Work Comp Roundup

Vocational Rehabilitation Qualified Rehabilitation Consultant Misconduct

October 30, 2019 by Michael B. Stack

Vocational rehabilitation and working with a Qualified Rehabilitation Consultation (QRC) can reduce workers’ compensation costs and get an injured employee back to work in a timely manner. Problems can arise when the QRC starts acting like an advocate for the injured employee. Members of the claim management team and other interested stakeholders need to be on the look-out for QRCs gone wild – and ensure they are working for the rehabilitation plan, and not the employee.

What are QRCs?

QRCs are trained vocational rehabilitation consultants than assist employees in post-injury return-to-work and medical management activities. Requirements for QRC registration are typically governed by administrative rules established by an industrial commission. They are appointed following a work injury where the employee’s injury is severe enough to require extended time off work. They should have a solid medical background, and understanding of the labor market and empowering employees to return to suitable gainful employment.

Acting in the Best Interests of the Rehabilitation Plan

QRCs will meet with an injured employee at appointed times set forth in statute or rule and determine the vocational goals. This includes an assessment of various factors, which can include:

The nature and extent of the employee’s injury;

Restrictions and other limitations placed on the employee post-injury;

Transferable job skills and ability of the employee to return to work;

Ability of the date of injury employer in returning the employee to work, including in a light-duty capacity.

QRCs are required to be neutral parties and not an advocate for the employee. The best interests of all parties need to be carefully balanced and taken into consideration.

Qualified Rehab Consultant Misconduct

QRC misconduct is defined by statute or rule in each jurisdiction. There are general principles that govern the conduct of a QRC. Proactive members of the claim management team need to be on the look-out for these factors and take appropriate action against a QRC that steps outside their role.

Failure to perform rehabilitation services with reasonable skill because of negligence, habits, or other cause. This can include a number of different factors and behaviors. It can be something as basic as missing meetings or appointments, and consistently not returning telephone calls in a timely manner. It can also include failing to properly supervise QRC interns and support staff;

Engaging in conduct that is likely to deceive, defraud, or harm the public;

Fraudulent billing practices, or failing to properly bill for vocational rehabilitation services; and

Engaging in adversarial communication or activity. This can include behaviors such as offering opinions on the facts of the case, litigation strategy, requesting information not related to the rehabilitation plan, failing to report all relevant information, and not complying with authorized requests for information.

QRCs need to take their responsibilities seriously. Let the attorneys advocate for their client(s).

Removing a QRC From the Rehabilitation Plan

Each jurisdiction has the mechanisms and standards for removing a QRC from the rehabilitation plan and installing a difference vocational assistant. Most states look at the “best interests of the parties” when making such changes. Factors for consideration include the following:

Loss of trust of the QRC. Claim handlers making this argument should provide concrete evidence on how the QRC has “picked sides” in a dispute – become an advocate for the inquired employee;

Duplicative time and costs that may be incurred as the result of the removal/change in QRC. This is an argument that can be made when the claim management team opposes the change in QRC;

Reputation and years of experience and complexity of assignments by the individual; and

Geographic location of the QRC. In some instances, one QRC may be better than another if the employee relocates.

Conclusions

QRCs play an essential role in vocational rehabilitation and getting an injured employee back to work. Claim handlers need to be diligent in making sure the QRC is doing their job and being an advocate for the rehabilitation plan, and not a party. Failure to do so will result in an employee being off work for a longer time, and more money spent on vocational rehabilitation costs.

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: http://blog.reduceyourworkerscomp.com/

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

Filed Under: Medical & Pharmacy Management

Closing Down Vocational Rehabilitation Workers’ Comp Cases

October 29, 2019 by Michael B. Stack

Vocational rehabilitation is an essential workers’ compensation benefit for employees suffering from the effects of a work injury. It not only helps the employee understand their medical care and treatment, but provides them with assistance in getting back to work. This reduces the money spent on a workers’ compensation claim and improves program efficiency. Members of the claim management team need to examine their files to ensure this benefit is being provided in a responsible manner. When there is no longer a benefit to the employee, steps must be taken to discontinue services.

When is Vocational Rehabilitation Appropriate?

Vocational rehabilitation services are provided to employees who are qualified under a workers’ compensation law. This is a benefit that did not come into acceptance in most jurisdictions until the 1970s. It is generally not available to an employee unless they have been off work for an extended period of time.

In order to qualify, a consultation is usually performed by a Qualified Rehabilitation Consultant (QRC), and a recommendation is made regarding the employee’s status. Factors generally considered include:

Whether the employee is permanently precluded or is likely to be permanently precluded from engaging in their usual and customary occupation or from engaging in their pre-injury job;

Whether the employee is reasonably expected to return to suitable gainful employment with the date of injury employer; and

Whether the employee can reasonably be expected to return to suitable gainful employment through vocational rehabilitation services by taking into consideration the treating physician’s opinion regarding the employee’s ability to work.

Vocational Rehabilitation is Being Provided – Now What?

During vocational rehabilitation, the QRC will issue regular progress reports. It is essential that the claim handler monitors vocational rehabilitation once it has been approved. These reports outline the services being provided and the progress the employee is making in recovering from the work injury. Important issues to consider when reviewing periodic reports are as follows:

New or continuing physical limitation that significantly interferes with the completion of the rehabilitation plan;

Whether the employee is participating fully with the plan; and

Whether the goals of the plan should change, or be modified.

Steps should be taken to termination vocational rehabilitation services if it appears the employee will not benefit from ongoing assistance from the QRC.

Do Not Pass Go: Shutting Down Vocational Rehabilitation Services

Each jurisdiction has the prescribed method one must follow in order to terminate the rehabilitation plan, and discontinue ongoing services from the QRC. While the process may differ, there are general requirements that are considered when putting an end to vocational rehabilitation serves.

A new or ongoing physical disability that significantly interferes with the completion of the rehabilitation plan. This is sometimes the case when the employee has a significant setback in their medical care or new injury or disability that is not related to their work injury;

The employee is not cooperating with the vocational rehabilitation being provided by the employee. Common examples include missing medical and physical therapy appointments, or failing to keep in contact with the employer and/or QRC; and

The employee is not participating effectively in the implementation of the rehabilitation plan.

The focus of the arguments made to terminate ongoing vocational rehabilitation services is whether the employee would benefit from additional vocational rehabilitation assistance. The party seeking to cease these services has the ultimate burden of proof. Grounds for stopping these services that are absolute usually include:

An employee who has returned to work with a negligible wage loss, or without a wage loss. Expectations of near-term future earnings can also be taken into consideration;

Settlement of a workers’ compensation case, which closes out future vocational rehabilitation services;

The employee is no longer making themselves available for services;

Death of the employee.

The closure of a rehabilitation plan generally requires a form to be filed with the industrial commission.

Conclusions

Members of the claim management team must closely monitor every workers’ compensation benefit being received by an employee. This includes keeping abreast of the employee’s status and cooperation with vocational rehabilitation benefits. While this is a useful benefit, steps should be taken to terminate it if evidence supports the conclusion the employee would not likely benefits from ongoing vocational rehabilitation services.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Medical & Pharmacy Management

Maximize ROI of Workers’ Comp Management Improvements with the Right Insurance Structure

October 28, 2019 by Michael B. Stack

TO LEARN MORE ON THIS SUBJECT:

HOW TO DETERMINE WHICH WORKERS’ COMP INSURANCE STRUCTURE IS RIGHT FOR YOU

Registration – How to Decide Which Insurance Structure is Right For You

How does a company maximize the return on investment of implementing work comp management best practices?

Hello, my name is Michael stack and I’m the CEO of AMAX and the short answer to that question of ‘how does this company maximize their ROI’ is to start with the right insurance structure, whether that be guaranteed cost, or a retro or a captive, high deductible program or self-insurance policy. But the question is how does a company then determine what is the right insurance structure for them? So often I see this done in the marketplace so incorrectly and only a small percentage of the time is this actually done right. Most of the time it’s just sort of done Willy Nilly and you’re just guessing or the insurance broker says, Hey, I’ve got this really awesome retro policy with this XYZ carrier and I think you’re perfect for that.

The Right Insurance Structure for the Right Employer

Or, Hey, I’ve got this really awesome captive because I know captives really well and I specialize in captives and I think everyone should be in a captive and you should be going to captive to. In short, what often happens is that if an insurance broker is a hammer, everyone looks like a nail and if that hammer is a captive program or if that hammer is a high deductible program or if that hammer is a retro program or even if the hammer is a guaranteed cost program, where all you know is guaranteed costs, every single company you look at looks like they should fit into that program, which is not the right way to do it at all. You need to raise yourself up and have a higher level of professionalism in the marketplace to analyze an employer’s needs or if you’re an employer yourself to analyze your own needs and be able to ask the right questions to your insurance broker and risk advisor team.

So I want to talk about today is these four cornerstones of risk financing, what they look like and how you start to go about making this decision because when we’re talking about maximizing the return on investment, why are we implementing from a senior management standpoint, why are we doing all this work with return to work? Why are we working and our injury response systems? Why are we working on building out our medical networks and building this adjuster team and building out this partnership with all our whole risk financing, our risk management team? Why are we doing all that stuff? Of course, it’s to impact those injured workers, but particularly from a senior manager standpoint, it’s all about that bottom line and that’s what’s going to fuel, if you hit that bottom line right, then you’ll really be able to fuel that injured worker being able to really take care of them as well.

4 Cornerstones of Risk Financing

Let’s talk about these four cornerstones and what they are, and again, this is how you’re going to go about really starting to make an analyze this decision. I’m going to write these out here first.

These four cornerstones are:

Risk tolerance
WC Management Best
Predictability of your risk
Financial Impact

So these are the four cornerstones and I’m just going to run through these again very quickly cause this is all about changing the mindset and if you can get out of this video to change your mindset of how you examine this from being a specialist in retro programs where everyone looks like they fit into a retro program, to now being a professional in the marketplace to now determine via these four cornerstones and asking these questions and having this perspective and how you look at this to change up that, how that looks like for you.

Determining Risk Tolerance

Okay, so risk tolerance, how comfortable is an organization with this variability of risk? Are they really risk-averse and they want to be very conservative, they want to be very predictable. We’re going to write a guarantee cost check and we’re going to know that in our budget and that’s going to be solid and we can predict that out and we’re in great shape or can they handle a little bit more variability as far as what’s going to happen with their losses? That’s sort of question number one. What helps you then be more comfortable taking on more risk is these two things right here. These two things are going to help you be more comfortable in taking on more risk. One is if you know, whoops, I wrote best twice there. If you know you’re doing really well in your return to work program, you know you’re doing really well in your injury prevention program, you’ve really cranked that up, you’ve dialed everybody in, you’ve gone through the supervisor training, your supervisors know how to respond to injuries appropriately.

You’ve built out your claims handling team with your adjusters and you’re just cooking with gas. You can take on a lot more risk because you know you that you’ve reduced it on your own side. Same thing with this predictability of risk number. This is a big, big factor in this decision-making process. If you’ve ever going retro or high deductible or kept over self-insured, you start to look at this law of large numbers to say, well, how likely are we to now incur these losses? How likely based on actuarial data, big numbers based on this predictability of losses, how comfortable are we in this section? You’re going to get some help. You’re going to get some help from an actuary most likely to help you have this predictability of risk and the more comfortably without that, the more risk you can take on. So big two pieces here.

And then, of course, the financial impact is understanding that financial impact, both tax implications from your different structures and then that risk-reward feature as well as the more risk that you take on. Obviously, the more reward and organization it’s going to take.

Change Perspective of Risk Financing Decision Making

This is a very complex topic as you start to unfold it. And as you start to dig deeper into this. But again, the point of this video today is to change your perspective on how you look at this, to raise up your level of professionalism. To say that this decision is it about the market. This decision is about what’s best for the client, and if you are the client, if you are the employer client to now have these four things, your risk tolerance, how well you’re doing it, management of work comp, the predictability of risks, and then the financial impact on your organization.

Those are the four cornerstones of now you how you start to go about making this right decision to maximize that return on investment and get, my name is Michael stack and the CEO of AMAXX, and remember your work today in workers’ compensation can have a dramatic impact, as we’ve talked about here on your company’s bottom line, but it will have a dramatic impact on someone’s life. So be great.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Buying Workers' Comp

Medcor Announces the Purchase of Proactive Occupational Medicine

October 24, 2019 by Senior Editor

Chicago-based Medcor, Inc., a leading health navigation firm, announces the expansion of its services through the purchase of clinic operations and other assets from Proactive Occupational Medicine, Inc., an Ohio-based health services company. Medcor already operates over 240 onsite and nearsite clinics providing both occupational and general healthcare across North America.

Medcor Chief Operating Officer Ben Petersen said, “This acquisition complements and strengthens Medcor’s onsite clinical and safety staffing relationships. I’m excited to welcome Proactive’s talented staff into our team and to equip them with Medcor’s state-of-the-art systems.”

With this horizontal acquisition, Medcor expands its Construction Health and Safety business in the power and general construction industries. It also enters the steel industry, bringing to that sector Medcor’s evidence-based medicine and proprietary clinical systems.

Medcor Chief Financial Officer Mark Smolenski said, “This purchase demonstrates Medcor’s commitment to continue growing our construction practice and to deliver health navigation to new customers and new industries.”

Medcor Divisional Vice President of Construction Health and Safety Kevin Kelley said, “The addition of Proactive Occupational Medicine also enhances our service offerings by expanding our mobile audiometric and X-ray capabilities.”

Terms of the transaction were not disclosed.

About Medcor

Medcor provides health navigation through integrated services that include onsite and mobile clinics, injury triage, telemedicine, and safety staffing and training. Medcor serves clients throughout the United States and Canada across a wide range of industries. Medcor helps employers and their employees navigate the complexities of healthcare to achieve better clinical and financial outcomes. Learn more at www.medcor.com.

About Proactive Occupational Medicine

Proactive Occupational Medicine is an occupational health services company that has served clients in the power, construction, pipeline, steel, coal, automotive, manufacturing, chemical and lumber industries. Learn more at www.pominc.com.

Filed Under: Post Injury Systems

How to Control the 5 Variables that Impact MSA Amounts and Approvals

October 23, 2019 by Michael B. Stack

When is the right time to get a Medicare Set-Aside? What medical information is needed? And what can you do to expedite the CMS approval process?

These questions plague any organization trying to settle workers’ compensation claims with injured workers who are or soon will be eligible for Medicare. But understanding when, how and why MSAs are most appropriate allows payers to work proactively with an MSA vendor to reach settlements that are in the best interests of all parties involved.

Anne Alabach, the Workers’ Compensation Department Manager of CPC Logistics, joins Daniel Anders, Chief Compliance Officer at Tower MSA Partners to discuss Achieving Great Outcomes with Your MSA Vendor during the National Workers’ Compensation and Disability Conference® & Expo next month at Mandalay Bay Resort in Las Vegas.

The session will focus on the key indicators to determine success or need for improvement, ways to leverage partner relationships to drive down unneeded MSA costs, and variables that can significantly affect the amounts of MSAs as well as approval times from the Centers for Medicare and Medicare Services (CMS).

Prime Variables

There are a variety of factors that go into developing an MSA. There is not necessarily a ‘right’ or ‘wrong’ amount. What’s important is that the injured worker has enough money to pay for his injury-related medical expenses throughout his life, and the payer is not incurring irrelevant and/or unnecessary costs.

In addition to meeting the threshold for needing an MSA, injured workers should be at maximum medical improvement before one is even considered. An employee who’s about to undergo surgery or a change in medications is not at the point where an MSA should be developed.

Instead, it is most appropriate when the worker’s condition has stabilized.

The variables that should be considered to achieve the most suitable MSA include:

Time
Documentation
Legal
Medical
CMS MSA Review

Timing of the MSA

Time is of the essence — unless it’s not the right time for an MSA. As described above, prior to MMI is the wrong time to establish an MSA. Changes in treatment or services will undoubtedly mean new medications or procedures will be needed, at least in the short term. The MSA should, instead, be developed when there is a reasonably strong chance the person’s medical requirements won’t vary much going forward. CMS’ MSA review program is actually designed for the injured worker who is already at MMI.

However, MMI does not necessarily indicate all medications and other medical needs are appropriate; far from it. For example, medical records for the injured worker may include a medication that was prescribed just one time, months or years ago. It is not uncommon to see medications included in the MSA that the injured worker doesn’t even remember taking.

Uncovering those types of issues is invaluable in reducing unnecessary costs from the MSA. Talking with the MSA vendor about the injured worker’s current situation may reveal clinical interventions that place the case in a more favorable position.

Also, there may be case-specific recommendations based on jurisdictional issues and opportunities that would change the MSA amount. Working with a qualified MSA vendor can lead to major changes in MSA costs.

The Right Documents

Workers’ compensation stakeholders are often frustrated by delays in the CMS approval process. While some of the blame may fall on the agency, it is often the result of insufficient or inconsistent information provided. “An MSA is only as good as the information it is based upon,” according to Anders. Failing to give accurate and complete information may result in letters from CMS and errors in the MSA amount.

“Put yourself in CMS’ shoes,” Anders advised. That means to obtain and provide recent treatment records, or an explanation as to why those documents do not exist. Also, contradictory recommendations need to be corrected. The MSA vendor can ensure the right documentation is provided and is properly filled out.

Legal & Medical Issues

There may be legal justification to exclude or limit medical care in the MSA. Working closely with the MSA vendor can identify those issues.

Physician peer review, clinical oversight, and physician follow-up are the types of interventions that are critical in creating MSAs. Every aspect of the injured worker’s future medical needs must be explored, by obtaining and analyzing his past medical care. Inappropriate care that may be huge cost drivers should be singled out and eliminated where possible, while still ensuring the injured worker’s care is optimized.

Date of injury, accepted and denied dates of injury and body parts, compensable injuries, & diagnosis codes are just a few of the many things that must be considered.

CMS Review

Gaining CMS approval for the MSA, while not required by law, is often a best practice. The outcomes of these reviews are largely predictable — once the process is well understood.

Correctly following the guidelines in the CMS WCMSA Reference Guide, using the correct pricing in fee schedules and recognizing statutory limitations are a few of the factors that can lead to CMS approval.

Certain metrics identified in the MSA preparation and submission process can allow reverse engineering to correctly allocate the MSA and identify obstacles to settlement. An experienced MSA vendor can help pinpoint and analyze metrics to get CMS approval as quickly as possible.

Conclusion

Creating an MSA can be tedious, painstaking work, especially for those whose jobs are not solely focused on them. Those MSAs that gain quicker approval from CMS and are properly funded are developed by payers working in conjunction with MSA vendor partners who have the skills to carefully look at a myriad of factors that impact the injured worker and his medical needs.

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 the founder & lead trainer of Amaxx Workers’ Comp Training Center.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Medicare Set Asides (MSAs)

5 Criteria to Choose the Right Professional Administrator

October 22, 2019 by Senior Editor

It’s not often you hear of the government endorsing a particular service in the private sector. That’s what made it so unusual when the Centers for Medicare and Medicaid Services in 2017 “highly recommended that settlement recipients consider the use of a professional administrator for their funds.”

The 2017 statement spoke volumes about the need for injured workers and others to get help managing their money and lives post-settlement. The concept of professional administration is, unfortunately, highly misunderstood by many workers’ compensation professionals. But once stakeholders are exposed to the ins and outs of this unique benefit, they realize how it can easily be a win-win for all parties to a claim – and why CMS encourages the idea.

What is Professional Administration?

The vast majority of workers’ compensation stakeholders are keenly aware and focused on injury prevention and claim management. What few stakeholders address, however, is that life after a claim is settled. Employers, payers, and injured workers alike usually want claims settled as soon as possible. It gets these cases off the books and allows the injured party to move on with his life.

The problem is the logistics of actually getting to claim closure. The biggest question for everyone involved is often, how much money will it take? The employer/payer wants an amount that will cover the injured worker’s needs, but that is also fair and accurate. The injured worker, understandably, may be extremely fearful that he will run out of money too soon.

In many cases, the claim has been open for months, if not years. While the workers’ compensation system may be seen as adversarial to the injured worker, it at least provides a sense of security that his medical needs are being covered – even if he doesn’t necessarily like the providers and does not always get approval for treatments he believes he needs. Settling the claim means the injured party is on his own to manage whatever funds he has agreed to. Additionally, where there has been a claims adjuster and/or nurse case manager helping him locate and schedule medical appointments, they are now gone. Many injured workers become anxious when they realize they will have to manage their case on their own once they settle.

Professional administrators work on behalf of the injured worker post-settlement in multiple ways.

Clinical help. The professional administrator essentially takes over the role of adjuster/nurse case manager and provides the expertise, guidance, and logistical help so the injured party gets the medical care he needs. However, rather than having a specific group of physicians available and having to seek approval for treatments, the injured party is free to see any physician of her choosing and decide for herself whether to undergo certain medical treatments.

Money management. All too frequently people settle their claims, take the money in a lump sum, and exhaust the funds within a few years. That is why experts strongly recommend structured settlements for injured parties who settle their claims. Depending on the injured party’s desires, the professional administrator can establish a bank account and act as custodian – receiving bills and paying them on behalf of the injured party.

Savings. Well-established professional administrators can make a significant difference in an injured party’s life through medical discounts; for physicians, medications, treatments, and other medical-related items. The best ones have partnerships with many providers and can provide deep financial savings, helping to ensure the injured party’s money lasts longer.

Medicare reporting. One of the issues that is often problematic for injured workers is addressing all the rules and regulations associated with Medicare Set-Asides. Injured workers who have an MSA as part of their settlements must strictly adhere to CMS’ requirements or risk losing Medicare benefits in the future. Professional administrators handle all annual reporting for MSAs and ensure that the funds are not used for the wrong purposes.

The Right Professional Administrator

There are many professional administrators and finding one that is the ‘best’ for a particular injured worker is not a decision that should be made lightly. Along with the injured party and his advocates, stakeholders working on a claim should also research various companies to help make the best choice. Stakeholders want to know the injured party is taken care of and won’t call them six months after settlement with complaints and threats to sue.

There are certain questions that can differentiate the best professional administrators and how well they will meet the injured party’s needs:

Costs/savings. There is no free lunch, and just like any organization, professional administrators need to generate income. For those in the market, the price should balance against the savings to the injured party. One company may charge $1,000 while another charges $2,000. However, asking for the average savings in medical/pharmaceutical costs and savings on the MSA funds tells the real story of the ‘costs’ to the injured party over the long term. If a company does not track this information or won’t provide it upon request, that should serve as a red flag.

- The vast amount of medical and other personal information provided to a professional administrator must be protected. Find out what, if any steps the company takes to protect members’ information, whether they undergo routine technology and financial audits, and if they are HIPAA compliant.

Customer service. The relationship between the injured party and the professional administrator is lifelong, so it’s important to know all questions and concerns will be taken seriously and addressed appropriately. Find out if and how the organization measures its customer service, such as through surveys of members. Talking with existing members is also a good way to determine the quality of a company’s customer service. The company should be willing to provide references and a look at a survey of members, if they exist.

Technological convenience. Many people want to be able to get information online. Some professional administrators provide easy-to-access information, such as funds spent/remaining, names/addresses of providers, medications prescribed, recent visits, analyses of spending and savings, etc. On the other hand, some people are not comfortable with doing everything via phone/tablet/computer and should have the option of a phone number to call with their questions.

Additional services. Professional administrators should have partnerships with many other experts that can help with post-settlement issues. The company should be able to provide lists of additional services, and experts offered.

Conclusion

A well-run professional administration company is an invaluable asset for an injured party who settles his claim. Those that have the most experience and expertise not only help these workers post-settlement, but their inclusion in the process often helps move claims to settlement more quickly.

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 the founder & lead trainer of Amaxx Workers’ Comp Training Center.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Professional Administration

Ergonomic Self-Assessments Reduce Injuries Among Office Workers

October 21, 2019 by Michael B. Stack

Keeping workers comfortable can reduce costs for employers/payers. The more a worker experiences discomfort, the more likely she is to develop musculoskeletal pain and injuries.

Low back pain, one of the most common reasons for lost workdays, may be due to an improperly adjusted workstation. Improper chair heights, constantly reaching for the mouse, and holding a phone handset between the head and shoulder takes a toll on the body after long periods of time.

Making a few simple adjustments can have a tremendous impact on improving employees’ health and wellbeing and reducing workplace injuries. But many employers and even the workers themselves don’t realize the long-term effects of improper workstation ergonomics. However, easy-to-use tools are available that can have a significant positive impact.

Common Ergonomic Problems

Sitting in the same position for long periods of time, especially with awkward postures of the head, neck, and upper limb can cause pain and injury. One study showed that workers often use poor positioning that can lead to discomfort and musculoskeletal disorders. For example,

Armrests were used improperly or not at all. Instead, many workers rested their arms on the desk, which can lead to elevation of the shoulders and increased tensions in the neck, shoulders, and trapezius muscles. They also sit forward in their chairs, instead of getting lumbar support, which can cause pain, especially if workers are in this position for more than four hours at a time.

Monitors are often placed too low, forcing a flexion of the cervical spine.

A mouse that is not aligned with the shoulder, as is often the case, forces the shoulder in abduction, which has been associated with musculoskeletal symptoms of the neck and upper limbs. Long use of the mouse can cause musculoskeletal disorders in the neck and wrist.

Workers who use desktop phones typically did not have headsets available, forcing them to hold the phone between their heads and shoulders, causing strain on the spine and shoulder. Workers who text may develop hand and wrist discomfort if the forearm is not properly supported.

Self-Assessment Ergonomic Fix

Office workstations come in a variety of styles and typically allow for multiple adjustments. Proper ergonomics ensure the worker is comfortable and not putting himself at risk of pain or injury.

One tool increasingly being used allows the worker to see how well he is or is not ensconced in his workstation; in terms of his posture, the height of the equipment, the reachability and other factors.

Called Rapid Office Strain Assessment (ROSA), provided by MyAbilities, it enables the worker to conduct a reliable self-assessment and provides self-guided training to make sustainable office ergonomics changes, based on the latest in ergonomics research.

ROSA consists of a video and diagram-based checklist that can quickly quantify the exposure of workers to risk factors in office workplaces, and provide users with immediate risk levels and intervention strategies. Each ‘page’ of the checklist corresponds to a particular risk factor. The worker clicks on the most appropriate box for each. Based on the responses, a score is calculated that identifies whether the worker is at high or low risk for injury.

Chair.

- The ideal is such that the worker’s knees are at 90° and reach the floor. The worker checks the most appropriate box, such as:
  - Knees at 90°
  - Chair too low — knee angle < 90°
  - Chair too high — knee angle > 90°
  - Chair too high — feet don’t touch the ground
- Insufficient space under the desk for worker to cross his legs
- Chair height is not adjustable
- There should be 2-3” (one fist) between the edge of the chair and the knee. The boxes question if the seat pan is too short, too long, or not adjustable.
- The elbows should be at 90°, and the shoulders relaxed. The boxes question the armrests’ height, width apart, and adjustability.
- There should be adequate lumbar support so the recline is between 95 – 110 degrees. Questions in the boxes pertaining to the angle of the backrest, and whether there is adequate – or any – lumbar support.

Monitor

- The monitor should be positioned so the top is slightly below eye level, and the head is in a neutral position. Questions related to the height level as well as glare and the presence or lack of documents holders.

Mouse

- The mouse should be in line with the shoulder, and the wrist kept straight. The assessment questions whether the mouse is positioned too far away from the body, the pinch grip, and whether it is located on the same or a different surface from the keyboard.

Keyboard

- The wrists should be straight while typing. The questions pertain to the height and positioning of the keyboard.

Phone

- This should be accommodated via a headset or held in one hand. Questions ask about hands-free options and how far away it is located.

A score for each element is tabulated depending on the worker’s answers, and a final, overall score calculated. On the scoring of 1-10, anything over a 5 is considered a high-risk factor for MSDs and suggested for tweaking.

The final report includes assessments and recommendations for adjustments to reduce the risk. These reports, and the recommendations contained within them, have proven to reduce discomfort in office workers. All of this is possible without the use of new office equipment – just adjusting the existing furniture.

Conclusion

ROSA is one of the simpler and less expensive tools to enhance ergonomic appropriateness for office workers. One of its advantages is that the worker himself can experience how a simple adjustment increases his comfort, thus increasing the likelihood he will adhere to the change.

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Return to Work and Transitional Duty

Dispute Questionable Workers Comp Claims

October 16, 2019 by Michael B. Stack

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

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

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

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

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

Retroactive denials of primary liability and other considerations

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

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

Dealing with injuries that are not proportionate to the work injury

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

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

Dealing with the “illegitimate” claim

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

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

Conclusions

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

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Causation and Compensability

Ensuring TPA Quality Control of Adjusters

October 15, 2019 by Michael B. Stack

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

Multi-level Screening and Training Requirements

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

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

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

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

Other Quality Control Requirements

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

Reviewing a candidate’s credit history;

Criminal background check; and

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

State and federal laws may apply to this process.

Commitment to Continuing Education Required

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

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

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

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

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

Roundtable for High Exposure Claims: “Roundtable” is used to discuss the claim with senior adjusters, managers, and the employer. If a significant exposure is identified, the file should be assigned to a senior-level adjuster. The roundtable can also be used to brainstorm the file and come up with ways to limit exposure.

Conclusions

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

Contact: mstack@reduceyourworkerscomp.com.

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

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

Filed Under: Claim Management

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

October 14, 2019 by Senior Editor

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

Step into My World – The Life of a Claim Handler

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

What do you know about the injury details?

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

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

Who was injured?

Did the worker tell someone?

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

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

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

Just the Facts Ma’am

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

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

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

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

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

The Devil is in the Details

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

Avoiding Spoliation of Evidence – Saving Money through Subrogation

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

Conducting a Complete and Accurate Investigation

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

Conclusions

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

Amaxx LLC is a workers’ comp educational company focusing on cost containment systems to help employers reduce their workers’ comp costs by 20% to 50%. Amaxx offers Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is the Certified Master of Workers’ Compensation designation through the Amaxx Workers’ Comp Training Center.

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

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

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

Filed Under: Claim Management

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