Work Comp Roundup

Fentanyl in Workers’ Compensation – 4 Ways to Keep Injured Workers’ Safe

February 26, 2019 by Michael B. Stack

Fentanyl is 100x stronger than morphine. Carfentanil is 100x stronger than fentanyl. For injured workers who become addicted to prescribed opioids, that can be a death sentence.

Armed with information about the latest illicit drugs and a willingness to adopt certain strategies, payers can ensure their injured workers get the most appropriate treatment and avoid becoming victims of the latest drug nightmare.

Heroin, Fentanyl, and Analogues

The dangers of unnecessary opioid use have been well documented and publicized for several years. To its credit, the workers’ compensation has been at the forefront of efforts to stem what has become a national crisis. But often overlooked are injured workers who already are, or become addicted to these prescription drugs and turn to the illicit drug market for relief.

Opioid prescribing dropped by nearly 9 percent in 2017, according to some accounts. However, some injured workers who were already addicted turned to heroin, leading to fatal overdoses from that drug. More recently, additional drugs have taken over the market, many of which are far more potent than opioids.

As described in It’s Not Just Heroin Anymore, a white paper from myMatrixx, synthetic opioids such as fentanyl have risen on the black market, mainly due to economics. Where heroine requires growing the opium poppy plant, harvesting the resin and processing it into the final product, fentanyl is purely synthetic, meaning it can be made easily and cheaply.

“Fentanyl is 50 times more potent than heroin and 100 times more potent than morphine,” according to the research paper. “Even more alarming, however, is the fact that there are compounds with molecular structures closely similar to fentanyl (analogues) that are drastically more potent and these are now making their way into the hands of drug addicts.”

Illicit makers of fentanyl have found in analogues a way to circumvent the regulations of the Controlled Substances Act. The CSA classifies substances based on their chemical identity. Since the fentanyl analogues are not on the list as identified controlled substances, they, technically, are not illegal substances.

There are 4 fentanyl analogues that are legal for medical use, including:

Carfentanil, only for veterinary use, it is normally dispensed as an elephant tranquilizer. It is 100 x stronger than fentanyl. myMatrixx notes it has been linked to increases in overdoses in the Midwest in particular.
Sufentanil
Alfentanil

Other analogues of fentanyl are Schedule I under the Controlled Substances Act.

What to Do

Most people prescribed opioids do not become addicts; however, anyone can develop an addiction. That is why it is imperative for workers’ compensation stakeholders to take every precaution to prevent addiction and address it appropriately in injured workers affected.

Here are ways payers can keep their injured workers safe:

Educate providers. Despite their good intentions, some treating physicians are not trained in dealing with pain and/or opioid prescribing. They may also not follow evidence-based guidelines. Payers who develop solid relationships with network and/or area physicians can work with them and make sure they understand how to mitigate the risks.

For example, providers should know to:

Avoid prescribing opioids as a first line therapy
Screen patients for addiction before starting opioid therapy and continuously throughout treatment
Conduct urine drug screenings to monitor compliance
Be aware of, and adhere to formulary restrictions
Watch for, and address aberrant behavior
De-escalate or discontinue opioid therapy when necessary

Provide strong clinical oversight, of physicians and pharmacies. Working with a pharmacy benefit manager and/or carrier is a place to start.
Ensure providers are aware of alternative therapies to opioids and encouraged using them
Intervene when there are concerns of opioid overprescribing. Having another physician talk with the provider can be effective. Insurers and/or third-party administrators often have medical personnel available to help.

Summary

The opioid crisis within the workers’ compensation system has improved in recent years. However, it is far from over. Stakeholders should stay up-to-date on the latest issues surrounding the problem and take steps to protect their injured workers.

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/

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: Prescription Drug Use & Abuse

5 Critical Pieces of Information to Confirm Following a Work-Related Injury

February 25, 2019 by Michael B. Stack

How to Execute A Bulletproof Workers' Comp claim

There is no time in a worker’s compensation injury claim more important than that time immediately following the injury to find out actually what the heck happened. Hello, my name is Michael Stack. I’m a CEO of Amaxx and today I want to walk you through the five critical pieces of information that you need to confirm immediately following an injury.

Employer Injury Report / Adjuster Recorded Statement

Now, this is either done by the employer when they’re filling out those forms. You’re going to get a certain piece of this information. But also then by the adjuster when the adjuster is taking their recorded statement. Let me run you through those five critical pieces of information that you need to confirm and lock down so that there’s no gray area later and you’re trying to put the puzzle pieces together and figure out what the heck happened when you could have just confirmed this right away when the information was still clear in everyone’s mind.

5 Critical Pieces of Information to Confirm Following a Work-Related Injury

Let’s talk about what these things are.

You need to confirm the mechanism of injury
If there are any witnesses there at the scene that saw exactly what happened,
What body parts were involved
If that individual injured worker has previous injuries or not,
And then finally who the healthcare providers are, who their primary doctor is, etc.

Let me run you through those again. The mechanism of injury. What and how did the injury occur. The witnesses. The body parts. What exact body parts were involved. Was it the elbow only? Was it the knee as well? Was it the hip? They landed on their back. What was involved and what was not involved. If there were any previous injuries and then if there were healthcare providers, what healthcare providers have they seen in the past, so that you can locate those medical records and get a lot more information on what exactly has occurred with this individual and injured worker, so you can make the right decision, which is what we’re trying to do here in worker’s compensation.

How to Execute A Bulletproof Workers’ Comp Claim Investigation

For more information on this, for more in-depth training on this, I have a fantastic new course. It’s called how to execute a bulletproof work comp claim investigation. I walk through these five things with our special guest Stewart Colborn, who’s a defense attorney out of Texas. It’s great in-depth training in how to do this and how to do it right out of the gate. You could check that out on a link below. Again, my name is Michael Stack. I’m the CEO of Amaxx. Remember your work today in worker’s compensation can have a dramatic impact on your company’s bottom line, but it will have a dramatic impact on someone’s life. So, be great.

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

Contact: mstack@reduceyourworkerscomp.com.

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

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

Record and Document Even Minor Work Injuries

February 19, 2019 by Rebecca Shafer, J.D.

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

Why Document Minor Injuries

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

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

Put A Copy in Personnel File

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

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

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

Contact: RShafer@ReduceYourWorkersComp.com.

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

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

What Is Likely The Problem With Your Work Comp Program

February 18, 2019 by Michael B. Stack

It was late one March evening and a taxicab going over 115 miles per hour smashes into the back of a police car. Instantly setting that car on fire, and the officer was trapped inside. Hello, my name is Michael Stack, I’m the CEO of AMAXX.

Burning Shield – Jason Schechterle

This past week I spent several days at the annual meeting of the settlement planning organization Ringler, he’s one of the partners on my website here at Reduce Your Worker’s Comp. Now it was a great couple of days spent networking and learning and sharing ideas, but one of the highlights of that conference or of that meeting was the keynote presentation given by Jason Schechterle, who was the officer who was inside of that car hit by the taxicab. Now Jason experienced severe burns on his face, his neck, his head, and over 40% of his body. He underwent over 50 surgeries to recover from that event. His message was powerful in his keynote presentation, and the book that he wrote called the Burning Shield. I recommend checking it out.

Accountability In This Life

Jason’s message had a lot to do with taking an honest look at our circumstances, and taking accountability for where we stood and what happened. There were so many powerful lessons and inspiring keynotes that he gave throughout the course of that presentation. The one that struck me the most went like this, he said good or bad, we have an accountability in this life. Why me is not a question is not a question we can ask. He said good or bad, we have an accountability in this life. Why me is not a question we can ask. Good or bad, we have an accountability in this life. Why me is not a question we can ask. That lesson and that sentiment is so applicable to so many areas of our life. Today we’re gonna talk about how that applies to your work comp program.

You Are Likely Looking At the Problem

What I see so often, particularly from employers, is that we want to blame everyone else. It’s the adjuster, they have too high of caseload. It’s that stinking doctor, he’ll never release my employee to work or that case manager’s not getting it together. Or my attorney, he’s a real pain in the butt or she’s a pain in the butt. Or that investigator, if that investigator would just have done their job we wouldn’t be in this mess that we’re in right now. It’s such a common sentiment that we feel in our work comp programs, and generally within our own lives. Per Jason’s lesson, we need to think about how that applies to our lives, and how that applies to our work comp programs as well. Because when you wake up in the morning and you’re looking in the mirror, you need to realize that you’re likely looking at the problem.

Again my name is Michael Stack, I’m the CEO of AMAXX. Remember your work today in worker’s compensation can have a dramatic impact on your company’s bottom line. But it will have a dramatic impact on someone’s life. So be great.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://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: Structured Settlements

Ten Light Duty Work Ideas

February 14, 2019 by Rebecca Shafer, J.D.

So you have decided to provide some light duty or transitional work for injured workers to decrease wage loss expense. First of all, congratulations! This is the first step in decreasing claims costs. The wage expense in a comp claim is most usually the biggest cost, and any chance you have of decreasing that cost should be taken. But what should the workers do? What if they do not follow the rules and get hurt again? What if this light duty work hinders the rehab and recovery?

These are all common issues and concerns. But there are ways to work around them with jobs that already in the workplace for these workers to do. Jobs that are no more or less strenuous than anything else they do on a daily basis while out of work. If stumped for ideas as to where to start, use this information, and then further customize your jobs based on the building blocks we list below. These will not apply to all areas of every employer, but at least it offers possible job ideas.

Janitorial tasks

Although not glamorous, janitorial tasks are a much-needed function of the workplace. A broom is not heavy so sweeping the floor and back storage areas are not only sanitary but can also reduce risks for slips and falls due to debris. Maybe wiping down machines and making sure they are in proper working order is a job the injured party can do based on their level of experience. With winter looming, salting entryways and making sure rugs and mats are in good shape and in good working order is a must to prevent falls. Mopping could also be done, but it can involve lifting and twisting with a wet, heavy mop, so make sure your worker is capable of that before you assign that task to them. The goal is to have them working with light materials and prevent exertion that can cause further injury.

Maintenance tasks

There may be a lot of jobs around the shop that are not done on a regular basis. Oiling machinery will increase the performance of the machine, as will changing belts, cleaning guards, checking saw blades, or cutting surfaces.

The tasks are not limited to only machinery. Light painting can freshen and improve the look of the work floor. Replacing broken faucets, light bulbs, cracked mirrors, or repairing/caulking windows that may be not closing properly can also help. Checking outlets for proper power wattage is another one. Go out on the floor and ask workers what needs to be done or what is not working properly and make the injured worker a “to-do” list. There may not be enough work for them to last weeks, but at least it gets them back to work and doing something while in recovery mode.

Office tasks

These jobs can include answering the phone, taking sales orders from clients, copying materials for files, or scanning paperwork for example. Ask the office staff about any upcoming projects and what needs to be done they have been putting off for a while. Chances are there are some sedentary work tasks available and needed, and this is a perfect task for your injured worker to do. That way a fully functional worker without work restrictions can focus on more important tasks, or jobs that are more strenuous in nature.

Inventory

A lot of employers carry a certain level of inventory for workplace needs. Obviously, the amount of inventory being carried depends on the type of workplace. But if you have the need, this is another light task the injured worker can do. Taking proper inventory and ordering more supplies is also another task to cross off your own to-do list. Have the injured worker tally up what is currently in stock, what needs to be ordered, and when it should arrive before supply runs low. This is also a good time to have the worker shop and price supplies. You might be able to find another vendor that can provide a better supply for a lower price. This way not only gets the injured worker back to work, but the employee is also saving you money in the long-term.

Job supervision and reporting

If the injured worker is unable to do the normal job, maybe the employee can still go out on job sites and help the other workers. Not only supervise the overall job, but the worker could also assist in gathering light materials needed for the job. If the work involves ladders and scaffolding, have someone on the ground to help the other workers, so they do not have to go up and down the ladders repeatedly to fetch materials or tools.

The injured worker also can report back like how the job is going so far, and recommend any changes or needed materials for the job site. This will keep the job running on time for completion, and it is just another task that nobody thinks of until the issue arises. You stay on top of the job status, and if certain recommendations are suggested and implemented, maybe that job is completed sooner than expected, resulting in a happier client.

Performance reviews

If there is a management member out of work due to a claim, maybe now is a good time to bring them in to do annual performance reviews. This way they can pull all the personnel files on the workforce, review them, get updated feedback from other supervisors on what the current performance is like, and then sit down with the employee to conduct a review and suggest improvements. Again this may not supply the injured workers with weeks and weeks of work, but at least it is something that needed to be done. And if you have the right candidate to do it then it makes sense to have that person complete the task.

Security

A lot of larger employers, such as grocery stores and retail businesses, have in-house surveillance cameras. The injured worker can monitor the day to day surveillance, clean up messes or spills, rotate product, place shelf signs, or any other light task that may need to be done. Theft prevention can also be addressed; however, you do not want the injured worker trying to apprehend anyone and get injured again.

Accounts payable/receivable

Another sedentary job is shifting the injured worker over to helping with accounts receivable/payable. Your business probably has vendors to pay, and you also may have clients that have outstanding invoices. Have the worker take over the books, and see if they can collect payment on some of the invoices that have not been paid. Sometimes a faxed invoice to a client followed up by a phone call is all it takes to get the invoice paid. This task will clean the books up, and make the company current with payments that are coming in and going out all the time.

Assign a helper

If the injured party has restrictions but can still do most of the job, assign an entry-level helper to go along and do the tasks that they cannot do. This provides the newer employee a chance to learn more about the business and job duties, and it allows the injured worker to keep doing the normal job, now with the assistance of a helper

Reach out to the injured party for ideas

When you just cannot think of anything for the injured worker to do, reach out to them and see what ideas the employee has. The incentive for the worker is the chance to return to work, and maybe make the normal pay instead of collecting reduced wages on workers comp. Sometimes great ideas are suggested. So keep an open mind, solicit some ideas from them, and try to do what you can to implement those job ideas.

Summary

Trying to create jobs for injured workers can be a difficult task. But with an open mind and some creativity, get injured workers back to work. Not only does this cut down on the workers’ comp expense but it also can complete some overdue tasks. Put some thought into it, and ask others around the workplace for ideas. Together you should be able to come up with a list of tasks that need to be done. Every dollar saved on wage loss will count in the end. Keep track of the cost of having these workers come back to light duty work, and weigh it against the cost of keeping them out of work, only returning at full duty. You will be surprised at the cost savings of implementing a light duty work program.

Contact: RShafer@ReduceYourWorkersComp.com.

Workers’ Comp Roundup Blog: https://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

Evaluating Medical Evidence to Make Better Workers’ Comp Decisions

February 13, 2019 by Michael B. Stack

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

Evaluating the Medical Evidence from a Physiological Standpoint

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

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

Making the Right Assessment

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

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

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

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

Does the overall medical evidence as presented fit the alleged injury?

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

Application in Claims Handling Practice

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

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

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

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

The list of possibilities is really endless.

Conclusions

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

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://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 Cost Containment

WCRI’s Annual Workers’ Comp Conference Features Latest Research and Efforts to Address Opioid Epidemic

February 12, 2019 by Senior Editor

With more Americans dying from opioid overdoses than car crashes, the Workers Compensation Research Institute (WCRI) is devoting a session at their upcoming 35th Annual Issues & Research Conference to discussing the latest research and efforts to address the opioid epidemic. The conference is taking place February 28 and March 1, 2019, at the Renaissance Phoenix Downtown Hotel in Phoenix, AZ.

“The dangers of prescription drug misuse resulting in death and addiction constitute a top public health problem in the United States,” said WCRI CEO John Ruser. “We believe this session, which combines research and what is happening on the ground, will be of great value to our audience.”

During this session, WCRI’s Vennela Thumula will present the Institute’s latest research on correlates of opioid prescribing to injured workers, which can help public officials and other stakeholders better predict which injured workers are more or less likely to receive opioids. Next, Letitia Davis with the Massachusetts Department of Public Health will discuss the results from a recent study they published on factors that may contribute to differences in the rate of opioid-related overdose deaths among workers in different industries and occupations. Then, Jacqueline Kurth and Jason Porter of the Industrial Commission of Arizona will discuss efforts taken by Arizona Gov. Doug Ducey and the Commission to address the opioid epidemic in their state.

The theme of this year’s conference is “Breaking Down Barriers to Improve Injured Workers’ Outcomes.” It will feature the latest research from WCRI, engaging sessions on the latest trends, and examples of industry stakeholders coming together to tackle some of the system’s most important challenges. The following are a few of the session titles:

Challenges and Opportunities of Telemedicine
From Washington State to Washington, D.C. – a Model for Returning Injured Workers to Work
Group Health Deductibles and Workers’ Compensation
Has There Been an Erosion of Workers’ Compensation Benefits?
How Unions and Management Can Create Successful Return-to-Work/Stay-at-Work Programs
Moving the Needle: Innovative Employer Ideas

The WCRI conference is a leading workers’ compensation forum for policymakers, employers, labor advocates, insurance executives, health care organizations, claims managers, researchers, and others. Conference participants will leave with new insights, valuable networking contacts, and a better understanding of key issues in today’s competitive environment. To learn more or to register, visit https://conference.wcrinet.org.

The Cambridge-based WCRI is recognized as a leader in providing high-quality, objective information about public policy issues involving workers’ compensation systems.

About WCRI:

The Workers Compensation Research Institute (WCRI) is an independent, not-for-profit research organization based in Cambridge, Massachusetts. Since 1983, WCRI has been a catalyst for significant improvements in workers’ compensation systems around the world with its objective, credible, and high-quality research. WCRI’s members include employers; insurers; governmental entities; managed care companies; health care providers; insurance regulators; state labor organizations; and state administrative agencies in the U.S., Canada, Australia, and New Zealand.

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Filed Under: Workers Comp News

Quick Claim Reporting – The Workers’ Comp Silver Bullet

February 11, 2019 by Michael B. Stack

Nearly every claims management team is looking for the silver bullet to cure all their workers’ comp issues. Many vendor services will claim to be this solution, but there is only one that doesn’t cost any money – quick claim reporting.

The origins of the term “silver bullet” is derived from Philip of Macedonia (the father of Alexander the Great), and the belief the element contains magical properties that can kill just about anything, including supernatural beings. It later gained fame in American folklore in the 1930s with the tales of the Lone Ranger – who used silver bullets to dispense justice in the Wild West.

Like the Lone Ranger, members of the claim management team are charged with the responsibility of pursuing justice as they manage claims. This includes educating clients on best practices to improve program efficiency and reduce costs.

Remove Quick Claim Reporting Barriers

The failure to report a work injury remains a barrier in many programs. This is driven by the concern employers have when filing claims – they fear negative changes to their “experience rating modification.” The result will be increased premiums or losing coverage, and being forced into a state’s assigned risk plan pool.

When educating employers on the claims process, it is important to reiterate the following points and encourage prompt reporting of all work injuries:

Statutory requirements an employer purchase insurance. Do not be afraid to use it. Insurance is a necessary cost of doing business;

Highlight your program’s claim management toolbox. This includes post-injury response, return-to-work/transitional job placement, medical cost containment and medical care coordination. Prompt investigation and reporting of fraud, waste, and abuse are also important; and

Education on reporting requirements. This should include information on how prompt reporting of work injuries can reduce penalties by a state industrial commission, which in turn impacts your workers’ compensation insurance premiums.

Impact of Late Claim Reporting

There are many significant problems caused by late reporting in the workers’ compensation process. Effective members of the claim management team can serve as a resource when it comes to this process. This starts with encouraging employers to report their known claims in a timely manner.

Penalties: Industrial commissions generally monitor all required filings and the compliance department will issue penalties according to statute or rule. Most jurisdictions place an emphasis on the timely reporting of claims and prompt payment. This includes a graduated penalty system will impose sanctions on the insured and insurer when reporting is not done. The fines increase based upon the frequency of late reports, including the First Report of Injury, and late payment of workers’ compensation benefits to the employee; and

Increased claim costs: Studies from the National Council on Compensation Insurance (NCCI) demonstrate delayed reporting increases costs to a program in other ways. According to this report, the median cost of a workers’ compensation claim increased dramatically if it was not reported within two weeks from the date of the injury – generally an increase of up to 51%. These claims were also found to be subject to more litigation, which included the use of an attorney. The report also determined quicker reporting allows for a better and more complete investigation.

Improved Claims Investigation Techniques

An effective investigation of any work injury must start with the employer. This includes preserving the accident scene, making sure the injury is documented correctly and evidence is not destroyed. From a claims management perspective, this can be frustrating as claim handlers are not included until after the fact. They can be proactive in promoting efficiency by helping their client’s in order to do a more complete job.

Make sure all employees receive immediate and first-class medical care and treatment following an injury – even if it only includes the proper cleaning of a wound and dressing it to prevent infection;

Preparation of work injury investigation kits. Items in these kits should include forms to document the injury, checklists to make sure all relevant information is is logged correctly and reminders to preserve evidence. Taking photographs is often a must; and

Preservation of evidence. This can include defective equipment or documentation of floors, stairs or work This can matter when it comes to subrogation efforts down the road.

Conclusions

Members of the claims management team should use the “silver bullet” of quick claim reporting to drive down program costs and provide outstanding service. Part of the process must including educating all interested stakeholders in the workers’ compensation system to identify areas of improvement. By taking these steps, a program can be cost-effective and efficient.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://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: Management's Role in Workers Comp

Dealing with Chronic Pain in Workers’ Compensation

February 7, 2019 by Michael B. Stack

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

Understanding Chronic Pain

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

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

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

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

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

Reasonableness and Necessity of Care in Chronic Pain

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

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

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

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

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

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

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

Conclusions

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

Contact: mstack@reduceyourworkerscomp.com

Workers’ Comp Roundup Blog: https://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

Steps to Optimize Medicare Set Asides Before — and After — Settlement

February 6, 2019 by Michael B. Stack

Most workers’ compensation practitioners agree: Medicare Set-Asides can be a pain in the neck. It takes time, resources and skill to create an MSA. In addition, any snag could result in a loss of money — for the injured worker as well as other parties involved.

The myriad of moving parts and high chance for error, along with getting approval from the Centers for Medicare and Medicaid Services are the reasons a specialized industry has arisen around MSAs as well as other components to Medicare Secondary Payer compliance. By understanding such things as when, how, and where to get an appropriate MSA and ensuring post-settlement assistance is available for reporting and follow-through, stakeholders can settle more claims and feel confident they are doing the right thing for injured workers and other parties involved.

MSA Realities

Here are a few sobering, post-settlement, realities from a professional administrator that demonstrate why MSAs cause angst to so many:

There were 51% more phone calls from Medicare on MSA administration in 2018, compared to 2017
Medicare inquired on virtually 100 percent of lump sum MSA exhaustions
Medicare checked in on 1-out-of-every-3 structured settlement exhaustions
CMS is adding more technology and getting smarter about compliance every year, especially with the post-settlement administration of the MSA.

In other words, don’t expect the government to ease up on ensuring Medicare’s status as the secondary payer in workers’ compensation cases anytime soon. Quite the opposite is happening as Medicare becomes more intent on not only ensuring the MSA was accurately put together but that the funds are spent appropriately.

MSA Q&As

Here are appropriate questions you need to ask and what to look for.

When is the right time to obtain an MSA?

When an injured worker has reached maximum medical improvement. Someone who is about to have or just had surgery, or is changing medical providers is not an appropriate candidate because his medical situation is likely to change. The injured worker should have his medications and treatment stabilized.

How can MSA amounts be deemed sufficient for the injured worker but not excessive?

You want to make sure the injured worker has the funds he needs to live out a fulfilling life, but don’t want to spend unnecessary dollars. This requires working with an MSA partner willing to take a deep look into the injured worker’s situation, now and in the future. There may be some projected treatments and/or medications that are inappropriate and unnecessary. Things to consider are:

Generic alternatives to medications
Potential overuse of opioids
Inconsistencies between medical records and prescription drug history
Whether authorized medications are still being prescribed or used
Medications that are unrelated to the occupational injury
Planned surgery that the injured worker does not want or need
Estimated costs for surgeries and other treatments that may be unrealistic
Frequency of physician visits
Rated age/life expectancy
Evidence-based medicine; to ensure it is being followed

What is clinical intervention and why is it important?

Identifying and clarifying these and other issues takes leg work. The MSA vendor must be willing and able to work with treating physicians and others to get the correct answers, as these are key to both saving money and protecting the injured worker.

This may include

Physician follow-up
Clinical oversight
Peer-to-peer review, where another physician is brought in to work with the treating physician
Addressing inappropriate care — another area where peer review is advantageous

There are situations, for example, when a particular medication is listed as being current but is no longer being prescribed. The solution is to have both the injured worker and the treating physician write statements specifying the date the medication ceased to be prescribed or used.

Another typical example is when a treating physician had discussed a specific treatment — such as a spinal cord stimulator, but later determined it was not necessary. The cost of a spinal cord stimulator can be in excess of $150,000. In that case, the MSA partner should seek a statement from the treating physician confirming the treatment is no longer necessary or reasonable.

What are indications of an effective MSA partner?

When considering organizations for partnerships, facts and figures tell the story. Some to look for include:

CMS MSA approval rate
Percentage of MSAs with prescription medications, especially opioids
Percentage of cases settled
Savings from clinical interventions
Rate of development letters
Average MSA approval amount

“These metrics determine the success or failure of an MSA program in limiting allocation amounts and facilitating settlement,” says Dan Anders, Chief Compliance Office of Tower MSA Partners. “Your MSA partner should be using these key performance indicators to drive the outcomes you want to see.”

Post-Settlement MSA Support

Just because the MSA has been developed and approved by CMS and the claim settled, does not mean things cannot still go wrong. Complying with CMS requirements — including reporting duties — is crucial. That’s why it’s just as important to have a post-settlement strategy set up before the claim is settled. If the injured worker unintentionally fails to adhere to CMS guidelines and the money runs out —

They jeopardize their future Medicare benefits
They may be forced to reimburse all the money that was misspent, up to the full settlement amount
Their attorney(s) and/or others (including the adjuster/payer) may also be pulled back into the case, which can cause unnecessary burdens and work on everyone involved

Those in the best position to ensure things go smoothly after the settlement are professional administrators. These are neutral, third-party experts who handle all compliance and annual reporting for MSAs. Additionally, professional administrators establish a bank account for the injured worker’s future medical care and act as custodian — receiving the medical bills and paying them on behalf of the injured worker.

“There are a lot of things that happen in the settlement process that could confuse an injured worker,” said Marques Torbert, CEO of the leading professional administration company, Ametros. “Injured workers are worried about getting better. A professional administrator makes sure the injured worker has a support system and access to savings and support post-settlement while helping to keep them in compliance.”

A professional administrator should have extensive physician and pharmaceutical networks, which results in cost savings for the injured worker and extends the life of the MSA. Top-notch professional administrators demonstrate significant cost savings for injured workers while also protecting Medicare’s interests by maintaining the viability of the MSAs account over those workers’ lifetimes

Average Savings From Top Professional Administrator

63% on provider bills
28% on other medical expenses
50% with bill review adjustments

Many advocates for injured workers are finding that bringing in professional administrators during the settlement process can be extremely valuable. Because they are neutral third parties, they can serve as mediators for competing interests; such as carriers, and plaintiff and defense attorneys.

“Bridging the gap to settlement can sometimes be difficult,” says Torbert. “At the end of the day you have several stakeholders at the table, the only party that stays with the injured worker well after the settlement is the professional administrator. Being able to show the injured worker that they will be taken care of can help all parties come to a resolution.”

The benefits of professional administrators are such that CMS itself last year “highly recommended” injured workers consider using them for MSA administration.

Conclusion

Injured workers who have been in the workers’ compensation system for long periods are often hesitant to settle their claims due to fears of running out of money. An improperly developed or utilized MSA is one of the main reasons that fear can come to fruition. Having the right partners involved brings peace of mind to injured workers, as well as all parties involved in settlement.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://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)

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Dealing with Chronic Pain in Workers’ Compensation

Steps to Optimize Medicare Set Asides Before — and After — Settlement

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