An important role of the claims management team is to coordinate with employers and defense interests to make sure quickly reporting workplace injuries is a top priority of your organization.  It is easier for claims to be evaluated and decisions regarding primary liability to be made in an effective and efficient manner when injuries are quickly reported.  There are many steps claims management teams can make to develop important work injury compliance steps, which includes the use of evolving technology.

Emphasis the Importance of Reporting Workplace Injuries

There are several steps that employers can make to ensure workers’ compensation claims are reported in a timely manner.  This starts with developing a culture of understanding on the part of the employees.  This goes beyond making sure the proper posters are displayed in the workplace:

• Make all new employees aware of workers’ compensation information at the time of hire. This includes providing documentation to new hires about the name of the company’s workers’ compensation insurer and other contact information;

• Provide documentation on how work injuries should be reported and the information needed to make a report of injury; and

• Ensure that the employer has a contact person to make sure the First Report of Injury is filed timely with the workers’ compensation insurer. In some instances, employers and their staff are unsure how the process generally works.  Making sure these persons understand the process is important.

All workers’ compensation insurance carriers and third-party administrators can provide information to their insured on these processes.

Ensure of Culture of Compliance from the Top

The best workers’ compensation programs at the employer level have a culture of compliance and consistency.  This means that senior-level leaders within an employer need to emphasize safety and ensure that reports are being dealt with ethically and honestly.  All employees need to be treated with respect and dignity.  Other steps can include:

• Preparation, issuance, and posting of quarterly safety reports. State industrial commissions typically require the posting of job site injury information.  This should be viewed as the baseline requirements – do not be afraid to go beyond those requirements; and

• Highlight improvements to safety within the workplace. This ensures that all employees understand the important role they play in the process.

Eliminate ‘Accident-Free’ Incentives

Employers often attempt to drive a culture of safety through creative programs that provide cash incentives for ‘accident-free’ days. These types of programs are a mistake because studies demonstrate they have an adverse effect where employees feel they cannot report a workplace injury.  In reconsidering these original programs, employers should focus more on a metric that encourages the timely report of work injuries.

Provide Effect Reporting Tools

Technology has created many opportunities for employers to ensure all workers’ compensation claims are reported by employees in a timely manner.  It also allows employees to provide greater detail, including documentary evidence that allows for quicker and more accurate decisions concerning primary liability.

One example of matching technology with efficient and effective work injury reporting is app-based technology.  The development of this technology is cheap, and it is easy to implement.  With a vast majority of employees having smartphones, it is something nearly anyone can upload and use.  Features that can be used on these apps include:

• Completion of the First Report of Injury and uploading to the employer, insurer and other interested stakeholders;

• Easy communication with the injured worker and the claims management staff. Communications include information regarding primary liability determinations, request for documents and prior authorization requests; and

• Payment status and direct deposit of indemnity benefits. This allows for injured workers to receive payments immediately, and avoids the uncertainties of mailing a check.

Conclusions

The workers’ compensation process starts with the reporting of workplace injuries. This is a process that causes confusion, delay, and frustration in the process.  Proactive members of the claims management team can work with their insured to improve the reporting process through reforms to internal processes.  It can also include the development and implementation of app-based technology to make the process efficient and user-friendly for all employees.

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

Contact: mstack@reduceyourworkerscomp.com.

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

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

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

Determining lag time is one of the easiest things to measure in workers’ compensation. Yet many organizations put little if any effort into it. More than likely they don’t see the value in tracking that particular metric.

But those that do report better outcomes for their injured workers and significant dollars saved for their bottom lines. There’s substantial research to back them up.

Why Workers’ Comp Claim Lag Time Matters

Lag time refers to the time period from the moment of injury until it is reported to the insurance carrier. For example, if an injury occurs on Oct. 1 and the insurer receives notice of the claim on Oct. 3, the claim will have a report lag of two days.

Tracking a company’s lag time is fairly simple, since every claims handler or adjuster has the information. The goal is to have shorter lag time, as several studies reveal tremendous cost differences.

Kemper Insurance Study

Kemper Insurance did a study and found that a claim reported within 30 days is 48 percent higher on average than a claim reported within 10 days of an injury.

The Hartford Insurance Study

The Hartford looked at 53,000 permanent partial and temporary claims and found the cost of a claim increases with each passing week before the incident is reported. Compared to an injury reported within week:

• Within 2 weeks the claim was 18 percent more expensive
• Within 3 weeks the claim cost 29 percent more
• Within 4 weeks there was a 31 percent cost difference
• Within 5 weeks, the claim was on average 45 percent more expensive

NCCI Study

NCCI’s study found “the closure ratio — the ratio of the number of claims closed within 18 months of the report date to the total number of claims — is inversely related to the median claim cost … the highest closure ratios are for claims reported in Weeks 1 and 2. Claims reported after Week 2 are less likely to be closed at 18 months…”

The study also found that median claims costs were lowest for claims reported after the day of the accident but within two weeks. It noted that claims reported on the actual day of the accident can be costly, as these are often the most serious injuries and require emergency care.

Additionally, longer lag times were associated with:

• Greater attorney involvement —12.8 percent after more than 1 week, increasing to 148 percent more than 5 weeks after injury.
• More use of lump-sum payments
• Lower paid-to-incurred ratio at 18 months
• Lower closure rate at 18 months.

The data indicates that claims with a lag time of more than two weeks are more complex, take longer to close, and have longer disability durations.

Why Workers’ Comp Claim Lag Time Is Important

There are many possible reasons that increased lag times result in increased costs. Experts speculate some include:

1. An injured worker may visit a primary care physician rather than an occupational physician who understands return-to-work and other elements of the workers’ compensation system.
2. The worker may feel he and his injury are being ignored, that the company doesn’t care about him. That could drive him to seek an attorney.
3. Quicker reporting means faster medical treatment which results in faster RTW rates.

Tracking lag time helps you and others at your organization better understand how well your program is working. You can use it, along with the available research to show the cost savings you are achieving by having shorter lag times.

Organizations with multiple divisions can compare the lag times for each to show which are doing a better job of getting injuries reported quicker.

Improving Workers’ Comp Claim Lag Time

Getting injuries reported to the carrier as quickly as possible takes a concerted effort and should be embraced by everyone in the organization. The employee needs to report the injury immediately and the supervisor must complete the necessary paperwork to get the report to the carrier as soon as possible. Senior managers should consider the issue a priority as well.

Getting the buy-in of all involved takes some education, so everyone understands the value in shorter lag times and the process required. Injured workers should be made aware that reporting an injury sooner means they will get medical attention and care they need immediately. Supervisors and managers need also to understand the financial impact of shorter lag times.

There are several ways to ensure better lag times:

1. An employee brochure. This should explain the workers’ compensation process and be provided to all personnel.
2. One-pager. A short notice that explains the process for reporting an injury should be available to all employees. It can be posted in areas where workers congregate, placed in company vehicles, and even provided on the back of a lanyard.
3. Employee training and retraining. In addition to providing written material, new hires should undergo training on proper incident reporting. This should be repeated as retraining annually.
4. Supervisor education. All supervisors and managers should be well versed on the process required once an employee reports an injury. This can even be part of their performance reviews.
5. Make it easy. A complicated reporting process is more likely to incur longer lag times. There should be a single contact within the organization to report injuries when a supervisor or manager is unavailable, such as a single phone number.

Summary

Improving and tracking lag time are fairly simple processes and can have a tremendous impact on the company’s bottom line. The sooner an injury is reported, the sooner the worker will receive medical care and return to work, and the better off the organization will be.

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

Contact: mstack@reduceyourworkerscomp.com.

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

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

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

Over the years, state and federal governments have enacted a number of safety regulations in workers’ compensation programs to provide for a safe working environment.  Even for the best employers following workplace safety guidelines, accidents do happen.  When they do, it is important to follow recognized procedures when responding to work injuries.  Failure to properly report and respond to the injury can have significant adverse consequences.

Penalties under State Workers’ Compensation Act

Being aware of requirements under a state workers’ compensation are important for an employer who is required to purchase and maintain workers’ compensation insurance.  It is important to be aware of the statutory guidelines associated with a number of responsibilities an employer has once someone is hurt at work.

Some common errors and omissions are as follows:

1. Failure to file the First Report of Injury in a timely manner;
2. Commencement of wage loss and other workers’ compensation benefits; and
3. No clear guidance to injured workers as to their rights and responsibilities when it comes to medical and rehabilitation benefits.

While an employer is not required to give an injured person legal advice regarding their work injury, each state has basic responsibilities under the Act to their employees.  It is important for employers to understand their obligations and properly follow through after an incident.

A best practice to communicate with employees regarding workers compensation benefits is to provide an Employee Brochure. The employee brochure will provide information on the principles of workplace safety, the benefits to the employee workers compensation provide, an action plan for what to expect, and information on the role played by medical providers.

Compliance with State and Federal OSHA Regulations

The Occupational Safety and Health Administration (OSHA) is a federal agency within the Department of Labor that has congressional authority to implement workplace health and safety.  All states have similar departments that also advise employers of additional state regulations that govern these same issues.

In addition, the responsibilities imposed by a state workers’ compensation act, employers are also required to implement applicable state and federal policies.  In the context of work injuries, this often includes accurate reporting of certain injuries and provides parties with information about incidents.

Various OSHA requirements also require employers to have various safety postings and make them available to all workers.  One such posting includes Material Safety Data Sheet (MSDS) requirements that contain information about harmful substances.

Impact on Experience Modifier

In order to accurately price workers’ compensation premiums, companies offering insurance base a premium around an employer’s “experience modifier.”  This calculation is based on a period of three years of loss and is recalculated annually.

While the purchase of workers’ compensation insurance is a significant driver in costs for businesses, it is fraud to not report workplace incidents.  It is also not ethical to “pay off” an injured employee so he or she does not file a workers’ compensation claim.  If an employer is caught engaging in such practices, it can result in loss of insurance, as well as civil or criminal penalties.

Loss or Evidence Spoliation

Immediate accident investigation is key to driving down costs associated with workers’ compensation claims.  Failing to investigate a claim from the onset can have a number of adverse consequences.  The following is a partial list:

1. Failure to identify and interview witnesses to the event;
2. Loss of physical evidence that may diminish chances of recovery against a third party in a subrogation claim; and
3. Court sanctions for the loss or spoliation of evidence.

Conclusions

Failure to report and respond to a work injury can cause problems in the end.  While there is the moral obligation to help a person suffering physically from an injury, there are also a number of legal obstacles that can be difficult to overcome.

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

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

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

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

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

SUBSCRIBE: Workers Comp Resource Center Newsletter

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

Adjusters are very particular on wording, especially when it describes an injury or event.  Below I am going to use some real-world examples of injury descriptions from real work comp claims.  Don’t laugh, you may be the one reporting injuries this way.  If you are, hopefully you will find some helpful tips to be more expressive going forward:

Example #1: “Injured Back Lifting Boxes”

For example, an adjuster reads the injury report on a new claim and the description reads “Injured back lifting boxes.”   That entire statement says nothing in the mind of an adjuster, other than the back is the area injured.

Supervisors often provide little information

The employer is often contacted first, and this is sometimes a mixed bag of results.  They confirm a back injury, but another supervisor was there and that person knows more about it, they just heard through the grapevine that so and so got hurt last night and are not back at work today.  That is the extent of what the supervisor knows, and the other contact person was not at that location and has no idea what is going on.

First of all, that phone call was a waste of time for both people.  Not only did the adjuster get zero information from the employer, but now the adjuster has to talk with the claimant without any prep information, and no information on the accident details.

Then when the adjuster calls the injured worker, the injured worker states that he/she was injured when they “Lifted a 65lb box and felt a pop in their back which radiated down the legs causing them to drop the box and EMS was called to take to hospital due to severe pain.”

The employee always does the best job of describing an injury.  Leave it to them to tell the adjuster every detail.  And they should, because they are hurt and they want everyone to know what hurts and how they were hurt, and they want treatment for everything that hurts.

This entire scenario is how a loss control protocol should not work.  Every claims person out there loves that an employer has a loss protocol set up, and they follow it to the T.  But, what information are they actually providing the adjuster?

Injury response procedure goal should be to provide adjuster with as much detail as possible

The claims person is the one that needs as much information as possible, before they talk to the claimant within a 24-hr period post-notification of the claim.  But if the employer can’t help the adjuster with any information, what good is having protocol to begin with?  Sure, you reported the claim timely, but it is void of any real information that is helpful.

I understand that there are technical limitations.  Most injury forms only give you a little area to type in what happened, but be creative and descriptive.  That is what will help the adjuster.

Better yet, if you are not using Injury Triage, you should be.  The triage nurse will get the details of the injury, assess its severity, and recommend the property treatment.

Example #2 on a hernia claim:  “Worker lifted boxes all day and has hernia.”

What kind of boxes and how much did they weigh?  Were they lifting one box and had a specific incident that was diagnosed a hernia, or did this person come in and say they have a hernia?  How long is “all day?”  This entire injury statement says nothing other than a hernia.  A great way to correct that statement is “lifted a 45lb box/felt pain/clinic diagnosis hernia.”  Now in that statement, you know the worker was lifting a box, it weighed 45lbs, and that they must have went to the clinic right away because a hernia was already diagnosed by the clinic doctor.  That is good information to know!  Now the adjuster knows more about the injury, the diagnosis from the clinic doctor, and that it appears to be a specific isolated incident.

Example #3 “While unpacking parts she felt a boom in her back.”

I am far from a physician, but that is the first time I have heard of a boom in relation to an injury.  So she felt a boom.  What is a boom?  Is that burning pain?  Shooting pain?  A strain? Where was the boom, in her low back or upper back?

Other descriptive words do a better job.  Words like “sharp” or “shooting” or “burning” pain help adjusters with the type of pain this worker had at the time of injury.  A way to correct that statement is to label the pain differently, using the examples above.  Also always be sure to include the injured area as specific as possible.  Descriptions such as “While unpacking 2lb parts she felt a sharp pain in right low back.”  Now you have given the adjuster something to work with.  We know the part weight, the type of pain, and the location of the pain.

Challenge Yourself To Provide Specific Information

The reason why all of this is important is because of when the adjuster takes the statement from the employee.  Using example 3, the worker may say she had pain all over her back, or she may say she had pain in a different location, or she may say the parts were 25lbs each and not 2lbs in order to make her claim sounds more convincing.

So think about your injury statements.  Be as descriptive as possible while providing as much information as you can.  We all know there are only so many words you can put in that description, so challenge yourself to address weight, injury locations, pain types, and anything else you can fit in there.

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

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

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

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

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

SUBSCRIBE: Workers Comp Resource Center Newsletter

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

The employer’s first report of a possible accident can be a dangerous trap when dubious claims are being reported. This is due to the fact that first injury forms are not designed to capture the information necessary to make decisions which are critical in the first days following an accident report. The decisions can be triaged into categories: there has been a clearly compensable accident, there has not been a work related accident, there has been a report which requires further investigation. (The second, there has been no compensable accident, also requires further investigation to document reasons for an objection.)

First Report Often Lacks Depth And Quality Information

The reasons why the first report of injury is a dangerous place to stop can be illustrated by the well known true story of the coincidences involving the Titanic and a book, “Futility”, published in 1898, twelve years before the Titanic sank. The book described a large luxury passenger ship, the “Titan” which carried only half the number of lifeboats necessary to save all the passengers. It sank in the North Atlantic in April when it struck an iceberg 400 miles from Nova Scotia. More than half the passengers were lost. The ship’s speed was the same as the Titanic, the length the same, the tonnage the same. The book became well known as a nearly supernatural prediction of the sinking of the Titanic.

But readers will be disappointed with the book and find that the sinking is part of a brief episode which has nothing to do with the plot. The major story is the improbable survival and redemption of an alcoholic crew member who eventually marries his lost love.

Assist Your Adjuster By Including “See Attached”

Therefore, a first report should not be like a book review of “Futility”, exciting but completely misleading unless further material is provided. An insurance examiner reading a first report can be forgiven if they do not follow up on clues that are missing from the report. Most employers assume that after they complete the first report the carrier will do the rest. They usually will, but only if some interesting additional material is provided to get them started.

The best way for an employer to arouse healthy interest by the carrier is to insert “see attached” to the box which asks for a description of the accident. Nearly every first report forms assumes that the accident did occur and is work-related. But the space provided on the forms is almost never large enough to accommodate the lengthy explanations required of non-compensable claims. “See attached” is employed to arouse interest and provide a place for the additional material.

What sort of material should be included? Alternate explanations of what did, or didn’t occur is a good place to start, with relevant documents attached. A list of possible witnesses is also advisable, but not witness statements. Statements are usually not nearly as precise as necessary and can lead to further confusion, which never helps an employer.

Document Where, When, and How an Incident Occurred

Documents are far better than witnesses, which is why they should be given priority. They attend hearings when requested and never change their stories, which is why judges and lawyers consider them troublesome and dangerous. Documents can come in many forms and the best ones pin down precisely where, and when, an incident did, or did not, occur. Employees have been known to place dates on their accident claims when the business was, in fact, closed. “Witnesses” are sometimes listed as being at the place of work when they were, in fact, in other countries. Exposure to dangerous chemicals is listed when no such chemicals were ever at the place of employment.

The above discrepancies can best be dealt with by attaching proper documents to the employer’s report and following up with a phone call to the carrier to make sure that the material is received and receiving the proper follow-up attention.

The best reports of injury are filled with facts, not suspense.

Author: Attorney Theodore Ronca is a practicing lawyer from Aquebogue, NY. He is a frequent writer and speaker, and has represented employers in the areas of workers’ compensation, Social Security disability, employee disability plans and subrogation for over 30 years. Attorney Ronca can be reached at 631-722-2100. medsearch7@optonline.net

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

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

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

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

SUBSCRIBE: Workers Comp Resource Center Newsletter

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

What would be the best way an employer can measure its own involvement in its compensation claims? What can an employer do, without having to go to outsiders, to see where there are preventable deficiencies? Thirty nine years ago, a young lawyer just out of law school saw the answer and hasn’t changed his opinion since then. Just count the boxes left blank on the form that employers file with the carrier and the compensation board in reporting new claims.

Number of Blank Boxes is Best Predictor of High Comp Costs

The number of blank boxes is the best predictor of an unnecessarily high xmod, overlitigation for no purpose and extended disability. So, an employer needn’t call in experts to detect, measure and correct that problem. Just count the blank boxes. And take the time to learn what happens to those blanks.

Every box on a form is there for a purpose. The employer’s first report sets the path and pace of nearly everything that follows on a claim. But persons responsible for completing that form will, sooner rather than later, fall into the habit of thinking that there will not be consequences to cutting a few corners from time to time.

To be fair to the employer, some questions on the form cannot be answered if the employer is diligent about promptly completing the initial report. For example, a question which asks what the carrier claim number is – a number that won’t be assigned until much later, but which is on the form “just in case’ the form is being filed late.

Leaving Blank Details About The Injury Is Demanding Trouble

But a report which leaves blank how the injury occurred or fails to mention what body parts were injured is more than asking for trouble. It is demanding it – and the wish shall be granted.

Employers should not think that silence by the comp system in the face of partially completed forms is an indication that nothing is going wrong. Actually, the number of partially completed forms is so great that they are the rule rather than the exception, but that doesn’t mean that they are without consequences. The blank boxes are the single greatest contributor to easily avoidable high comp costs.

Best Results Go To Those That Make The (surprisingly small) Effort

Employers should be cognizant of the “principal of differentiation”. There are few significant advantages to being average in claims situations. The best results go to those who make the extra effort that put them in the top few percent in performance – ESPECIALLY in reporting the details of new claims. (A surprisingly small amount of extra effort is all that it takes to go from average to outstanding.)

A blank box, or a box containing the answer “unknown” either slows progress of a claim, brings it to a halt, or entrenches it on the wrong path. As common as these errors are, they receive little of the attention that they justifiably deserve.

But an employer, before calling a carrier, agent or broker to complain should first – count the blank boxes.

Author: Attorney Theodore Ronca is a practicing lawyer from Aquebogue, NY. He is a frequent writer and speaker, and has represented employers in the areas of workers’ compensation, Social Security disability, employee disability plans and subrogation for over 30 years. Attorney Ronca can be reached at 631-722-2100. medsearch7@optonline.net

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

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

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

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

SUBSCRIBE: Workers Comp Resource Center Newsletter

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

Most workers that are injured are quick to blame their employer if an issue arises with coverage or denial of their work comp claim. Once you break away the layers of the injury details it can start to tell a different story. Oftentimes the failure to communicate will fall on the shoulders of the employee, who should know better to begin with.

For example, take a case of a knee injury in which the worker banged his knee on a metal frame while working. At first he thought the pain would go away, so he didn’t say anything right away. Later on in his shift, while his supervisor was walking by he shouts out to him that he hurt his knee, and that was it. The supervisor barely hears him in passing, and continues about his day. A week later he limps over to the HR department and wants to go to the clinic to treat. This is the first the HR person or work comp supervisor is hearing of an injury.

Who Is To Blame For An Unreported Injury?

So where is the fault in this scenario? Is it the injured worker who fails to actually talk to his supervisor and fill out an accident report? Or is it the supervisor who fails to follow up with the worker to find out what he said?

In my opinion, the fault is on the worker. Most carriers and employers are soft on this issue. If someone casually reports an injury, then waits a week to start treating it, you have no way of confirming what happened during those days he was allegedly injured and not treating with a doctor. In the end it becomes the workers version of the story versus the supervisors. In my book, if both sides fail to agree, then it is a disputed file and no benefits should be paid out.

The worker has the burden of proving that he was injured in the course and scope of employment. He also has to show how he was injured, what injured him, who he told, if he had witnesses, and all the other tidbits that go in to proving and having a claim. If the worker fails most of these issues, then how can an adjuster in good faith deem a claim like that compensable?

It should be an open and closed denial, but it is not. More often I see claims like this accepted, treatment is covered, and then surgical costs and wage loss benefits are paid out on a claim that had no business being paid. Leakage all over the place! Plus if you are self-insured or on a high-deductible plan, that is your money going right out the window.

Avoid Problems With a Clearly Communicated Accident Protocol

To avoid these situations, you have to have a clearly communicated air-tight accident protocol process. Steps have to be laid out and communicated to your workers on what their responsibilities are should an injury occur. You have to stick to your process you have in place, and any non-compliance should result in a claim denial and also disciplinary actions for failure to report a claim handed down to the allegedly injured employee.

This is what will get the attention of your workforce on the floor. Discipline and enforcement are the only two options you have. If you give one guy a break on the protocol, then you have failed your own system that is set up to protect you.

Enforcement of these measures will have to be drilled in to the heads of your supervising staff. They have to know if a worker comes to them with an injury, they have to stop what they are doing and complete the incident paperwork. Creating this paper trial is essential to the work comp process. Failure to comply on the supervisor’s part should lead to the same disciplinary measures that your other workers are held to. This makes it fair for everyone, and keeps the chain of communication running. Any breakdown of that line of communication fails the system.

A Work Comp Case is Either 100% or 0% Compensable

Going back to the adjuster’s point of view, I always say a compensable work comp case is either 100% or 0%. It can’t be a case where you think the worker is 70% legit and then pick up the case as compensable based on that. Even if the injured worker has a compelling story, if the employer cannot give the same injury details or scenario then they had a breakdown in communication somewhere. They have to figure out what went wrong before you can move the case forward one way or the other. I tell employers that disputes can be filed asking for more time to investigate the case. Sometimes the supervisor finally admits that yes, the worker came to them with an injury and they failed to complete the paperwork. The worker has witnesses, an objective injury, and no secondary motive to lie about it. One side will eventually have to give.

As claims professionals, we cannot be everywhere at once. In my opinion, you are always better off letting the investigation proceed, than just picking up the case as compensable only later to find out that the employer had tons of issues regarding the compensability of the case after completion of their own investigation.

Use investigative means wisely, and hold the employer to their own due diligence on their investigation as to what happened and why it happened. Remember, if it is not 100% clear and compensable, it is 0%.

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

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

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

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

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

SUBSCRIBE: Workers Comp Resource Center Newsletter

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

As crazy as it sounds, a lot of people do not know if they are hurt. Here is the scenario: A worker tweaks their back during some sort of work activity and they do not tell anyone that day. The next day they mention something to their supervisor about flaring up their back pain. The supervisor asks if they are ok and they answer “I don’t know.”

This happens all of the time. It is always surprising as to how a person doesn’t know if they are hurt or not. It should be simple. You are either hurt or you are not, right?

Many Minor Claims Can Be Avoided With Early Medical Treatment

Of course this is wrong. If every worker in the plant made a claim when they experienced some sort of pain you would have 9,000,000 claims each month. You trust that if the worker is really hurt, that they will tell you and want to report a claim. However, much of the time, they are not sure, and do not know what to do. So they tell their supervisor, expecting to get some sort of guidance. But the guidance doesn’t come from said supervisor.

This is a great opportunity that is missed. I tell employers if this situation happens, get the employee medical treatment by calling a 24 hour injury triage nurse (or send to a clinic if triage is not set up). It is better to be safe than sorry. But most employers are stubborn in this regard, and instead of getting them medical attention they say “Well let me know if you are hurt and we can address it at that point.”

What happens is the worker doesn’t go back to said supervisor. Because in their mind, they did go to the supervisor and told them they are hurt, and it got them nowhere. Now they work through the pain until they make it so bad they can no longer work at all. Then they want to report a claim and want to go get medical treatment. The only problem is now it is a month later.

When the adjuster gets this claim, they see the injury date as being a month ago and all sorts of red flags go up. Why wasn’t this person sent to the clinic a month ago? What happened between a month ago and now that they want to go get treatment? Why was this not reported a month ago like it should have been?

The answer is simple: The employer doesn’t want to get dinged for another possible injury on their loss run (many claims are avoided by using Injury Triage). It makes them look bad, and they worry about increased premiums and underwriting and OSHA recordings and so on.

This problem is all over the place in work comp like an epidemic. I tell employers all the time if someone comes to you and says they might be hurt, you should get them medical attention (ideally with Injury Triage) right away, because a simple back strain if caught early is super cheap to get rid of. If you wait until a month later and the guy can barely stand up straight, this is going to be a claim that is around for at least a few months, if not longer. Plus the cost is probably 4 times more now than had you sent the worker for treatment a month ago. You are shooting yourself in the foot by waiting.

If Someone Says They Might Be Hurt, They Probably Are Hurt

Just the mere fact that the person said they think they might be hurt is enough to seal the deal that they are probably indeed hurt. Employers should not be afraid to report an injury, particularly to an injury triage nurse. A call to a triage nurse does not trigger a claim, it merely gets the employee evaluated by a medical professional that will give a recommendation for home care, or further evaluation by a medical professional.

Sadly, this is the environment we are in. Fear of increased costs hang around the employer, like a monster under the bed of a 6-year-old. They know it is there, but just want to ignore it and hope it goes away. But this is not make-believe; this injury will rear its ugly head again in the near future, so there is no point in trying to sweep it under the rug.

Both Employees & Employers Need to Be Educated on Injury Reporting

The responsibility doesn’t sit only with the employer in this situation. The employee also has to know if they are hurt or not. Employees are in the same fear boat: They do not want to get in trouble, they do not want to deal with work comp, and they do not want to be hurt. So they hope it will go away. Chances are it will not. In the end they get punished by this delay in treatment and reporting. The adjuster says “Hey anything could have happened in this last month, so why should I pick up the tab when we are not sure what exactly happened?” And they are right. Injuries that are reported promptly with immediate medical treatment are going to be picked up more often than those with delays in reporting and medical treatment. So due to a lack of reporting and treatment, they deny the claim most the time. Denied claims such as these lead to a lot of litigation, because the employee knows they hurt themselves at work, and the carrier is just not so sure due to the delay. They feel they are better off denying it and seeing what happens.

All of this can be avoided. The way it has to work is two-fold: (1) the employee has a duty to report an injury to a supervisor and (2) the employer has a duty to get the injured worker medical treatment and report the information to the carrier. If everyone would just follow these rules then they will have a more streamlined work comp program where everyone is responsible and doing what they are supposed to do.

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

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

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

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

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

SUBSCRIBE: Workers Comp Resource Center Newsletter