3 Ways TPAs Use Analytics to Drive Better Claim Outcomes

Third-party administrators are often considered an integral part of the claims management process. Some would even call them claims process workhorses. Once a workers’ compensation claim begins, TPAs have a litany of things to do to help get the worker back on the job and the claim closed.

 

While such a service may seem invaluable, there is much more a TPA can do. Savvier TPAs become long-term consultative partners. By using advanced analytic tools in combination with a deep understanding of an employer’s unique situation, TPAs can help drive better outcomes for injured workers and their employers/payers. As stated by Mark DeLew, VP of Consultative Analytics at Broadspire, “a key role of the account executive is to understand the client’s objectives and then translate those with our analytic tools into Key Performance Indicators KPIs.”

 

What these TPAs do specifically, is help organizations come to realize:

 

  • Determine an Organization’s Objectives and Identify Opportunities to Improve
  • Define the Organization’s Goals and Priorities.
  • Manage Project with a Systems-Based Approach

 

 

  1. Determine an Organization’s Current State and Identify Opportunities to Improve

 

Getting an accurate picture of where a company currently stands involves a team effort. The TPA needs experts from many different facets of the claims management process to truly understand what is happening in the organization. Nurse case managers, adjusters, quality assurance personnel, utilization review specialists, intake setup personnel, data conversion experts, and others are needed for this step.

 

The TPA account executive needs first to understand the organization’s current state and identify opportunities for improvement.

 

  • What is the overall health of the program?
  • Are return-to-work rates trending up or down?
  • What is the litigation rate?
  • What is the loss rate?
  • What percentage of claims are closed, and within what timeframes?

 

Drilling down to identify these key cost drivers is the start of realizing what is actually happening in the company.  DeLew noted this analysis needs to be done “in collaboration with the cross-functional team of claims adjusters, team managers, nurses, and clients and to understand the root cause why.”

 

Once these are known and the reasons for them, the TPA can work with the organization to find areas for opportunities and the right solutions.

 

For each significant trend, the root cause must be determined. Interviewing those on the cross-functional team is a crucial part of the process to help come up with actionable items.

 

DeLew gave an example of a client who found its incurred claims costs were trending higher but did not know why. Broadspire introduced a virtual peer, a benchmark based on other similar companies within the same industry. Using a predictive model that took into account various factors, they drilled down for such things as age, body part, cause, and nature of the injury, and compared them with those of the virtual peer. They found that in this particular company, age was a big driver of increased costs.

 

Broadspire then went back to the cross-functional team to come up with potential solutions to the increased rate of older workers having workplace injuries.

 

 

  1. Define the Organization’s Goals and Priorities.

 

Tools such as the virtual peer can help determine where a company is headed. Advanced analytics can be used to create a cost-benefit analysis to help an organization better understand what is likely to happen. Savings are then projected based on loss experience.

 

One potential area of focus is Return to Work. Looking at the average RTW date vs. the release date for injured workers can help to see the real cost of not getting injured workers back to work quickly.

 

The figures can also be presented by showing different regions of the country where the lag times, and hence, the costs may be greater or smaller. The result might be to discuss improving RTW rates in a specific area. Showing those in charge the costs of not getting an injured worker back is more likely to prompt buy-in from managers and others. Joel Raedeke, Senior VP of Consultative Analytics at Broadspire states, “this metric is one that we like because it clearly shows costly behavior and gives concrete data to drive action.”

 

Litigation is another area where advanced analytics from a TPA can help drive better outcomes. ‘Dollarizing,’ the litigation can help a company see its costs related to how quickly claims are litigated, as well as the impact of particular defense firms. “Statistics on how quickly claims are being litigated can help identify prevention opportunities. Then comparing the impact of defense firms on outcomes helps to mitigate costs even further,” said DeLew.

 

Using infographics and timelines can illustrate where the company is going. For example, let’s say a company wants to reduce its loss pick by 6 percent and decrease its open inventory by 22 percent. A year-long timeline can be set up. It may start, for example, with the TPA account executive aggressively pursuing claim closure with the cross-functional team, and setting meetings with the actuary to understand cost drivers. The ensuing months would then contain a variety of other steps to show how to achieve the goals. “Infographics and timelines allow us to visualize with a client stepping into that future state and the steps needed to achieve their goals,” said Raedeke.

 

 

  1. Manage Project with a Systems-Based Approach

 

Emails and spreadsheets are the status quo for the industry, but not necessarily the best way. Trying to manage multiple projects with multiple people involved can be tedious and inefficient.

 

Account management can instead be done in a way that gives full visibility and track-ability in real-time. A system based approach eliminates the necessity to wait until the weekly meeting to get an update on what everyone involved is doing. “Better operating tools allow an account executive to efficiently manage a large team and achieve the goals of large projects,” said Raedeke.

 

 

Conclusion

 

Best in class TPAs that can an organization determine their current state of workers’ comp management, set realistic goals for improvement, and use a systems-based approach to project management using better operating tools and sophisticated analytics can help organizations vastly improve their outcomes and decrease their costs.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

 

Understanding Work Comp in the Healthcare Industry

Hospitals Nursing Homes Workers CompInterested stakeholders in the healthcare industry face many unique challenges in terms of finding affordable workers’ compensation insurance coverage.  This is especially the case when it comes to those who operate hospitals, clinics, and nursing homes.  These challenges include rising premiums based on the nature and extent of work injuries and accompanying restrictions on activity that serve as a barrier when it comes to getting an injured employee back to work.

 

 

Understanding Nursing Homes and Work Comp

 

Nursing homes can be found in every state.  Many are privately owned and managed, but regional and national nursing home companies are gradually increasing their share of the market.  The workforce of the nursing home will consist of:

 

  • Registered nurses (RN);

 

  • Licensed practical nurses (LPN);

 

  • Nurses’ aides;

 

  • Administrative staff;

 

  • Food service; and

 

  • Housekeeping

 

The primary workforce issue is often the training and turn-over among the nurses’ aides.

 

 

Dealing with Work Injuries at Nursing Homes

 

Safety is normally emphasized in nursing homes to protect both the patients and the staff.  Nursing homes are built to protect the patients and staff, which tends to lower the risk of injury.

Physical hazards and causes of injury to nursing home employees include:

 

  • Lifting and moving of patients, the most common cause of work-related injuries;

 

  • Musculoskeletal injuries; and

 

  • Needle sticks and dealing with infectious diseases communicated via bodily fluids.

 

Medical care for workers’ compensation injuries in this line of work is readily available because most states require a duty nurse to be on duty at all times.  Minor work-related injuries, including cuts, bruises and abrasions, can be treated by the on-staff nurse or by other nurses on duty.  For more severe injuries, medical facilities are often located nearby.

 

Reducing Indemnity Benefits in Healthcare Settings

 

The cost of indemnity benefits for workers’ compensation injuries at nursing homes averages approximately the same as work comp benefits for all industries. Occupational diseases and associated disability benefits occur infrequently among nursing home employees.

 

Some categories related to nursing homes that would have the same or similar work comp issues include:

 

  • Hospitals including acute care hospitals;

 

  • Home health services;

 

  • Retirement centers;

 

  • Boarding homes; and

 

  • Assisted living facilities.

 

While many of the jobs in this industry require the ability to lift patients (heavy lifting), accommodation may be possible. Equipment such as mechanical lifts and friction-reducing devices decrease both the frequency and severity of the injury and make temporary accommodation easier to accomplish.  A union contract may serve as a barrier to return-to-work issues in some instances.  It is important to keep these issues in mind when negotiating a labor contract and to seek cooperation from union representatives on these issues.

 

Notwithstanding this matter, there are ways to get injured healthcare employees back to work in a timely and efficient matter.  Possible temporary transitional work includes:

 

  • Office Workers: Look for ways to accommodate prolonged sitting and standing as needed, or to elevate a broken limb.  Lifting beyond physician assigned abilities could be done by another employee.

 

  • RN, LPN & Nurses’ Aides: Utilize other employees to do the “heavy” lifting of patients or equipment. Provide equipment to make patient transport non-strenuous.

 

  • Food Service: Identify tasks within the cafeteria or snack bar within physician assigned abilities such as light cleaning or working the cash register.

 

  • Other Employees: Consider placement at an Information Booth to help visitors with directions or assistance.

 

  • Light Janitorial: Employees can use a broom and long handle dustpan to clean up spills and litter.

 

Conclusions

 

Engaged stakeholders in the healthcare and nursing home industry need to be creative in managing workers’ compensation claims and reducing program costs.  This required them to seek creative solutions to manage medical care based on the severity of the work injury, and look to get an employee back on the job within their restrictions.  This may require compromise, but will promote savings in the long run.

 

 

 

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.

Create System to Gather All Needed Workers’ Comp Claim Information

7 Ways Your TPA May Be Underpaying Your Company Workers Comp PaymentsGarbage in; Garbage out!  If you are putting garbage into your workers’ compensation program, it goes without saying the results will not be pleasant.  Now is the time to focus on gathering all the necessary information to obtain high-quality results in order to pay claims appropriately, and improve efficiency.

 

 

Create a System That Creates Repeatable, High-Quality Results

 

A significant improvement in the world of claims management over the years is the implementation of an electronic system for entering and managing claims.  Used by employees of the Carrier/TPA, this is an automated system that assigns risk if certain conditions are present.  These systems allow for the following:

 

  • Claims professional to gather more information in less time;

 

  • Provides for appropriate follow-up on responses to high-gain issues; and

 

  • Assists in the evaluation of information systematically.

 

 

 

System Guides the Questions So Nothing is Missed

 

The person receiving the claim for the Carrier/TPA will have questions that need to be answered.  If the answers are positive for certain criteria, the system will assign the claim a risk number within certain values from the software. The higher the score, the more risk is assigned to the claim. The system will be used initially for 3-point contacts to the injured worker, the employer, and the medical provider.  Positive responses to certain criteria will pop up other questions to ask which ensures the adjuster does not forget anything that can be crucial to the claim.

 

Processing claims through a system like this allows the claim handler to understand the “pain points” of a claim when it arrives at their desk.  This will better direct their investigation and reduce unnecessary or excessive time spent on a claim.

 

 

 

Encourage Claim Handlers to Follow Best Practices

 

The implementation of a bonus system is another tool to use.  Carriers/TPAs often use a bonus system to reward adjusters, and these bonuses revolve around timeliness of their contacts, resolution of their claims, and overall reserve savings by proactive claims handling.  This encourages the claim handler to follow best practices.

 

Claims practices can also be classified based on their system score.  Medical only claims or minor lost-time claims can be routed to the appropriate adjuster, instead of going initially to a senior level claim handler.  Other inefficient claim handling processes include assigning a claim based on what information is listed in the injury report.  This process can be inefficient if the injury report was completed in error.  Time and money can be saved when each claim handler is making the highest and best use of their day.

 

 

Using Outside Service Providers When Necessary

 

Outside service providers can be used immediately in certain circumstances.  These assignments can include:

 

  • Field Nurse Case Manager: These service providers should be used in instances where the employee will require significant or extended medical care and treatment.  This can equate to large cost savings as this month can include crucial moves within the claim, preventing missed work when a return to work could have been possible.

 

  • Medical Specialist: Claims involving complex injuries can be referred to a specialist at the onset of a claim where the identified injury will likely require surgery or extensive physical therapy.  Instead of waiting for the paperwork the case manager can get it at the appointment and send it to the claim handler the same day, instead of when the actual medical reports come in with the bill weeks later.

 

 

Conclusions

 

Several technological advancements are going on within the claim industry.  As an employer, you should be open to new technology, and trying new things in order to be more proactive in the claim process.  Oftentimes the claim handler is very set in their ways, and there can be some resistance to the introduction to new techniques and new technology.  These advancements are made to help all parties involved to make the process more streamlined and more effective for the claims profession.

 

 

 

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.

Case Study: $5,000 in Savings from Non-Profit Return to Work Option

Reduce your workers' comp case studyThe longer an injured worker is out of work, the less likely he is ever to return. Statistics show an employee who is out of work for 6 months has only a 50 percent likelihood of going back, and the number increases exponentially after that. There are many reasons this occurs.

 

 

Disability Mindset

 

Being out of the work environment means losing touch — with colleagues, the daily routine, and the feeling of being productive, which for many, is vitally important to maintain a sense of self-worth. Depression and frustration, not to mention pain, can set in and quickly turn to anger.

 

Instead of focusing on the recovery process, injured workers who are out for long periods of time may turn their attention to retaliation. Instead of thinking about healing and returning to their pre-injury normal lives, these workers may instead start to embrace their ‘new normal’ lives. They develop a disability mindset and start to direct their energies to ways they can stay permanently out of the workforce.

 

 

Work as Therapy

 

There is a plethora of research that demonstrates returning to the workforce in some capacity increases the worker’s engagement in the recovery process, and improves his emotional and physical health. But many organizations either don’t subscribe to this idea, or they are unable to accommodate these employees.

 

Too many employers have the attitude that they don’t want an injured worker back unless they are 100 percent recovered and fully able to completely step back into their position. Unfortunately for these employers, statistics bear out the fact that returning workers in some capacity leads to better outcomes and saves money for the employer.

 

In some cases, it’s difficult or even impossible to find modified or light-duty work for the injured employee at the worksite, due to the nature of the work and/or the worker’s injuries. One solution that wise organizations are taking is to partner with nonprofit and charitable organizations. Employers that take this approach see their injured workers recover within the expected timeframe and back at work, saving them unnecessary costs and headaches.

 

 

Case Study: (Provided by Broadspire):  $5,000 in Savings From Non-Profit Return to Work Option

Challenge:

 

A worker who sustained multiple wrist injuries from an occupational accident had an extended recovery. His employer was able to provide him with light-duty work — for a while. However, when the employee needed a third and final surgery, his company could no longer accommodate him.

 

A Broadspire field case manager quickly noticed the injured worker was becoming depressed. The situation could have easily and quickly spiraled downward.

 

 

Solution:

 

Broadspire’s ‘Worker on Loan’ program is designed for exactly this type of situation, where an injured worker’s employer has no opportunity for light-duty work. After the field case nurse reported the injured worker’s situation, the Broadspire adjuster contacted the employer who agreed to try the Worker on Loan Program.

 

In this instance, Habit for Humanity was able to provide work for the injured worker. It turned out to be a great fit, as the employee’s former job was in construction. The field case manager soon reported that the worker’s mood improved significantly. Once he started working with the revered organization, he was able to feel productive and help others.

 

 

Results:

 

This case perfectly illustrates the value of work as a viable response to an injury. Instead of going into a deep depression and staying out of work indefinitely, this injured worker was actually able to return to full-duty at his normal job — nine weeks earlier than planned! The result was a win-win for the injured worker, the employer, and Habit for Humanity, which got the benefit of his expertise.

 

Total Savings = $5,000

 

 

Conclusion

 

Keeping an injured worker engaged with the workforce is vital to achieving the best outcomes. Collaborating with nonprofits is a perfect answer for companies that understand this but may not have light-duty options available.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

4 Quick Tips to Get Adjusters to Follow Account Handling Instructions

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HOW TO SCRIPT WINNING ACCOUNT HANDLING INSTRUCTIONS

Registration: How to Script Winning Account Handling Instructions

 

 

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.

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