chronic Pain

 

All compensable medical care and treatment in workers’ compensation must be “reasonable and necessary.”  Given a lowered burden of proof, courts will generally approve medical care if it is demonstrated to provide a benefit to the injured employee and aid in their recovery.  When reviewing medical care, members of the claims management team should evaluate the following factors, especially when it involves chronic pain issues:

 

  • Evidence of a treatment plan: All recommended medical care and treatment should have a defined plan to cure and relieve the effects of a work injury.  Concerns should be raised when proposed care is open-ended.

 

  • Documentation of treatment details: Questions should be raised (especially with physical therapy or chiropractic care) when it appears the provider is merely using a word processor to copy/paste the symptoms of an employee, the care provided and results of the treatment.

 

  • Degree and duration of relief: While the standard of compensability in workers’ compensation is low, threshold matters of lasting and long-term relief should be present in medical records.  If care appears to be palliative in nature, it should be aggressively defended.

 

  • Frequency of medical care: Medical treatment parameters generally require long-term care to be on an “as needed basis,” and not based on a set schedule.  Proactive claim handlers should scrutinize medical records to determine if patterns develop in medical care.

 

  • Relationship between treatment goal and returning the employee to suitable gainful employment: In all but a few limited instances, the goal of any treatment modality should focus on returning the employee back to work following an injury.  Dangers occur when the employee becomes deconditioned and does not improve the strength and endurance of an employee.

 

  • The cost of medical treatment in light of relief: Finders of fact in workers’ compensation are generally more willing to approve a form of medical care and treatment if it has either a stated goal of returning an employee to work, diagnosing the underlying problem, or is rather inexpensive and/or non-invasive.  Care can also become duplicative, which should be a concern. Examples of this include recommendations of chiropractic care in conjunction with physical therapy.

 

 

Conclusions

 

Dealing with chronic pain issues require members of the claim management team to be proactive.  This includes understanding the dynamics of these claims and various effective treatment modalities.  It also requires and deeper dive into medical records and investigating the claim to only pay for medical care that is reasonable and directed at returning the injured employee back to work.

 

 

 

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: 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.

Effective Handling of Medical Only Workers’ Comp Claims

medical-only workers comp claimsMedical only workers’ compensation claims are sometimes viewed as being unimportant and routine.  This mindset can cause issues and lead to larger problems within a claim management team.  If left unchecked, it can significantly impact the ability of a claims team to handle a large number of claims and not settle workers’ compensation claims in a timely manner.

 

 

Medical Only Workers’ Comp Claims – Defining the Issue

 

Medical only workers’ comp claims are those that involve an injury where the employee only receives medical care and treatment, or the wage loss is confined to the “waiting period” under a workers’ compensation act.  In these claims, the employee’s medical care and treatment may be as short as one office visit, or as long as several years.  The important thing to remember is money is being spent and the claims need to be properly managed.

 

 

 

Avoiding Pitfalls in Medical Only Workers’ Comp Claims

 

Members of the claim management team that work on these claims are generally newer claim handlers with less experience.  The work may be monotonous, but it is still important.  Members that are working these claims should pay close attention to detail, which includes the following issues:

 

  • Ensure the injured employee receives prior authorization when necessary to receive medical care and treatment;

 

  • Understand requirements as it released to applicable medical treatment parameters and fee schedule payments; and

 

  • Review applicable claims to ensure managed care protocols are followed, if applicable.

 

This process also requires the claim handler sets the proper reserves on a claim.  In order to accomplish this goal, the claim handler needs a complete understanding of workers’ compensation protocols.  It is also important to ensure the employee remains gainfully employed to avoid exposure for indemnity and wage loss benefits.

 

 

 

Move Cases Forward – Not Letting Dust Settle

 

All members of the claim management team need to act in an honest and ethical manner. This includes treating the injured employee with respect and dignity.  All payments should be made when legally required. The importance of properly handling medical-only claims is echoed by a National Council on Compensation Insurance (NCCI) report that found the following:

 

  • About 80% make the transition within 12 months of the date of injury;

 

  • Medical-only claims that become lost-time claims cost an average of 40 times more than those that remain medical-only;

 

  • Carpal tunnel claims are the most likely claims to transition from medical-only to lost-time, with the probability of such a transition being approximately 34%;

 

  • The larger the incurred value (paid plus case reserves), the greater the probability of the claim becoming a lost-time claim; and

 

  • The probability of a claim transitioning increases with claimant age until age 65, and then it declines.

 

 

It Takes a Team to Manage (Medical Only) Claims

 

All members of the claim management team need to take a proactive approach to medical only claims.  Even claims that are reserved at lower amounts – $500 to $1,000 – can reduce a program’s efficiency and effectiveness.  Small dollar amounts allocated across countless files add up.

 

  • Claim Managers: Be a leader and work hard to make sure all members of the team are moving claims toward settlement.  A file that collects dust impacts everyone;

 

  • Claim Handlers (more experienced and indemnity handlers): Provide guidance and assistance to newer members of the team.  Make sure they know how to be efficient and effective.  Mentorship can pay dividends across the team by building morale.  It also demonstrates you are capable of handling more complex matters; and

 

  • Medical-only Claim Handlers: Pay attention to what is going on.  Understand there is a learning curve so do not shy away from constructive feedback.  Never be afraid to ask questions.

 

 

Conclusions

 

At the end of the day, the only good file is a closed file! This starts with a program-wide review of medical only claims.  Make sure these files are properly reserved and files that can be settled are moved toward closure.  It is also important for everyone on the claims management team to be involved and work together for the good of a program.

 

Mental Health Workers’ Comp Claims

Mental Health Workers’ Comp ClaimsReducing costs is challenging when it comes to mental health workers’ comp claims. This is based on a number of different factors that separate these claims from common physical ailments and injuries.  In order to be successful in reducing workers’ compensation program costs, members of the claim management team need to take extra steps in determining liability and making sure the claim is properly defended if there is a dispute regarding causation, and reasonableness and necessity.

 

 

Understanding Mental Health Workers’ Comp Claims

 

Workers’ compensation laws originally covered only physical injuries.  As social norms changed, so did the concept of what constitutes a “personal injury.”  As laws developed, mental health workers’ comp claims gained acceptance and allowed employees to receive wage loss and medical benefits for claims that did not involve traditional physical injuries.

 

The laws in jurisdictions vary, so it is important to understand how the law applies, the required standards and medical support necessary for a mental health workers’ comp claim to be found compensable.  There are two general categories of mental injuries claims:

 

  • Physical/Mental Injuries: This injury originates with a physical injury (specific incident or workplace exposure), and morphs into a psychological and/or psychiatric claim.  Common examples include an aggravation and/or acceleration of an underlying condition that is worsened as the result of the physical trauma.

 

  • Mental/Mental Injuries: This is an injury that results from work-related mental stress or stimulus that produces in many cases symptomology or ailments deemed to be compensable.  An early example of this type of claim comes from Wisconsin where students at a high school demanded a guidance counselor be removed from her position.  The counselor developed a severe neurosis tension state that was eventually determined to be compensable.  School District No. 1, ILRC, 62 Wis. 2d 370, 375, 215 N.W.2d 373, 376 (1974).  Compensability in other instances has included cases where the employee merely observed someone else being injured at work.  International Harvester v. LIRC, 116 Wis.2d 298, 341 N.W.2d 721 (Wis. Ct. App. 1983).

 

 

Determining Issues of Compensability

 

It is important to note the legal standard for these types of injuries varies.  There are common themes that run through statutes supporting these types of claims that a member of the claim management team must keep in mind when making determinations of compensability and whether denying the matter is appropriate:

 

  • Whether the mental condition arose from a situation greater than the “day-to-day” emotional stress one would otherwise experience;

 

  • Whether the alleged mental condition really exists based on objective medical evidence; and

 

  • Whether the workplace exposure or conditions as compared to everyday life is a substantial contributing factor in the mental health condition and/or disorder.

 

Some jurisdictions require additional medical evidence to support a claim for a mental health injury.  Examples of this include a requirement the mental diagnosis must be given by a licensed psychiatrist or psychologist, and/or meet the described criteria found in the Diagnostic and Statistical Manual of Mental Disorders (DSM).  Limitations can also be placed on these claims if the underlying condition is the result of disciplinary action, work evaluation, job transfer, layoff, demotion, promotion, termination, retirement or other good faith actions of an employer.

 

 

Special Considerations When Investigating Mental Health Workers’ Comp Claims

 

Like physical injuries, psychological and/or psychiatric claims require members of the claims management team to investigate the “mechanism of injury” when determining issues of initial compensability and reasonableness/necessity of claims.  This includes:

 

  • Obtain a complete set of medical records for the employee and make additional inquiries regarding medical care and treatment related to the employee’s mental health and any history of family/personal counseling;

 

  • Investigate treatment for chemical dependency issues. This should not be limited to the employee, but members of their immediate family; and

 

  • Reviewing issues concerning other factors that may impact the alleged injury and time off work. Factors to consider include periods of unemployment, bankruptcy, gambling problems, and other financial losses.

 

 

Conclusions

 

Issues concerning mental health will continue to dominate workers’ compensation claims as we learn more about it and its impact on one’s well-being.  The result is members of the claim management team will need to better understand how it can impact a claim and seek to run a better program to control costs.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: 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.

 

Evaluating Medical Evidence to Make Better Decisions

Evaluating Medical EvidenceMembers of the claim management team are called upon to evaluate the medical evidence and determine issues of reasonableness and necessity of medical care and treatment, along with determinations of causation and primary liability.  These decisions have a significant impact on an individual claim and effectiveness of a workers’ compensation program.

 

 

Evaluating the Evidence from a Physiological Standpoint

 

Imagine the next claim that lands on your desk involves a meat production worker.  The employee is a 62-year-old man who’s work activities require him to process meat on a bench that is no higher than his waist.  During this process, the employee will turn in one direction to place the finished product for further processing and sale, and turn in the other direction to place the undesirable portions of the product for disposal.  None of their work activities require the employee to lift objects above chest level or over his head.  The employee is now claiming a progression of symptoms that involve stiffness, which has now culminated in “frozen shoulder” syndrome.

 

Should the alleged injury be accepted?

 

While the cutting of meat and its processing are repetitive, not all claims of repetitive trauma are compensable.

 

 

Making the Right Assessment

 

Claim handlers deal with many barriers when reviewing matters and determining questions that have real consequences.  This includes rigid timelines that can result in sanction or penalty if not done right or within a timely manner.  Questions that must be considered include:

 

  • Did a work injury actually occur – even if it only aggravated or accelerated an underlying condition?

 

  • What role if any, did the work activity contribute to the injury, disability and/or need for medical care and treatment?

 

  • Even taking into consideration the employee’s age and possible prior injuries, did the work activity advance the underlying condition to the point of compensable injury?

 

 

In terms of the above scenario, the claim handler worked with a medical expert to review the claimed mechanism of injury, prior medical records and other information to allow for a primary denial.  It was noted that the contemporaneous medical records and work history did not support a work injury and the claimed mechanism was inconsistent with the subsequent medical diagnosis.  In sum, because the physiological body mechanics in question did not fit injury, the proactive claim handler was effective and proactive in denying the claim.

 

 

Application in Claims Handling Practice

 

It is important for members of the claim management team to review their files and determine if the medical evidence fits in not only workplace exposure/repetitive injury claims, but also specific incident injuries.  Examples of how this can be used in specific injuries include:

 

  • How the employee fell or what they were doing when they fell;

 

  • Angles of fracture and the type of fracture following a slip/fall; and

 

  • The nature and extent of an injury based on pre-existing conditions such as degenerative disc disease for back and neck claims, and claims involving joints such as knees, shoulders, and

 

The list of possibilities is really endless.

 

 

Conclusions

 

Members of the claim management team face many challenges in their position on a daily basis.  It is of utmost importance that claims handlers make proper decisions after having investigated a claim in a timely manner and making evidence-based decisions.  This includes taking the time to obtain information on how the injury took place, they can save time and money for their program and clients.

 

 

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: 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.

Durable Medical Equipment Often Overlooked for Cost Containment

Durable Medical Equipment Often Overlooked for Cost ContainmentSelf-insured employers who are trying to control the cost of medical care within their workers’ compensation program will often use medical triage, nurse case managers and pharmacy benefit managers, but overlook durable medical equipment (DME).  Durable medical equipment is reusable medical gear or reusable medical products necessary for the injured employee to function at home or away from a medical facility.  Durable medical equipment must be prescribed by a doctor and most DME will have no benefit to a person who does not have an injury or occupational illness.  The need for durable medical equipment is closely related to the severity level of an injury — the higher the level of severity of an injury, the greater the probability that an injured employee will need DME.

 

 

Can Be Expensive, However Cheaper Than Hospital

 

Depending on the nature of the DME, it can be very expensive adding considerable medical cost to the workers’ compensation claim.  Examples of DME that can add substantially to the claim cost include:

 

  • Oxygen tents

 

  • Hospital beds

 

  • Motorized wheelchairs

 

  • Power operated vehicles

 

  • Lift chairs

 

  • Continuous positive airway pressure (CPAP) machine

 

  • Iron Lungs

 

  • Traction equipment

 

  • Prosthetic limbs

 

  • Transcutaneous electronic nerve stimulators (TENS units)

 

  • Air beds or fluid beds

 

 

While some DME can be expensive, it is always much cheaper for the injured employee to be at home using DME than it is for the injured employee to be in a hospital room, nursing home or other type of convalescent facility.  The cost of medical care supplied away from the home can range from 100% to 1000% higher than the cost of medical care at the injured employee’s home with DME.

 

In some liberal jurisdictions, the range of DME has been expanded to include such items as:

 

  • In-home spas

 

  • Whirlpools

 

  • Hot tubs

 

  • Orthopedic/specialty mattresses

 

  • Air conditioners

 

  • Dehumidifiers

 

  • Hearing aids

 

 

Prescription Written by Doctors Should be Verified

 

Prescriptions for these types of items are normally only written by doctors chosen by the employee’s attorney.  If the employer is confronted with a prescription for specialized DME of this type, an independent medical examination of the injured employee can be completed to verify the need for the specialized DME.  An alternative is to have a utilization review or a peer review of the prescription to verify the medical necessity. A different approach is to have the request for specialized DME reviewed by the workers’ compensation board or industrial commission for their concurrence or denial.

 

 

Claims Adjuster Should Arrange for Purchases

 

If it is determined the specialized DME is necessary, the claims adjuster or the nurse case manager should arrange the purchase of the specialize DME.  This will allow the adjuster or nurse case manager to obtain the necessary equipment, but restrict the purchase to what meets the doctor’s prescription, but does not exceed it.  For example – the doctor writes a prescription for a Tempurpedic mattress and the industrial commission rules it must be provided.  If the claimant is left to select and order the mattress, the claimant will select the $6,000 version, while if the adjuster is responsible for obtaining the mattress, the adjuster will select the $3,000 version that meets the requirements of the doctor’s prescription.

 

Some DME is not expensive and is commonly provided to injured employees.  Examples of less expensive DME includes:

 

  • Commode chairs

 

  • Walkers

 

  • Canes

 

  • Crutches

 

  • Nebulizers

 

  • Non-motorized wheelchairs

 

 

Hold Durable Medical Equipment Costs Accountable

 

If the state medical fee schedule includes DME (some state fee schedules do include DME while others do not), and if there is no question in regards to the medical necessity of the DME, it should be submitted to the medical fee bill review service for control of the cost of the DME.

 

In the states where the state fee schedule does not address DME, the self-insured employer should make arrangements with a company that specializes in DME to provide all necessary DME.  A pre-arranged pricing agreement for the DME items listed above will reduce the cost of DME.

 

 

 

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: https://blog.reduceyourworkerscomp.com/

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Writing an Effective Independent Vocational Evaluation Letter

Independent vocational evaluations (IVE) are used to assist members of the claims management team in determining a variety of issues related to vocational rehabilitation and disability matters. Similar to an independent medical examination, an Independent Vocational Evaluation is costly and often only performed once during the course of a disputed workers’ compensation claim. When spending the money on an IVE, it is important to do your homework first in order to save time and money. Part of this includes preparing a proper letter and asking the right questions of the evaluator.

 

 

Preparing the Independent Vocational Evaluation Letter

 

The Independent Vocational Evaluation will typically not take place until just prior to a settlement conference, mediation or hearing on the merits. Part of the preparation includes obtaining the necessary background information on the employee and understanding their medical condition(s). Information to consider obtaining and sending the expert include the following:

 

  • Medical records: This included medical records regarding co-morbid conditions, surgeries, treatment immediately after the work injury and subsequent medical care and treatment;
  • Education and Work History: This is information that will be obtained during the course of discovery. It is important for the examiner to have a complete picture of the employee’s background and possible transferable job skills; and
  • Deposition Testimony: Having sworn testimony under oath is keep to giving your expert proper foundation.

 

 

Questions to Ask Your Vocational Expert – Writing the Independent Vocational Evaluation Letter

 

The letter to your vocational expert may likely end up in evidence at the hearing. This is why your letter should be completely factual and without bias. Commonly asked questions may include the following:

 

  • Given the employee’s age, education, employment experience, transferable skills, relevant labor market, and employee’s disability and restrictions, what jobs exist in the relevant labor market in substantial numbers that the employee is capable of performing?

 

An Independent Vocational Evaluation is often used to determine if the employee is capable of working in any capacity, and if there are jobs located near them. This is often information defense interests will want to know when defending claims involving exposure for permanent total disability (PTD) benefits or retraining claims.

  • Given the employee’s age, education, employment experience, transferable skills, relevant labor market, and employee’s disability and restrictions, what is the employee’s current earning capacity? Please give a range for any capabilities and give a median or average earning capacity opinion.

 

The issue of an employee’s earning capacity is often in dispute when an employee needs ongoing vocational rehabilitation benefits. It can also be an issue in high-exposure cases where the employee suffers a significant injury requiring disabling restrictions assigned by the employee’s treating doctor.

 

  • Perform a labor market survey to determine if there are actual jobs that do exist in the relevant labor market that the employee would be capable of performing. Please discuss actual jobs that are available within the restrictions provided by the treating doctor.

 

Labor market surveys are commonly used in retraining claims. One criterion that is often in dispute is whether the employee has conducted a good faith job search, or if there are jobs available for the employee once they are retrained in a new field.

 

  • In your opinion, is the employee performing a diligent job search?

 

The quality and sincerity of a job search are often in dispute when a claim is in litigation. This is a legal issue and results in a “battle of the experts.” The vocational expert will examine the number of applications submitted by the employee, the methods the employee is using when searching for a job and how much time the employee spends looking for a new position. Having accurate and complete information is key.

 

 

Other Matters to Consider

 

It is also important to make clear with your vocational expert that they provide a discussion regarding their answer. This will be useful if live courtroom testimony or admitted deposition testimony is not given at the hearing. Any expert worth the money you are paying should not object to such a request.

 

 

Conclusions

 

A well-written letter to a vocational expert can pay dividends in workers’ compensation cases. Timing, preparation, and knowledge of the issues are key. Failure to do so can be harmful when defending a claim, as well as hurting one’s chances of success.

 

 

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: https://blog.reduceyourworkerscomp.com/

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Surveillance is Often Used Incorrectly

Surveillance is Often Used Incorrectly

Members of the claim management team need to be creative when investigating workers’ compensation claims and to determine issues of compensability.  This includes using claim investigation techniques that go beyond interviewing the employee, witnesses, experts, and reviewing medical records.  To be effective, proactive claim handlers and investigators need to do a deeper dive to reduce program costs.


Surveillance is Often Used Incorrectly

Over the years, defense interests in the workers’ compensation industry have become dependent on using private investigators to conduct surveillance on an injured worker.  Surveillance is a recommended and effective technique. However, it is often :

 

  • Limiting surveillance to one day: The problem is this provides only a Not obtaining of what the employee is doing and allows for them to argue you watched them on “a good day;”
  • Not obtaining complete background information on the employee: This includes not knowing the habits of an employee and what activities they might be doing when under the watchful eye of an investigator. In worst case scenarios, the employee will do nothing at all – not even coming outside their home; and

 

  • Following the rules: Many jurisdictions have specific timelines as to when and how documentary evidence from surveillance needs to be disclosed to the employee and/or their attorney.  Failure to follow these rules can have significant consequences.



Using Other Resources to Uncover Favorable Claim Information

Claim handlers need to be creative and ethical when uncovering information on a claim and developing their theory of the case.  This requires patience, persistence, and creativity.


Job Site Videos

Job site videos are useful in a number of ways when done.  For example, if an employee is claiming that a certain activity (especially those that require repetitive movements) is includes using of an injury, it allows for a medical expert to evaluate whether be effective of injury is consistent with the objective medical evidence.  It also reduces or eliminates the ability ofan employee to exaggerate movements, including the frequency at which it is performed.

When creating such videos, it is important to remember key items.  This includes having a workplace station or machine set up exactly how it was at the time of the injury. When possible, have the employee to perform the motions or movements.  If this is not possible, itis essential to have someone of a similar size perform the activity.  Failure to exactly recreate these motions in question can result in the job site video not being admitted into evidence at the hearing.


Timing and Work Schedules

Records documenting the coming and going of an employee, an employee and the number of shifts they worked can be relevant in a number of circumstances. Instances when this can be useful include the following circumstances:

  • Claims made by the employee as to their physical presence at a location at a specific time, or when other identified witnesses claim to have been present;

 

  • The number of hours or shifts worked by an employee.  This is important information to have in workplace exposure cases; and

 

  • Tracking movements of traveling employees. This can be important when trying to determine the applicability of “portal-to-portal” coverage where an employee may have made a personal deviation, which took them outside the “course and scope of” their employment

 



Social Media Investigation


While fewer Americans are using social media platforms on a consistent basis, it is still relevant to any claim investigation.  Key points to remember include checking common programs such as Facebook, Twitter, and Instagram.  Ethical considerations apply.  Do not obtain access to an employee’s account under false pretenses or by using a strawman.  Attorneys representing defense interests should also take note of case law that warned, “It should now be a matter of professional competence for attorneys to take the time to investigate social networking sites.” Griffin v. Maryland, 192 Md.App. 518, 535 (2010).


Conclusions

Running an effective workers’ compensation claim program requires hard work and creativity.  In order to be cost-effective, one needs to think outside the box and go beyond the “cookie cutter” approach to investigating and defending workers’ compensation claims.  By looking for alternative methods, members of the claim management team can make better decisions and move cases toward settlement.




Michael Stack - Amaxx

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

Contact: mstack@reduceyourworkerscomp.com

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

©2018 Amaxx LLC. All rights reserved under InternationalCopyright Law.

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

Avoid Workers’ Comp Penalties and Other Pit Falls

Avoid Workers’ Comp Penalties and Other Pit FallsMembers of the workers’ compensation claims management team are on the front line when it comes to investigating a claim and making timely payments of benefits.  Failure to do so can result in penalties to a workers’ comp program and cause interested clients to lose confidence in the process.  Transparency and consistency are key.  Now is the time for all claim handlers and their managers to better understand the various rules and requirements in jurisdictions they handle, apply these procedures correctly and make good faith determinations to avoid common pitfalls in the claims process.

 

 

Common Errors that Result in Workers’ Comp Penalties

 

Many rules govern workers’ compensation insurers and third-party administrators.  It is important the claims management team understands these rules and make proper determinations.

 

  • Frivolous Denial of Liability: Denials of primary must state why a claim is being denied.  This includes stating a factual and legal basis for not paying on a claim or deny specified treatment.  This can also include a failure to fully investigate a workers’ compensation claim in a good faith manner or make inaccurate statements following the investigation.

 

  • Nonspecific Denial of Liability: Denials of primary liability must also be specific.  The requirements to avoid this type of penalty vary, but generally, denials must be sufficiently specific to convey clearly, without further inquiry, the basis for the denial.  Denials based on the premise that the injury did not “arise out of and in the course and scope of employment” must also include additional information supporting this position, so the injured employee knows why a matter is not being paid by the insurance carrier.  Avoid excessive “legalese” when denying a matter.

 

  • Late Denial of Liability: Applicable laws generally require a determination to be made promptly.  In many instances this is between 10-14 days.  When a member of the claim management team receives a reported injury, it is important for them to determine the first day of disability and when the employer received notice of disability.  Knowing this information can ensure the claims professional issues the denial promptly.

 

  • Late Filing of First Report of Injury (FROI): The employer plays an important role in completing the FROI.  This is important as most state workers’ compensation laws require this form be completed and filed with the industrial commission in a timely manner.  Claim handlers must ascertain when the employer receives notice of the injury or disability to determine when the FROI must be filed in a timely manner.  An effective claim management team should help train employers on these issues to avoid delay and penalty.

 

  • Late First Payment of Benefits: There are also time requirements for the insurance carrier or administrator must make payment on admitted claims.  Important information for the claim handler to know to avoid a penalty for late payments includes: the first day of disability, when the employer received notice of the injury or disability, if the employer is paying the ongoing employee wages, and requirements regarding the payment of wage loss benefits.  Coordination and cooperation are

 

 

Other Prohibited Claims Practices

 

Workers’ compensation insurance carriers are also required to operate honestly and ethically.  This includes not acting in bad faith.

 

Insurance carriers that operate fraudulently may be subject to discipline by a state commerce department.  When underwriting workers’ compensation insurance policies, it is important carriers, and administrators follow through on contractual promises and provide what is covered under the policy.  Failure to do so can result in a carrier not being able to sell insurance in a state or subject to other sanction.

 

In the same regard, an insurance carrier should avoid bad faith tactics.  This includes not dealing fair with parties subject to an insurance contract.  This duty is known as the “implied covenant of good faith and fair dealing.”

 

 

Conclusions

 

Members of claim management teams and their insurance carriers have a contractual and ethical obligation to serve their insureds.  This is accomplished by following the rules established under a workers’ compensation statute that require good faith claims practices.  Failure to do so adds to the costs of a workers’ compensation programs and can jeopardize a carrier’s ability to underwrite workers’ compensation policies.

 

 

 

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: https://blog.reduceyourworkerscomp.com/

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

ODG Announces Release of Job Profiler Powered by MyAbilities Into Its Industry-Leading Guidelines

ODG Announces Release of Job Profiler Powered by MyAbilities Into Its Industry-Leading GuidelinesAUSTIN, TexasNov. 28, 2018 /PRNewswire/ — ODG, an MCG Health company(USA) has announced a partnership with MyAbilitiesTechnologies to incorporate a unique new product option, the ODG Job Profiler, into its industry-leading medical treatment and return-to-work (RTW) guidelines.

 

The ODG Job Profiler is an innovative software platform powered by MyAbilities™ which will be made available as an add-on to the ODG by MCG User Interface. The ODG Job Profiler adds job demand data across every industry and occupation by providing a comprehensive database of physical, cognitive, and environmental demands specific to over 30,000 jobs spanning nearly every industry. This solution helps insurers, third-party administrators (TPAs), and employers identify and mitigate the risk of injury by creating a customized Physical Demands Analysis (PDA) for each job function, adjusting disability duration guidelines according to job demands.

 

Case managers, claims adjusters, site managers, and clinicians will be able to collaborate around job-specific lost-time goals and activity modifications, with the shared goal of expediting return-to-work while implementing proper measures to prevent workplace injuries.

 

“The ODG Job Profiler offers a valuable complement to our treatment, return-to-work, reserving, and risk-analytics tools, supporting a comprehensive, evidence-based solution set. Innovative and technology-enabled, it enhances efficient collaboration and communication between payer, employer, and provider around what matters most: function. The art and science of return-to-work have never been better,” said Phil LeFevre, Managing Director of ODG.

 

“We are convinced that all stakeholders will experience better injury prevention and management by using the ODG Job Profiler which is empowered by the congruence of advanced ergonomics, artificial intelligence, digital job-matching, and risk assessment technology. The ODG Job Profiler revolutionizes claim and human asset management by creating a new industry-standard paradigm,” said Reed Hanoun, CEO of MyAbilities.

 

 

About MyAbilities

 

MyAbilities is a technology company delivering workplace risk mitigation and injury management strategies using Artificial Intelligence (AI) and robust data analytics.

 

MyAbilities develops software solutions to help employers assess their jobs, identify risk and prevent injuries using proprietary AI, computer vision, analytics, ergonomic risk analysis, and injury prevention strategies. Post-injury, MyAbilities support claim administrators with an evidence-based claim and medical management software for the resolution of injuries and illnesses in workers’ compensation, and disability programs to reduce costs of claims and expedites return-to-work. More information is available at http://www.myabilities.com.

 

 

About ODG

 

ODG, an MCG Health company, (www.mcg.com/odg) provides unbiased, evidence-based guidelines that unite payers, providers, and employers in the effort to confidently and effectively return employees to health. The clinical guidelines and analytical tools within ODG are designed to improve and benchmark return-to-work performance, facilitate quality care while limiting inappropriate utilization, assess claim risk for interventional triage, and set reserves based on industry data.

 

About MCG Health


MCG, part of the Hearst Health network, helps healthcare organizations implement informed care strategies that proactively and efficiently move people toward health. MCG’s transparent assessment of the latest research and scholarly articles, along with our own data analysis, gives patients, providers, and payers the vetted information they need to feel confident in every care decision, in every moment. For more information visit www.mcg.com or follow our Twitter handle at @MCG_Health.

 

 

For media inquiries, please contact:

 

Name: Daphne Worrall
Title: Marketing Manager, ODG by MCG
Tel: 406-622-5516
Email: daphne.worrall@mcg.com

 

Name: Sarah Reid
Director of Operations MyAbilities Technologies
Email: sarah@myabilities.com

 

 

Related Links

 

Visit the ODG website

 

 

SOURCE ODG

 

Related Links

 

http://www.mcg.com/odg

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