Complex and severe injury claims are a leading driver of workers’ compensation claims costs. The greater the complexity and severity of an employee’s injury the larger the number of medical providers involved in the medical treatment. The primary physician often engages other specialists, therapy services, diagnostic testing, pharmacy usage, etc. The result of involving many different medical providers in the injury claim is the primary physician is often not fully aware of all aspects of the injured employee’s medical treatment.

Doctor Standard Treatment Protocol Not Designed in Employees Best Interest

A primary doctor has many individual patients, making it difficult to impossible to spend the time evaluating the overall best course of medical treatment for a particular injured employee. To compensate for the limited amount of time a physician can spend with any one patient, it is the doctor’s normal practice to follow a standard protocol for each injury type. These standard treatment protocols tend to have various built-in tests and procedures designed not in the best interest of the injured employee but designed to protect the doctor from claims of negligence and/or medical malpractice when the injured employee does not achieve expected results.

Senior Nurse Reviewer Provides Medical Expertise to Help Adjuster Make Good Decisions

Workers’ compensation adjusters often wonder if all the diagnostic tests, therapy sessions, injections, prescriptions, and repetitive office visits are really worthwhile. Adjusters, not being trained medical professionals, may doubt the need for various medical procedures and attendant costs but are without the skill set needed to discuss with the primary medical provider the various medical services being utilized. Fortunately, there are workers’ compensation medical professionals – senior nurse reviewers – who have the expertise to review with the primary medical provider, and all other medical service providers, the need for each medical service provided to the injured employee.

Senior Nurse Reviewers – nurse case managers with the highest level of medical expertise and experience – assist employers, adjusters, medical providers, and severely injured employees with guidance and coordination of complex injury claims. By overseeing the medical care and coordinating medical treatment, the senior nurse reviewer reduces or eliminates unneeded medical services while the injured employee receives all necessary medical services promptly.

A senior nurse reviewer reduces claim costs in a variety of ways, including:

• Assisting the injured employee in the navigation of the medical universe.

• Facilitating communication between the injured employee, the medical providers, the adjuster, and the employer.

• Creating a care plan for the injured employee and updating the care plan as needed.

• Questioning and addressing unnecessary medical treatment.

• Keeping all medical care on track, eliminating delays in treatment, thus reducing the time the injured employee is off work.

• Coordinating the timely delivery of diagnostic testing, therapy, and medical appointments with other medical specialists.

• Providing on-going case oversight to eliminate unnecessary medical services.

• Identifying and addressing obstacles to the employee’s recovery.

• Addressing any deviation from established disability duration guidelines.

• Facilitating the quickest possible light duty or full duty return to work for the employee.

Senior nurse reviewers are not physicians but nurses with many years of experience. If the senior nurse reviewer and the medical provider disagree on what is the best interest of the injured employee, the senior nurse reviewer turns to doctors and medical specialists, who have contracted with the senior nurse reviewer’s company to provide a high level of expertise within their medical specialty. The senior nurse reviewer then has the contracted medical specialist consult with the injured employee’s doctor on a peer-to-peer basis to arrange for the best course of medical treatment for the employee.

Overall Impact of Senior Nurse Reviewer is Reduction in Claim Costs

The overall impact of using a senior nurse reviewer on complex and severe workers’ compensation claims is a reduction in the employer’s overall claim costs. The use of senior nurse reviewers results in two types of savings:

• Lower indemnity cost by the injured employee quicker return to work.

• Lower medical cost by eliminating unnecessary medical services.

For assistance in locating a senior nurse reviewer for your complex and/or severe claims, please contact us.

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/

©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.

So last week I’m having lunch with a business associate and he says to me, “You know, I haven’t done a lot of business in work comp. Can you explain to me how it all works?” Hello, my name is Michael Stack and I’m the CEO of Amaxx and that question is a great question, particularly for those outside of our industry and also for many, many of individuals within our industry, trying to figure out the complexity of the work comp industry itself. As you look at it from the outside, it’s extraordinarily complex but at its core, it’s extraordinarily simple.

Getting Injured Employees Proper Treatment Is Core of Workers’ Comp

You’ve got an employee and an employer, that employee gets hurt and our job is to just help them get better and get back to work. Very, very simple and to do that, you need a lot of help and you need a lot of people. One of those individuals and one of the emerging markets and emerging sub-markets even within the physician world, is the emergence of networks and specialty networks. Today I want to talk about that specialty network and what you should look for when you’re setting this up so you can get those individual employees the treatment they need and help them get back to work. Let’s talk about a couple things here.

Broad vs Narrow Networks

First thing you’re going to do is you’re going to look at whether you’re going to be using a broad versus a narrow network. The narrow network, these are the ancillary networks, these are the specialty networks that has been really quietly emerging within our industry over the last several years. It’s not a bad idea to have a combination of the two. You’ve got the broad network to cover most of your organization, and then the narrow network to bring in some of those experts in those particular fields. Now, these can be physical therapy, these can be mental health, these can ambulatory service centers, these could be chiropractic, a whole host of specialties within the medical field that put together these ancillary or specialty networks.

A couple things that I want you to just be aware of. There’s a lot that obviously goes into this, but what we’re trying to do, think about the core of what we’re trying to do is, we’re trying to get that individual employee the treatment that they need to get them back to work. Now, how do we do that? Bringing in these best medical providers, leveraging the fee schedules, the discounts on the fee schedules that can often come from these. So, a couple of things that I want you to just look for, particularly if you’re evaluating a network and evaluating whether or not to bring in some of these specialty or ancillary or networks, which again have been emerging in the last several years.

Network Coverage

First thing that I want you to look at his coverage, next is access and the last one, or at least the last one we’re going to talk about today, is credentials, so coverage, access and credentials. Can you cover the entire geographic area of where your employees are? If you’re a regional or a national employer, is there the appropriate coverage that that employee could actually get to that provider in a reasonable amount of time to get the treatment that they need?

Network Access

Number two, are they accepting new patients? Are they accepting new patients? Workers’ comp specific patients. I can’t tell you how many conversations I’ve had with injured workers where they said, “You know, I got a list of five doctors and the first three I called, they didn’t take work comp at all and the fourth one I called, he wasn’t taking any new patients, and then the fifth one did take new patients and took work comp, but he was two hours away.” Coverage and access, incredibly important to get to that fundamentally simple concept of what it is we’re trying to do in this industry, help our employees get better, help them get back to work. You got to have the right doctors that are going to help them do that.

Credentialing

And then finally, particularly as it comes to network, what credentialing are they doing? Are they board certified? Do they have X amount of experience? Do they have certain criteria as far as the outcomes that they’re delivering? What is their credentialing of the networks? Work comp can be extraordinarily complex in how it’s all put together, but remember at the core, what it is we’re trying to do. Just get our employees the treatment that they need and help them get back to work. These couple of tips in regards to providers and network can help you do that.

Again, I’m Michael Stack, CEO of Amaxx and remember your work today in workers’ compensation can help you have a dramatic impact on your company’s bottom line, but it will have a dramatic impact on someone’s life, so be great.

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/

©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.

Monitoring and managing workers’ comp transportation expenses can drastically improve the claim expense cost, especially on larger work comp claims. Unfortunately, claims adjusters and/or nurse case managers often overlook this important expense, thinking to save money by not using a transportation service.

Attempting to cut costs in this category is not an option, and here’s why.

Controlling Work Comp Transportation Expense Is More Than Ordering an Uber

Controlling transportation expense is more than ordering an Uber for the employee to get to the doctor or writing the employee a check for personal automobile mileage.

When the employee is physically unable to travel unassisted or does not have access to transportation and will have multiple visits to the treating physician or other medical providers, a transportation company specializing in workers’ compensation claims is needed. Services of a transportation company are arranged by the adjuster or nurse case manager, not by the employee.   The selection of a transportation company is based on the company’s ability to provide safe and reliable transport service whenever needed.

A full service transportation company saves the claims office a significant amount of time, since the adjuster or the nurse case manager can spend many calls and emails coordinating employee transportation needs. Often employees reschedule doctor appointments for their own convenience and the transportation must be scheduled all over again. Or worse, employees “forget” their medical appointment and are not ready to go when the transportation arrives, knowing the doctor will not see them if they are very late arriving.

Experienced work comp adjusters know the more subjective the employee’s injuries are the higher probability they will miss their medical appointments, cancel medical appointments or reschedule them without advising the adjuster.

The professional transportation company will:

1. Schedule the transportation with the employee as soon as they are notified of the medical appointment.
2. Contact the employee the day before the medical appointment to confirm the pick-up time and the return home time.
3. Contact the employee the day of the appointment before they leave their business location to confirm the appointment is still the same.
4. Notify the claims office if there are any changes in the scheduled medical appointment, or if the medical appointment is missed by the employee.
5. Provide the adjuster or nurse case manager with a documented trip history as to their departure time from their business location, the time they picked up the employee, the time the employee arrived at the medical location, and the time they delivered the employee back to the employee’s residence.

While automobiles are the most common mode of transportation for injured employees, other modes of transportation are occasionally needed for the severely injured. The full service transportation company specializing in workers’ compensation claims is able to provide the work comp adjuster or the nurse case manager with other alternatives including ambulances, wheelchairs and stretchers.

Employee Has No Incentive To Locate Best Price for Transportation

In addition to saving the claims office considerable amounts of time, the professional transportation company also saves the claims office money. The employee has no incentive to locate the best price for transportation, as the employee is not paying for it. Also, the employee is not concerned about the cost for missed appointments. By the claims office controlling the transportation needs of the employee, the transportation cost is properly managed.

Author Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is 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/

©2017 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.

Leaving no stone unturned is critical to managing your workers’ compensation costs. With the number of steps from injury to resolution; the number or people involved from physicians to adjusters; and the number of possible outcomes from a band-aid to a large insurance settlement you cannot leave any single step to memory.

Create System to Ask All the Right Questions

Certain questions must be asked, forms must be filled out, and precautions should be taken. Your injury management system should ensure all the questions one should ask the physician on the telephone to be sure every “i” is dotted and ever “t” is crossed.

Formalize your questions in a checklist so these questions are asked uniformly; it’s not something that should be done on an ad hoc basis.

9 Questions to Ask Injured Worker’s Treating Physician

1. Introduce yourself and give the injured employee’s name, mentioning the employee has authorized you to speak with the doctor
2. Get and give all contact information.
3. Offer to email authorization so the doctor may discuss the employee’s condition.
4. Ask for diagnosis and whether it is work related.
5. Ask how the employee is responding to treatment.
6. Ask if prescribed medications could interfere with the employee’s job.
7. Does the physician recommend any significant limitations?
8. Can the employee perform a transitional duty job? If yes, obtain the employee’s work restrictions.
9. Is there anything else that I should know, that would help our employee recover more quickly?

This open-ended question gives the doctor an opportunity to provide information that is additional and helpful to the employer or the employee.

Keeping up with all these details assists your company in getting your employee healthy and back to work.

Author Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is 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/

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

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

The great healthcare debate in Washington, D.C., left many in our industry wondering what the ultimate impact would be on the workers’ comp system.  While the proposed republican bill has failed to pass, employers and payers can still take steps to ensure they are in the best position for the status quo – or whatever future legislation may be proposed.

Here are some areas to consider.

Employee Safety & Health

1. Wellness programs. If your company does not have one, this is a good time to consider the idea. Healthier employees are less likely to sustain workplace injuries or illnesses and more likely to recover quickly when they do. If your company has a program, look at its effectiveness. How do you measure its success? What is the participation rate? What kind of feedback have you received about it? Even if your wellness program is doing well, it may be time to try some new features or change it up a bit to encourage increased buy-in. If possible, connect wellness initiatives with nurse case management.

2. Focus on older workers. If you’ve thought about taking steps to increase safety and health among aging workers, now is a good time to do so. Improve the lighting, implement efforts to ensure hallways are free of obstacles, and look into assistive devices to reduce bodily strain.

Fraud Concerns

3. Step up investigations. You want to make sure you’re not hit with claims that are not work related; so when an injury does occur, make sure you don’t skip steps to uncover what really happened. Talk to witnesses, review any video footage, look at the timeline of events.

4. Scrutinize bills. To the extent possible, make sure your providers, attorneys, and others are not trying to cushion their potential income losses at your expense. If anything on a bill raises a question — ask about it. Any reputable vendor should be able to easily explain changes in billing.

Claims Management Processes

5. Use workflow automation to better manage your loss trends and reduce claims leakage. You might consider data warehousing to integrate legacy systems and multiple data sources to identify fraud and cost shifting, and to better manage performance.

6. Intervene early. Don’t let potentially high risk claims deteriorate. Work with your insurer or third party administrator to identify claims that could go south. Leverage clinical and specialty resources early in the claim cycle.

7. Use quality providers. Make sure you’re working with high quality partners, to help expedite claims and get your injured employees back to function and work. Medical providers should be outcomes-based with good track records of delivering the best care. They should also have a comprehensive understanding of occupational health. If not, look for new providers or educate those in your network.

8. Check the paperwork. Make sure your policies and procedures relating to employee health and safety are up to date and easily available to employees. If you have a drug-free workplace policy, for example, make sure it includes any recent related changes in your jurisdiction. Any relevant portion of the employee manual should also be reviewed and changed where needed.

Conclusion

At the moment it seems healthcare is going to remain unchanged.  However, whether or not there are future changes proposed, it behooves stakeholders to be prepared.

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

Author Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is 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/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

©2017 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.

A doctor holding an injured worker “hostage” and not releasing them to light duty work when applicable is a challenge that will never go away.  Over time I think many doctors have gotten better with this issue, but sadly many have not.  For those that have not, the end result is a claim that costs more dollars due to increased claim expense in the way of work comp wage loss payments.  These payments can go on for months, and it is 100% unnecessary and can be avoided.

So how do you handle a doctor that is holding your worker hostage?

1. Get a field nurse case manager on the file. The main culprit to a worker not being given light duty work restrictions is due to a lack of communication. The doctor asks the worker if there is light duty available, and the worker answers “No.”  So, the doctor takes their word for it, and leaves it at that.  Despite you faxing over questions and leaving messages to talk to the doctor, those requests fall on deaf ears.  They are taking the patient’s word, and leaving it at that.  This is not acceptable, and you should utilize a field nurse case manager to interject the fact that you can accommodate light duty with any restriction.  Use the nurse case manager as your voice, and see what result you get.

2. Explain that you want to focus on what the employee CAN do.  If you make your stance more about what the injured worker CAN do, rather than what they CAN’T do, you are going to get some results.  Asking questions such as “Can the worker drive?  Can they get groceries for themselves?  Can they sit/stand as needed?  Can they climb the stairs on their deck to get in to their house?”  If the answer to all of these questions is yes, then you have created your own restrictions.  If the worker can drive a car, walk around a grocery store, climb stairs, clean their house, mow their lawn, etc, then they can certainly perform a sedentary job at work.  After all if they can drive to the store they can drive to their job, walk in the door, and complete a sedentary job that is just the same as sitting home on their couch.  In all of my years I have never heard of a doctor saying a worker can drive to the grocery store but should not be driving to work.

3. Provide a detailed light duty job description the doctor can keep in their file. Many times a doctor will not release a worker to light duty because they were burned by it in the past. The doctor released a worker back to light duty, and then the worker was “forced” to complete job tasks outside of their restrictions and then further injured themselves.  I imagine this is rare, but all it takes is for that to happen one time and the doctor is hesitant to release another worker on a light duty work program. You can explain to the doctor that you have a formal program, a job description, enforcement of the duties, and monitoring of the position as a whole.  If this is explained to the doctor, they are going to feel a lot better about releasing this worker to light duty rather than just saying “Yes, we have light duty.”

4. Use an IME if you have to. Sometimes all of your efforts are going to fall short with the treating doctor.  Actually, if you threaten an IME to the treating doctor all this is going to do is make the treater pass the buck to the IME doctor.  If that is the case, so be it.  One IME bill is certainly worth getting a worker back to light duty versus allowing the worker to sit at home collecting a wage loss check .

5. As a last resort, use the legal tactic. This last tactic is not my favorite, but it is effective when needed. When a doctor holds a worker off of work and refuses to allow light duty or even to address activities of daily living as a basis for light duty work, use your legal maneuvers.

Doctors that hold their patients hostage are never going to go away.  But when you confront them with some of the tricks outlined above, you are going to have a greater success rate for getting your injured workers back to work.  Every job within your light duty work program is an important one, and this should be explained to the doctor every time.

Remember, your local physicians and clinics are supposed to be your assets, and not your adversaries.  Remind them of the common goal to get your worker whole again, and how psychologically a worker that stays working recovers quicker than one sitting at home watching attorney commercials on TV.

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is 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 founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a monthly basis working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

©2015 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 I have seen many a nurse case manager come and go.  They were in various stages in their career:  Younger, older, male, female, some with kids, some without kids, some with claims experience, some with no idea what they are doing–they just know they are no longer working in an ER Dept at 2am.  

An Effective Nurse Case Manager Is Important Adjuster Tool

Whatever the case may be, an effective nurse case manager is (Or should be) one of the claim adjusters most important tools.  Not only are they eyes and ears on the ground, but they should be confronting the treating doctor with the questions the adjusters needs in order to move the claim forward, address compensability, or to reach MMI.

It always surprises me when a claims adjuster doesn’t really know who their nurse case manager is.  What is their experience?  How long have them been doing case management?  Have they worked for any other vendors?  Did they work at a carrier as a telephonic case manager?  All of these questions have importance.

The relationship between adjuster and nurse case manager is very important, so I did some additional research on this topic. Does an adjuster really care about which nurse is on the file?  After all, nurse case management is an important role and has a lot of influence on the file.  So, what is the dynamic?

Nurse Case Manager Story From A Seasoned Adjuster In The Trenches

To answer this, I asked my adjuster friend of mine named Toby.  Toby is a field claims adjuster, and travels to his accounts and handles files on his own.  He stated that he has a nurse case manager specific for each account.  Not only does he bring the nurse in to tour the facility regularly, but he also creates a good working relationship between the nurse and the insured contact.  The three of them create their own triage group.  By keeping one specific nurse for each account, the nurse becomes a huge asset for the file.  This nurse knows the employer floor plan and work stations, knows the job duties, who to email with questions about repetitive motion, light duty assignments, and so on.  This makes life easier for Toby as an adjuster because he is allowing the nurse to run the medical portion of the file. 

He has developed a significant amount of trust in this relationship.  He knows the nurse has an ER department background, and said when they first met he explained his role as a claims adjuster, took the time to explain what his needs are, what he expects, why he expects it, and why it is important.  He taught the nurse about some of the legal challenges and medical challenges he faces in his role, and why the case nurse is such a crucial benefit to him, especially being out in the field.

Toby started him off with some files, and monitored if the nurse delivered on what he said he could do.  Many years later, he trusts this nurse with some of his most important accounts, and the outcome is mutually beneficial.

Be Proactive About Developing Your Own Relationships

The question becomes how you go about developing your own relationships. The answer Toby suggested is trial and error.  He stated when he was developing relationships in areas outside of his trusted nurse’s geographic region that a lot of nurses and their marketing vendors would promise the moon, but then when push came to shove their weaknesses would surface.  Some nurses were not aggressive enough.  Some talked a good game, but when it came time to do the dirty work they would roll over.  Over the years, he has seen some good nurses come and go, but he is always trying to meet new contacts, to strengthen his network of reliable, dependable, and effective nurse case managers.  To do this takes time, and each relationship has always started over a lunch. 

It is basically an interview process.  Those that have delivered for Toby have become a part his team of vendors he uses regularly on files.  As the months and files go by, the working relationships grow stronger, better, more efficient, and essentially seamless.  It becomes a team effort, with mutual goals and a strong knowledge of what to expect from each other.

How Well Do You Know Your Nurse Case Manager?

It is simply not enough for an adjuster to blindly put the trust of very important dollars in the hands of a nurse that they do not know.  The nurse represents the adjuster, carrier, and employer.  Cases spiral out of control all of the time, and the adjuster has a duty to either prevent that from happening, or to control the vortex as quickly and effectively as possible. 

So how well do you really know the nurse case manager you are putting on your file?

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, and founder of COMPClub an interactive training program teaching workers’ comp cost containment best practices.  Through this platform he is in the trenches on a monthly basis with risk managers, brokers, consultants, attorney’s, and adjusters teaching timeless workers’ comp cost containment strategies, as well as working with members to develop new tactics and systems to address the issues facing organizations today. This unique position allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com. 

©2015 Amaxx LLC. All rights reserved under International Copyright Law.

Employers/Carriers/TPAs/Brokers/Vendors looking for additional information FREE resources for Workers Comp cost containment best practices are invited to access Amaxx Workers’ Comp Cost Containment Essentials training series

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

Under many workers’ compensation programs, injured parties have a statutory right to vocational rehabilitation benefits.  These benefits include the right to retraining when other efforts such as job placement and search are not successful.  Due to the significant costs associated with retraining, it is important to claim handlers to understand how to handle claims of this nature.

What is Retraining?

Retraining in a typical workers’ compensation program involves a formal course of study in a school setting.  The purpose is to return an injured worker to suitable gainful employment.  Retraining can also include a spouse of a deceased employee.

In most instances, a claimant seeking these benefits must demonstrate through prior efforts that they lack the transferable job skills to attain a comparable post-injury economic status.  Other factors that come into play include the inability of the claimant to successfully re-enter the labor market given other barriers, including economic factors within their community.

Retraining Limitations

Most jurisdictions impose limitations to a retraining program.  These limitations can include the following:

• A specified number of weeks to complete a retraining program;
• Receipt of other workers’ compensation benefits, including indemnity benefits; or
• Payment for other associated expenses with the retraining program.

Understanding the scope of the laws and rules related to retraining are important as they vary by jurisdiction.

Retraining Eligibility

As a general rule, a retraining program will be evaluated under the following criteria:

• Whether the proposed retraining program is reasonable to return the employee to comparable positions.
• The likelihood that the employee with complete the program based on prior academic and vocational experiences, and their existing abilities and interests.
• Whether there are existing employment opportunities available for the position they are retraining.
• Potential future economic status once the employee has completed the retraining program.

Defending a Retraining Claim

In most jurisdictions, there are no statutory caps on the costs of a retraining program.  There are numerous workers’ compensation cases nationwide were an injured worker sought and was awarded advanced degrees, including a law school education.  It is important to review cases for potential future exposure and defend a claim properly from the onset.

• Early identification is key. While most might assume retraining is something for older employees, it should also be something to evaluate in cases involving younger employees.

• Investigate the employees past academic and vocational performance. This is especially true to people who may have dropped out of high school or failed to pursue a post-secondary education.  Retraining can also include vocational training, so never assume someone who does not graduate from a traditional four-year college will not seek retraining at a vo-tech institution.

• Obtain an expert opinion on the proposed retraining plan and the likelihood the employee will successfully complete the program. As part of using an expert in this area, it is important to identify deficiencies in the employee’s rehabilitation attempts and to determine also other retraining alternatives.

• Evaluate the costs of various options and seek opportunities to provide an equivalent program at a comparable, but cheaper institution. An example of this is whether a retraining candidate can receive a two-year education and have essentially the same outcome as if they would receive a four-year degree.

Conclusions

Retraining can be a costly part of any workers’ compensation claim.  Proper claim management, investigation and aggressiveness can help mitigate retraining costs.

Author Michael B. Stack, Principal, COMPClub, Amaxx Work Comp Solutions. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  He is co-author of the #1 selling book on cost containment, Your Ultimate Guide To Mastering Workers Comp Costs www.reduceyourworkerscomp.com, and Founder of the interactive Workers’ Comp Training platform COMPClub. Contact: mstack@reduceyourworkerscomp.com.

©2015 Amaxx LLC. All rights reserved under International Copyright Law.

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Telemedicine is viewed by many as an opportunity to reduce the cost of medical expenses and promote efficiency in the workers’ compensation system.  While this practice may be new in workers’ compensation claims, it should be something claim management teams look at to reduce the overall costs of a workers’ compensation program.

What is Telemedicine?

According to Wikipedia, telemedicine is “the use of telecommunication and information technologies in order to provide clinical health care at a distance. It helps eliminate distance barriers and can improve access to medical services that would often not be consistently available in distant rural communities. It is also used to save lives in critical care and emergency situations.”

Telemedicine in Practice

The concept of telemedicine is not new.  In fact, it has been used for over a decade in some areas.  By using the technology in the Internet and advances in other telecommunications, medical practitioners have been using “telemedicine” to care for remote patience.  It has also been used for practitioners to connect to others in the medical community to discuss case studies, review patient histories and provide better care.

Telemedicine is also being used to address a shortage of general practitioners and other specialists.  In most instances, the use of this service benefits doctors by allowing them to see more patients.  It also benefits patients who are not able to travel to a doctor’s office for a scheduled visit or have a disability that inhibits their mobility.

Uses of Telemedicine in Workers’ Compensation

Given the nature of telemedicine, there are a number of practical applications for this practice in the context of workers’ compensation.  These include the following:

• Reduce the expense of having an on-site medical professional;
• Allows doctors and triage nurses to assess injured workers from a remote location;
• Enables medical experts such as radiologists to evaluate images and prepare reports;
• Uses fully integrated technology to access information on a number of cases.

Medicaid and Medicare have also recognized the value and benefits of telemedicine initiatives.  These two important government programs are in the process of evaluating the effectiveness of it as a tool to meet the challenges of the 21^st century healthcare system.

Drawbacks to Effective Telemedicine Programs

As is typically the case with new initiatives, it is important to remember that there are drawbacks as the concept gains acceptance.

• Licensing of physicians. Many states are in the process of addressing these issues through regulatory reform and legislative mandates.

• Technological considerations. The key to any successful telemedince program is reliable Internet access for all parties.  This is sometimes an issue with people living in remote locations or from a lower socio-economic status.

• Patient satisfaction. While telemedicine allows people to communicate and see the person they are talking to, there is sometimes the lack of a personal touch people have grown to expect when receiving medical care and treatment.  Addressing these comfort levels in the context of the adversarial workers’ compensation system is important.

Conclusion

While there are some drawbacks, such as in-person contact, the use of telemedicine can improve the quality of care and reduce the costs in a workers’ compensation program.  It is worth the time for any serious claim management team to investigate their options in this area and determine if changes can be made to meet the needs of all stakeholders.

Author Michael Stack, Principal of Amaxx Risk Solutions, Inc. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  As the senior editor of Amaxx’s publishing division, Michael is on the cutting edge of innovation and thought leadership in workers compensation cost containment. http://reduceyourworkerscomp.com/about/.  Contact: mstack@reduceyourworkerscomp.com.

©2015 Amaxx LLC. All rights reserved under International Copyright Law.

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

One of the drivers of the high cost of medical care in workers compensation is the in-ability to get the right care, from the right provider, at the right time.  A network of medical providers and a strong pharmacy relationship may be in place that can deliver quality care at a reasonable, negotiated price.  However, if injured workers are not utilizing these networks, the opportunity for cost savings is lost.

This is especially true with workers’ compensation as the employee is rarely prepared for what to do in the event of an injury at the workplace.

Network Information Often Difficult to Access

At the time of injury the supervisor is often left in the precarious position to have to make a medical determination on the treatment for the injured worker.  He has limited information and limited resources to be able to give the proper direction for the highest quality care at the most cost effective price.

This lack of information is also a challenge for the medical providers, injury coordinators, and adjusters.  It frequently results in delays in medical treatment and can lead to unnecessary duplication of medical services, delayed return to work, lack of first fill pharmacy capture, and other inefficiencies.

Provide Critical Medical Information To Expedite Proper Care

Information For Medical Provider

The health ticket is a web based communication tool providing all the necessary information on the medical treatment to the medical providers, employer, employee and the claims payer. The health ticket will inform each medical provider of:

1. The employee’s name
2. The employer’s name
3. An identification customer number assigned to the employer
4. The date of injury
5. The workers’ compensation adjusting company’s name and address
6. The adjuster’s claim number
7. The nature of the injury
8. The name of ancillary network vendors and contact information
9. A telephone number to call with any general questions they have in regards to the injured employee’s medical care.
10. The medical care is limited to medical care arising from the date of injury only and for the specific injured body part.

Information for Injured Employee

The health ticket is also provided to the injured employee. It gives the injured employee the same information given to the medical providers.  In addition, the health ticket provides the employee with:

1. A phone number to call to locate additional medical providers – Or – refers the employee to the posting of panel physicians at the place of employment

Information Regarding Pharmacy:

Drug costs are the fastest growing component of medical care and often one of the most neglected areas of workers compensation cost control.  Providing the injured worker complete pharmacy information greatly increases the chances to capture the first prescription fill to take advantage of negotiated payment arrangements and utilization management services of the Pharmacy Benefits Management vendor.   The pharmacy information included is:

1. Participating pharmacies
2. Network identification numbers
3. Rx help desk

Information Regarding Utilization Review

As different workers’ compensation insurers usually have different limitations and different requirements on what medical care they can provide without the insurers approval and what medical care needs to be approved through Utilization Review, medical providers frequently have to delay care (adding extra return medical visits to the medical provider) while the medical provider determines whether or not Utilization Review is needed.  The health ticket will provide the medical provider with a list of the more frequent medical procedures needing prior approval, including [partial list]:

1. Non-emergency hospitalization, surgeries (both in-patient and outpatient)
2. Physical therapy
3. Pain management
4. Imaging procedures
5. Facet, trigger point or epidural steroid injections
6. Bone growth stimulators
7. Second surgical opinions
8. Durable medical equipment

The health ticket will provide the medical provider with the telephone number to call to obtain the Utilization Review, which minimizes the delay while the additional medical treatment is reviewed.

Information on Additional Services

The medical providers can also obtain from the health ticket the information needed to schedule additional services like:

1. Durable medical equipment
2. Home health care
3. Orthotics and prosthetic devices
4. Diagnostic imaging
5. Transportation and translation services
6. Physical therapy

Information to Connect With Adjuster Regarding Return to Work

Most importantly (from the work comp adjuster’s point of view) is the instructions on the health ticket to contact the adjuster for information on coordinating the employee’s light duty return to work.

Easily Accessible For Seamless Medical Treatment

The health ticket can be transmitted via the medical case manager’s website, email or fax.  The health ticket can be transmitted to the injured employee’s smart phone or other smart device.  This allows the injured employee to always have all the medical information available.  All users of the health ticket can access the health ticket through the website and print the medical care instructions.

Having this medical information not only makes for near seamless treatment of the injured employee, it also provides many benefits for the employer including:

1. A reduction in claim costs through:
   • Avoiding unnecessary medical treatments
   • Improved quality of medical care through medical network
2. It is customizable for the employer’s or insurer’s needs
3. Reduces the friction with the employee over the medical care
4. Increases the PPO network penetration
5. Increases voluntary compliance with Utilization Review

For more information on health tickets and how to utilize a managed care company providing these services, please contact us.

Author Michael Stack, Principal of Amaxx Risk Solutions, Inc. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  As the senior editor of Amaxx’s publishing division, Michael is on the cutting edge of innovation and thought leadership in workers compensation cost containment. 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.