Work Comp Roundup

Catastrophic Claims Handling Part 2: Team Approach, Preserve the Scene

October 31, 2018 by Michael B. Stack

Handling any workers’ compensation claims can be a challenge, but it is especially the case in catastrophic claims handling for workers’ comp’s most serious injuries. These claims can ruin lives and incur many millions of dollars in costs. Everything done to manage a claim becomes that much more critical when a severe injury is involved.

In addition to getting the right treatment to the injured worker as soon as possible and demonstrating care and concern for the employee as well as his family, it is also vital to investigate these claims as thoroughly and as quickly as possible. In addition to the best practices for claims handling, there are additional strategies that can ensure the best outcomes for employees, employers, and payers.

This article is Part #2 in Catastrophic Claims Handling Strategies, view Part #1 here.

Preserve the Scene

The cost and nature of catastrophic injuries is such you need to determine exactly what happened to cause the accident.

Was it a safety issue?
Did a machine malfunction?
Was it a guarding issue?
Was it a lack of adequate training?
Was it due to a vendor’s error?

The answer can make a significant difference in how the claim is handled – not from the injured worker’s standpoint but the claim itself. For example, if it is determined that a piece of equipment malfunctioned, the employer may seek money through subrogation. A training problem may signal the need for better and more frequent training. It may even turn out that the injury was not work-related. Such a determination can only be made by a careful, thorough review of the site and speaking with other workers.

While not a crime scene, all evidence surrounding the accident site should be kept intact to further aid in the investigation. That means not washing down the area – even if it is a gruesome scene. Any equipment that may have been involved should be roped off and made inaccessible to other employees. The employer should be instructed to keep all workers away from the area until it has been properly assessed by the claims adjusters and any other professionals who may be called in.

Team Members

Investigating a claim does not require the claims adjuster to be an expert on everything. But she must know where to get any information needed. A subrogation expert may be needed, for example, if it appears financial liability may be shifted to a vendor or equipment manufacturer.

Additional experts likely needed to fully vet the claim include:

Nurse case manager. This is typically the very first person the claims adjuster should contact upon receiving word of a severe injury. Some organizations have dedicated catastrophic nurses who specialize in these cases. The nurse can go to the hospital and meet with the various medical personnel to determine the extent of injuries, the prognosis and the care available at that particular facility.
Medical advisor. In addition to the NCM, a physician should be tapped to provide additional expert medical advice. If the worker has severe burns, the medical advisor may suggest transporting him to a burn center for more appropriate treatment, or a top-level trauma center rather than a community hospital. The physician should also obtain emergency room medical records on the injured worker.
Safety experts. Members of the safety department should be called in to help understand exactly what happened, why and how. These professionals can help decide what is needed to prevent another similar injury.
Home health expert. Once the worker is well enough to return home, decisions must be made about the viability of the home environment, whether modifications will be needed and if a care provider may be needed. The home health expert can work with the team to assess these needs.

Paying the Bills

Payers may be shocked when the first bills arrive on a catastrophic injury claim. There are typically up to 50 pages of itemized charges. These need to be carefully scrutinized to ensure only proper payments are made.

There are companies that specialize in this service. They typically charge a flat fee, then handle all the bills.

For companies that undertake the bill review process on their own, the medical provider can help determine if the charges included are accurate. There are a couple of points to consider:

Were all services included conducted? Because of the extent of items on the bills, you need to make sure you are charged only for those treatments that were done.
Were any elective treatments included? Services unrelated to the actual injury should not be included on these bills.

Conclusion

Handling a workers’ compensation claim that involves a catastrophic injury should be done with extreme care. You want to make sure the worker is well taken care of, and that the employer/payer is not paying unnecessary costs. The approach taken can be akin to doing a jigsaw puzzle, where the pieces ultimately fit together to form an accurate picture.

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

Catastrophic Claims Handling Part 1: Demonstrate Care and Investigate

October 30, 2018 by Michael B. Stack

Demonstrate Care & Establish Trust

Any injury that occurs in the life of an employee is disruptive, and even minor injuries can seem like major events. A serious catastrophic injury, by comparison, causes high stress, fear, and anxiety. Questions such as “will I ever work again,” “how will I support my family,” or “will I be able to walk my daughter down the aisle” are prevalent in the employee’s mind.

Demonstrating care and establish trust with the injured worker and their family is the highest priority item in your catastrophic claims handling plan. You need to establish that you are working together on the same team toward a common goal.

Visit the Hospital. Visiting the hospital is a non-negotiable requirement in a catastrophic claims handling plan. It serves as an opportunity to both give and receive information with the injured employee. You will express care and concern for the employee and ensure they understand and are comfortable with the process; as well as get a feel for the employee’s attitude, the kind of care received from the medical provider, and the prognosis.

Work with the Family. The injured worker’s family are typically the first people the adjuster or employer representative will see. They are likely scared for the injured worker and concerned about what is coming, how they will pay for medical care and other expenses, and how they will be able to juggle being with him and handling their daily routines. Leverage empathy and active listening to understand and meet the needs of the family.

It is critical to put yourself in the shoes of the injured worker and his family, to understand what they are going through and consider how you would want to be treated if it was your spouse or best friend. This leads to positive outcomes and prevents litigation.

The Investigation Elements

Investigating a workplace injury is, or should be routine for organizations. You want to find out what happened, how, when, where and why. Typically that involves things such as:

Talking with the injured worker
Identifying and taking statements from witnesses
Reviewing any available video – from the scene and surrounding areas
Assessing the accident scene

These actions may be a bit more complicated when a catastrophic injury is involved. Mistakes in the process can lead to unnecessary expenses and/or improper medical care. Properly investigating a catastrophic injury claim must be undertaken with the utmost care.

Carriers or third-party administrators often have specialized teams of experts available to conduct these and provide information to the claims adjuster. Each member of the team understands his responsibilities in collecting and saving information. In addition to the basic information needed, these professionals will get additional details, such as

When the employee arrived at work
When/where he was working when the injury occurred
Who was in the area at the time of the injury
Who, if anyone else was involved in the accident
What equipment was in the vicinity of the accident
Whether any machines malfunctioned
What actions were taken immediately following the accident/injury
How quickly the worker received medical care
When and where the worker was ultimately taken

The claims adjuster needs this information as quickly as possible before she questions the employer or the injured worker. The adjuster may either go to the hospital to meet with the worker and/or his family, or send a nurse case manager to the facility and go herself to the worksite first.

Those who have been conducting the initial investigation can meet with the claims adjuster once she arrives at the employer’s offices to discuss their findings. The adjuster can then take pictures and do a more thorough investigation before getting a statement from the injured worker.

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: Uncategorized

How Long Will My Injured Employee Be Off Work?

October 29, 2018 by Michael B. Stack

… We look at the work comp industry. What are the common questions that employers will ask when an employee is injured is how long is my employee going to be out. What is my expectation for how long they should be out, and then two, how do I know when they’ve started to go off the tracks?

Evidence-Based Medicine Injury Duration Guidelines

Today I want to introduce you or possibly re-introduce you to evidence-based medicine injury duration guidelines. There are two primary providers of this information in our industry. MD Guidelines and ODG Guidelines. Both credible sources of information and data that you can reference.

I want to walk you through an example here on the board. We’re going to talk about John who works in your warehouse. John’s job or part of John’s job is to lift 50 lb boxes, and he sustained a partial rotator cuff tear injury, which is the data that you see here on the board and this is provided by MD Guidelines.

Over here you can see the physical demands or the types of jobs from sedentary to medium to very heavy and heavy jobs. This is the expectation for recovery minimum, optimum, and maximum expected recovery time based on physician consensus of required physiological healing time. This is how long the body should heal based on this type of injury.

Example: Heavy Physical Demand Warehouse Position

Let’s take a look at this. Now, John’s 50 lb box lifting job would fall into this heavy category. You can see here that the optimum recovery time is 42 days. So even if I have no medical background or any medical training and you don’t have any medical background or any training in the medical field, you can look up this information and know very quickly it’s about six weeks that I can expect optimally that John should be back to his job. And it could be up to 85 days and it could be as low as just a couple of weeks here that he could be back to work, obviously based on a number of factors.

But this now starts to set your initial expectation just like that Google Maps app going somewhere you’ve never been, dealing with an injury maybe you’ve never dealt with before.

Now you also need to know when you’re starting to go off the tracks and so you look at John’s recovery time and now it’s clicking away and now you’re getting over here and you’re like, “Hey, what’s going on over here? Why is John not even close to recovering when the expectation should be that, optimally, you know, just within a couple of six weeks, you know, three, four, five, six weeks, he could potentially be back to work.” So what’s going on here? I’m off the tracks. My ETA has now gotten much higher than it was before. So it gives you that indication of when you’re off the tracks and potentially you need to work with your adjuster, work with your claims handling team, to bring in some other interventions to get back on the track and going in the right direction. Hugely valuable information to tap into and leverage to give you that information to make those appropriate decisions.

Common Mistake Employers Make with Injury Duration Guidelines

One last quick point I want to make here because I often see employers misinterpreting these numbers. Go back to this example of John. You say he’s going to be out six weeks. I’m not even going to think about bringing him back to work or expect he’s going to be back to work until this timeframe because that’s what the injury duration guidelines say.

I want to draw your attention up to here though. This is what transitional duty is all about. This is what late duty is all about. Sedentary and light jobs you should be able to get John back to work lickety-split within a couple of days even at the maximum required is four days. So within a couple of days, John should be back to work doing sedentary or light duty in a transitional duty type capacity.

When you do that, you’re going to angle John’s recovery time this way. When you leave John out of work and you don’t bring him back up here, you’re going to angle him this way and you’re going to probably end up being even further than maximum. When you get those people back to work right away you’re going to improve their recovery times. When you don’t, you’re going to make sure that recovery time is significantly longer, which as we know, anytime you see that ETA go up significantly higher when you’re driving, it’s not something you’re looking for and particularly in Workers’ Compensation. The impact of that is much greater. It impacts an individual’s life; it adds significant cost to your claim.

Again, I’m Michael Stack, CEO of Amaxx. Remember your work today and Workers’ Compensation, it 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: Return to Work and Transitional Duty

7 Strategies to Jump Start Workers’ Comp Delayed Recovery Claims

October 25, 2018 by Senior Editor

A company may have the best injury-management program possible, yet still, have claims that go south for no apparent reason. Sometimes called ‘creeping catastrophic’ these are claims that involve seemingly minor injuries that should heal fairly quickly and have the employee back at work in short order. For no apparent reason, these claims instead turn into long-term recoveries, with multiple treatments, surgeries, medications, along with exorbitant costs.

There are various reasons for delayed recovery claims. Typically, there are undetected psychosocial risk factors that come into play and render the injured worker unable to heal and return to function. Identifying, recognizing and intervening early in these claims is key to getting the worker back in action.

Delayed Recovery Claim Risk Factors

Chronic pain is the usual result of injured workers with psychosocial risk factors. For a variety of reasons, they have inadequate coping skills and develop persistent pain long after the injured tissues have healed.

Some of the more common psychosocial risk factors include:

Catastrophic thinking — a belief that the worst possible outcome is the most likely. The person feels helpless to deal with her pain and exaggerates the threat of pain sensations.
Fear avoidance/guarding behavior — the worker is unrealistically fearful of hurting himself more, so avoids almost all activity.
History of depression and/or anxiety
Perceived injustice — the person feels he has been unfairly harmed and assigns blame; to the employer, coworkers or someone or something else.
External locus of control — the worker believes someone other than himself can and must heal him, usually the medical provider. The person assumes no responsibility for his own

The worker’s pain persists, despite all medical efforts to heal the injury. These workers often end up having multiple surgeries. The medical provider who does not understand psychosocial factors are at play suggests a variety of treatments to cure the employee’s pain. This further exacerbates the worker’s external locus of control and legitimizes the person’s distress.

Workers with delayed recoveries often end up on a variety of medications, typically including long-term opioid therapy. And still, the pain continues and may even worsen.

Early ID/Intervention to Prevent Delayed Recovery

These claims often slip through the cracks; meaning the people managing them, as well as the employer and payer, fail to realize the extraordinary timeline and treatments that have been provided for many months or even years. By then, this ‘minor’ injury has turned into a long-term, expensive claim.

Flagging these claims as early as possible is essential to prevent them from rapidly deteriorating. There are a multitude of ways to identify these claims early in the process.

At least one company uses a pain screening questionnaire that has been shown to identify at-risk injured workers as soon as two weeks after an injury. Several insurers and pharmacy benefit management companies have developed programs to key in on at-risk claims fairly soon after an injury. A program that alerts stakeholders to potential problems with a claim is far superior to waiting until someone notices long after the claim has consumed a plethora of treatments and dollars.

Once a high-risk claim has been detected, those involved should intervene using a team approach. Ignoring it is not the way to go. The claim can be kept on track, but only if receives prompt and focused attention.

When psychosocial factors are involved, an approach other than biomedical must be undertaken. A biopsychosocial approach looks at the whole person, beyond just the injury itself.

Functional Restoration

An integrated system that involves several different disciplines involved has been shown to work well in delayed recovery claims. That may include, for example, physical therapy, occupational therapy, case management, psychology, the treating physician, and the injured worker and his family.

The team works in conjunction with one another and communicates among themselves and with the injured worker. Along with the person’s physical ailment, his psychosocial factors must also be addressed.

Among the interventions that are successful in treating injured workers with psychosocial factors are:

Pain education. Recent research has shown that pain, specifically chronic pain, causes structural and functional changes in the central nervous system. Rather than a sensation, chronic pain is a result of the person’s biology, psychological makeup, belief system about pain, and interactions with the environment.
Cognitive behavioral therapy. This is short term, typically involving a few weeks of sessions. It is goal oriented. Unlike long-term traditional psychotherapy, CBT teaches the injured worker different techniques to change his thinking and behavior, which ultimately teaches him how to cope with his pain.
Mindfulness training. Mindfulness meditation teaches the person to bring his attention to experiences in the present, rather than ruminating about his pain and injury.
This technique helps the worker gain more awareness of his physiological functions so he can ultimately control them. Instruments that provide information on the activity of certain bodily systems are used. People using biofeedback have been able to control their brainwaves, muscle tone, heart rate and pain perception.
Exercise/activity. Movement is one of the most effective treatments to help patients with chronic pain.
This can help the worker change his perceptions, thoughts and behaviors in guided practice.
Relapse prevention training. Strategies such as coping skills, the individuation of triggers for relapse, and self-monitoring techniques can help the injured worker stay grounded and avoid the negative thinking and behaviors that contribute to his chronic pain.

Conclusion

Workers’ comp delayed recovery claims represent approximately 10 percent of claims, but consume 80 percent of medical and indemnity costs. Too often they go unnoticed until they become nearly out of control. By understanding how to identify or recognize them early and intervening with proven techniques, the worker can recover and regain function.

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

Workers’ Comp Retraining: How to Review A Proposed Plan

October 24, 2018 by Michael B. Stack

Workers’ comp retraining claims made by injured workers can be expensive and time-consuming. When addressing retraining claims, it is important to members of the claim management team to evaluate the situation and make a reasoned response. This not only saves money in the long run, but promotes program efficiency.

What is Workers’ Comp Retraining?

Workers’ comp retraining is a vocational rehabilitation benefit available to an injured worker. In order to qualify, the employee usually is required to demonstrate they are not able to return to their pre-injury position and require additional education or instruction to achieve a wage comparable to their status prior to the injury. Permanent restrictions and attaining maximum medical improvement/need for future medical treatment are also important factors.

The benefits to an employee (and underlying cost to a workers’ compensation program) involve the following:

Payment for education or retraining to gain additional transferable skills. This is not limited to tuition at a school. It can also include the payment for books, materials, and other fees associated with a program; and

Wage loss benefits during the retraining period. The rationale for paying an employee additional wage loss benefits beyond what is otherwise required while they go to school is to allow them to focus on their education and not worry about other matters of concern.

Properly Evaluating a Workers’ Comp Retraining Plan

A workers’ comp retraining plan will outline the coursework the employee will undertake, along with the skills they will gain upon completion. It will take into consideration the types of positions available to the employee following completion of a program and likely wages. This is an expensive proposition and should not be taken lightly.

Factors to consider vary in each jurisdiction. Some common themes to review when evaluating a retraining plan should include:

The reasonableness of a plan compared to the employee’s ability to return to work with an employer through job placement services: Before retraining is considered, an injured worker should conduct some semblance of a job search. While this does not need to be exhaustive, an evaluation should be made as to whether the employee has sought work within their restrictions. This job search should also include a variety of different positions, and not necessarily within the area the employee was performing at the time of the work injury;

The likelihood the employee will succeed in the formal course of study as part of the retraining plan: The cost of any retraining plan, even if it involves a two-year course of study is expensive. Part of the review should examine whether the employee can complete the desired course. A careful evaluation of any proposed program should include the employee’s prior education, how they performed in the classroom and if an absence from a formal learning environment will result in failure. It may be necessary for someone with a minimal educational history to take remedial courses;

The likelihood as to whether the retraining program will result in reasonably attainable employment: This review should include a labor market survey of positions the employee will enter once they complete their retraining plan. Questions should be asked as to what jobs are open in the employee’s labor market and whether they will be around once the coursework is completed. While there are many unknowns given an ever-changing economy, this is an important factor to consider; and

The likelihood as to whether the retraining will produce an economic status as close as possible to that which the employee would have enjoyed without the work injury/disability: It is important to determine what wages an employee will realistically receive following completion of a course. Areas to examine include job placement services of the educational institution the employee will attend and how they are viewed in the marketplace. It is also important to determine whether the employee will be eligible for only entry-level positions, and how quickly they may advance.

Conclusions

Vocational retraining is an expensive benefit available to injured workers. Given the dynamics and exposures, it is important for proactive members of the claim management team to pay close attention to when someone is making a claim. This review includes various factors regarding their efforts to find work before making a claim, their chances of success and the end result. Failure to take these steps can result in unnecessary steps to any workers’ compensation program.

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

Use Workers’ Comp Basics to Attract and Keep Millennials

October 23, 2018 by Michael B. Stack

The workforce will change dramatically over the next 10 years. Regardless of the industry, many workers will be retiring in the next decade — if not sooner.

Attracting and keeping younger talent is imperative to maintain and grow an organization. Millennials, those born between the early 1980s and early 2000s are quickly overtaking the workforce. Therefore, it behooves companies to take steps that can make their organizations more attractive to these younger workers.

Many of the strategies that help prevent injuries and reduce workers’ compensation costs are the very same that will help companies get the best workers to position themselves well for the future.

The Culture

Research shows millennials are highly focused on making a difference in society, perhaps even more than on making money. They seek employers who share their ideals. Some of the ways employers can make their cultures more millennial-friendly include the following.

Offer Mentoring. Mentoring young employees is an effective way to provide support, as well as provide an open and inviting culture for new ideas and opportunities for organizational growth.
Soft skills — the ability to empathize and express compassion — are imperative for an effective injury management program. Employees who feel their employers are genuinely concerned about their wellbeing are more likely to engage in the recovery process. Studies show these workers heal and return to work sooner than employees who feel they are in conflict with the employer. In the same way, millennials are more likely to be attracted to, and want to stay with organizations that have a culture of caring.
Positive communication. Replacing negative terminology with positive messages may seem insignificant, but it can have a tremendous impact — on injured workers as well as millennials. For example, instead of telling an injured worker his claim was denied, rewording it to say the claim was not approved carries a different message — especially if the person saying it follows up with ways the worker can be treated; such as through general health insurance. Delivering ‘negative’ news to an employee should be worded in a way that still shows respect and caring for the worker.
Emphasis on safety. Employers want to prevent injuries; workers want to avoid getting hurt. Since the goals are the same for both, the idea of safety should be presented in a way that shows concern. Instead of dictating rules to workers and chastising them for not adhering to them, employers should communicate the reasons for safety rules with the overlying message that the company wants to protect its workers.
Simplify the message. If a new product or procedure is going into effect, it should be explained in as simple a manner as possible. Instead of inundating workers with pages and pages of unnecessary information, boil it down to the basics: what it is, why it is being implemented, and how and what changes it requires. Creating a simple document or brochure and holding a general meeting to explain it and allow for questions will help employees understand it better and make them feel part of the process.

Technology

Injured workers need the proper tools to recover and return to function. That includes access to appropriate medical care and the right information to help them engage in their own recoveries.

Prospective employees also need to know the right tools are available to them. Younger people have grown up with computers, smartphones, and tablets and used them throughout their educational and social lives. Companies seeking to hire and retain the best of millennials need to keep this in mind and update their systems to the extent possible.

But a complete overhaul of a company’s systems may not be feasible. Instead of completely revamping the company with the latest and greatest techno toys, companies should work with their employees and see where and how they can use new technologies to improve their systems — and retain younger workers.

Automation and artificial intelligence should not be viewed as replacements for workers. Instead, they can help with some of the more rote aspects of a person’s job, allowing the worker to spend time on more important aspects.

Smartphones and tablets may help get the job done better and faster. Rather than purchasing these for all employees, it might be possible to allow workers to use their own devices and providing them with specific apps, for example.

Conclusion

Working with, rather than against injured workers and providing them with quick and proper medical care leads to faster and better outcomes. Similarly, showing compassion for workers and providing them with the tools that best help them get their jobs done will help organizations attract and retain the best of the next generation of workers.

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: Risk Management

A Unique Perk For Workers with Limited or No Health Insurance

October 22, 2018 by Senior Editor

Some leading US companies offer a unique perk for injured workers who settle their claims with limited or no health insurance. They offer a service that gives these employees discounts on their medical care, support to navigate the health care system, and administration of their medical bills. It’s a way to give an injured worker an extension of their employee benefits while still maintaining control of their money after they’ve settled.

While this service is especially valuable for injured workers, it is not restricted only to them. Anyone can take advantage of these benefits to get a break on retail prices for prescriptions and other medical services along with support and advocacy. It’s a way to leverage the benefits of a post-settlement professional administrator without a formal agreement. Employers who can’t provide top-notch health insurance for their workers can direct them to these services as an alternative way to provide healthcare assistance.

The Benefits

Professional administrators offer significant price reductions for medications and medical treatments, as well as step-by-step guidance through the healthcare system — often via a 24-hour/7-day-a-week assistance to discuss healthcare issues. Injured workers with longstanding claims can find the comfort and peace of mind they need to finally settle their claims.

Injured parties with complex medical issues can sometimes be hesitant to end their relationship with the workers’ compensation system for fear of having to manage their money and health care needs on their own, as well as pay full retail price for prescriptions, doctor visits, and medical treatments. Working with a professional administrator after settlement can often be the answer for these employees.

Here’s how it works:

An injured worker or independent individual who signs up for the service is given a benefit card which can be used to pay for pharmaceuticals and other medical needs.
There is no obligation to use the card at any time, and the company cannot dictate when or how often the card is used, if ever.
Discounts off retail prices are available when the card is used.

The professional administrator does not have control over any specific amount of money. Instead, the user allows access to his bank account for only those services paid with the card from the professional administrator. The company simply processes payments made on the card through the person’s bank account. The better companies also provide the user with a report that tracks all payments made through the card in a given time period, which can be particularly helpful for those who trace Medicare payments.

Who Benefits Most

In addition to injured workers who have settled their claims, those who can gain the most through the services of a professional administrator include:

The uninsured. Those with no health insurance typically pay full price for their doctor visits, treatments, and medications; using a professional administrator results in significant savings to them. Additionally, they may want or need assistance locating providers and pharmacies as well as setting up appointments. Professional administrators provide these and other services.

Those with high deductibles. People who have health insurance with deductibles in the thousands often must pay full price for their medical services and/or Payments made through the card are not credited to the deductible. However, the discounts offered through a professional administrator can result in substantial savings.

Insureds with non-covered meds or treatments. Some insurance plans don’t include certain medications, or the discounts provided are insignificant. The discounts offered through the professional administrator may be greater.

Those looking for alternatives to high co-payments. Depending on the insurance plan, there may be high co-payments for visiting certain specialists or purchasing some medications. The professional administrator’s discounts may be lower than the out-of-pocket co-pay.

The services of a professional administrator are not appropriate for everyone, but for many, it is an alternative to paying high prices and trying to navigate the system alone.

Conclusion

Only a small percentage of injured workers who settle their cases are using professional administrators. But that is changing, especially since CMS’s recommendation last year that injured parties seek third-party assistance/professional administration after settling their claims.

Now, some of these companies have expanded their services to allow anyone to tap into some of the benefits of a professional administration without a formal commitment.

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: Professional Administration

7 Ways to Avoid Mega Workers’ Comp Claims

October 18, 2018 by Michael B. Stack

“There was an uptick in the number of mega workers’ comp claims in Accident Year (AY) 2016,” according to NCCI. “Ten claims of at least $10M have been observed for AY 2016 evaluated at 24 months. This is more than for any of the previous 15 AYs at a comparable maturity.”

The organization’s latest research brief drills down further and outlines additional revelations:

These multimillion-dollar mega workers’ comp claims are frequently the result of motor vehicle accidents or falls from elevated levels.
It is the Contracting industry group that has by far the greatest share of mega claims
The carpentry classification has had more mega claims than any other class over the past 15 years.
The trucking classification — representing short-haul and long-haul — ranks 2nd in both mega claims and all lost-time claims.
Central nervous system injuries (neck/spine or head/brain) and injuries to multiple body parts account for nearly 95 percent of mega claims. For lost-time claims, these categories make up only 16 percent of the claim total.
Hospital inpatient and home health care account for more than half of the mega claim medical costs. This is in stark contrast to all lost-time claims where physician expenses and hospital outpatient represent most of the medical costs.
Approximately two out of three mega claimants spend at least three months as a hospital inpatient, and approximately one in five are in the hospital for more than a year.

Armed with this knowledge, workers’ compensation stakeholders should focus their efforts on preventing these injuries — especially in the industries affected most.

Auto Accidents

Even though strains and slips/trips are the leading causes of loss for all lost-time claims, motor vehicle accidents accounted for more than 30 percent of $10 million+ claims. These are also the #1 cause of work-related deaths, accounting for more than 40,000 fatalities in 2016. The 14 percent increase from 2014 represents the largest jump in more than 50 years.

The federal government says fatalities from distracted driving grew nearly 9 percent in 2015, outpacing the overall increase in traffic accidents.

The three types of distractions for drivers are:

Visual — eyes on the road.
Manual — hands on the wheel.
Cognitive/mental — mind on driving.

Cell phones, one of the main causes of motor crashes lately, involve all three forms of distraction. One big problem is that drivers talking on cell phones may not realize they are mentally distracted. Also, this type of distraction usually lasts much longer than either visual or manual distractions.

Despite common thinking, hands-free talking on cell phone while driving does not reduce the risk — due to the mental distraction. The argument that it is similar to talking with passengers flies in the face of research. Actually, adult passengers share awareness of the driving environment and having them in the vehicle lowers the crash risk.

Unfortunately, educating employees will not lead to voluntary compliance. Employers need to implement and enforce specific policies about driving. These should state that employees who are driving:

Are not allowed to use electronic devices, either handheld or hands-free.
May not answer calls. Incoming calls must be directed to voicemail.
Are prohibited from reading or responding to text messages and emails.
May make an emergency 911 call can only after parking the vehicle in a safe location first.

The driving policy should include:

Clear language.
Documented training and communication.
A requirement for all employees to sign the policy.
Disciplinary action for violating the policy. This could consist of warning for the first two violations and termination for the third incident.

The effort to encourage safe driving should involve senior leadership, as well as managers throughout the organization. A person high up in the organization can send a letter to employees explaining that the policy is going into effect for any employee using a motor vehicle associated with company business and/or electronic devices owned or used for company business.

Falls

While half the fatal falls in 2014 occurred from a height of about 20 feet, 12 percent of them were from less than 6 feet high. Construction workers are at most risk, although falls can happen to anyone, anywhere.

Falls are 100 percent preventable. OSHA has a three-fold plan to avoid falls:

PLAN ahead to get the job done safely
PROVIDE the right equipment
TRAIN everyone to use the equipment safely

Whether work is being done from a ladder, scaffolding or on a roof, all three of these mandates apply.

Employers must look ahead to ensure a job is done safely. That means identifying how the job will be done, the tasks involved, and the safety equipment that will be needed. Safety equipment should be included in a job’s cost estimate.

The area where the work will be conducted should be scanned for potential hazards ahead of time. For example, there should be level ground if ladders are to be used.

Workers exposed to potential fall risks must be given the proper tools and equipment to ensure they get the job done safely. Depending on the job, that might include

Fall protection such as personal fall arrest systems and safety gear that is fitted properly to each worker.
A ladder or scaffold that is appropriate for the job.
Slip-resistant shoes
Harnesses
Safety nets.
Stair railings and/or handrails

Holes in which employees could fall should be guarded with a railing and toe-board or flor hole cover.

Every employee who works at a site with fall risks must be trained on how to set up the area and proper use of any equipment to be used. All fall-protection equipment to be used should first be inspected.

Summary

Employers and payers are spending millions of dollars and watching their employees suffer for years over claims that are completely avoidable. Implementing and enforcing some simple steps can protect the entire organization.

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

6 Steps to Keep Liability Settlements Out of Medicare’s Crosshairs

October 17, 2018 by Michael B. Stack

No one likes to pay for items that are not their responsibility. This statement is true of the federal government in the workers’ compensation industry as the feds have exerted control over settlements involving injured workers who are or will soon be covered by Medicare. An entire cottage industry has sprung up comprised of experts who develop Medicare Set-Asides (MSAs) and ensure Medicare’s interests are considered before a workers’ compensation settlement is finalized.

As the Medicare Set-Aside industry has grown and matured in workers’ compensation, a similar approach is now being considered with liability settlements. The law on the books for decades clearly says that Medicare is supposed to be a secondary payer in such settlements. Lately, there have been clear indications the Centers for Medicare and Medicaid Services (CMS) plans to take action on this soon. How it will ultimately shake out is up for debate. In the meantime, payers should at least be aware of what is happening and take steps to prepare.

The Issue

“The extent to which settling parties must consider Medicare’s interests in medicals in a liability settlement continues to be unclear.” Thus begins a new white paper discussing the issue and what can be done. Written and published by Tower MSA Partners, Navigating Through the Fog: Medicare, Future Medicals & Liability Settlements reviews the workers’ compensation experience with CMS, outlines likely scenarios for liability settlements, and provides tips for payers.

Liability insurance coverage protects the policyholder or self-insured entity against claims based on negligence, inappropriate action, or inaction that results in bodily injury or property damage.

Examples include

Homeowners’ liability insurance
Automobile liability insurance
Product liability insurance
Malpractice liability insurance
Uninsured motorist liability insurance
Underinsured motorist liability insurance

Medicare beneficiaries must notify Medicare when a liability claim is made against a party with liability insurance and the liability carrier must report to Medicare when it settles a claim with a Medicare beneficiary. When there is a settlement, Medicare expects reimbursement for any payments it covered that should have been paid out of the settlement.

The settlement becomes more complicated when there are future medical costs for the specific injury. If Medicare is billed, it may seek reimbursement. In those situations, Medicare’s interests should be taken into account, and a liability MSA may be advisable.

Medicare Has Not Yet Established Framework for Liability MSAs

Unlike the process for workers’ compensation MSAs, Medicare has not established a framework for reviewing LMSAs or provided any guidance on the issue. Instead, any CMS reviews for proposed LMSAs that do occur are done on a case-by-case basis and only by some regional offices.

The good news is that, so far at least, there are no known incidents of CMS denying payment or seeking reimbursement for injury-related medical care after a liability settlement. Tower MSA Partners anticipates action from CMS within the next two years. When that happens, according to the white paper, CMS will need to address issues including:

Review thresholds
Allocation of the MSA based upon a compromise formula
Documentation required to submit to CMS with an LMSA proposal
Whether the LMSA review will occur pre- or post-settlement
Timeline for LMSA policy implementation
Multiple defendants and mass tort settlements
Pricing of medical in an LMSA (usual and customary vs. Medicare rates)

Other factors that come into play with liability settlements include policy limits, statutory tort caps, negligence rules, pre-existing conditions, case law and other issues that may result in a settlement for less than the full value of the claim.

What to Do

With things up in the air regarding liability settlements, one question is whether a claim for reimbursement could extend to the claimant and the primary plan, as well as the claimant’s attorney. Right now, it is uncertain.

Despite the vagueness of the issue, Towers suggests payers take the following actions to protect themselves and claimants.

Identify whether the claimant is a Medicare beneficiary or has a reasonable expectation of Medicare eligibility within 30 months.
If Medicare eligibility is or soon will come into play, evaluate the necessity of future injury-related medical care. Is future medical care claimed in the settlement demand or alleged in the pleadings?
If there is a necessity of future injury-related medical care, will this burden likely be shifted to Medicare? For example, does the claimant have a source other than Medicare to pay future injury-related medical care; e., group health plan, which will likely cover future injury-related medical?
If Medicare is the likely source of future injury-related medical care, consider whether there are sufficient settlement funds to allocate a portion to fully fund future medicals. If so, then consider an LMSA as part of the settlement. If there are insufficient funds to fully fund future medicals, then consider an apportionment of the future medical allocation in relation to other damages allocated in the settlement.
Document the file and settlement/release in regard to steps taken to consider Medicare’s interest:

– If an LMSA or other type of allocation for future medical has been included in the settlement, ensure the plaintiff is aware of his or her responsibilities in utilizing those funds for future medical expenses.

– If the LMSA has been apportioned, document the reasons why such a reduction was taken.

– If no LMSA or allocation for future medical has been included in the settlement, then ensure the plaintiff is aware of the potential implications for future payments by Medicare for injury-related medical care.

– Document why no such allocation has been included in the settlement/release.

Besides the future medical considerations, remember as well to investigate and resolve Medicare conditional payments, including payments made through Part C Medicare Advantage Plans.

Conclusion

Medicare may begin denying payment for claims if it determines that payment should have been made through a liability insurance policy or another primary payer. Such a change would likely delay liability settlements. Therefore, it is imperative to work with an experienced settlement planning professional, as failure to comply with MSP provisions can result in severe penalties.

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)

5 Questions to Investigate the Mechanism of Injury

October 16, 2018 by Michael B. Stack

Members of the claims management team are required to conduct diligent investigations into workers’ compensation matters, investigate the mechanism of injury, and address issues of compensability. This is a task that requires them to determine if the information they receive fits the type of injury claimed. This includes not only injuries involving a specific incident, but also claims that culminated over a period of time. Failure to properly accomplish this task can result in protracted management of a claim and added costs to any workers’ compensation program.

The Anatomy of a Work Comp Injury

There are essentially two types of injuries employees sustain in the workplace. Each type of injury is unique in how they occur and the evidence one examines when deciding matters of primary liability.

Specific Incident/Sudden Onset: This type of injury is often easy to identify as it encompasses a specific injury that is easy to identify and occurs at a specific moment in time. These injuries include slip/falls, striking an object, an immediate onset of pain, or a fracture of a bone/joint dislocation.

Workplace Exposure/Repetitive Trauma: This is often more difficult to identify as to when the “injury” occurs as it primarily happens over a period of time. Common examples include the inhalation of dust, irritants or other substances that result in an injury/respiratory condition. In other instances, problems occur over a period of time that results in the degeneration of joints and discs. Questions as to the “date of injury” are often subject to contentious litigation as each jurisdiction defines when these injuries culminate. Examples include when the employee started missing time from work, when the employee first received medical treatment, or when the employee reasonably believes they have sustained a work injury.

Regardless of the type of injury, a complete investigation is required. Only deny claims in good faith.

Investigating the Mechanism of Injury

It is important for members of the claims management team to investigate and determine if the mechanism of injury (how it occurred) matches the claimed injury. It is also essential to analyze where the work activity is attributed to the work injury, or if the work condition was aggregated and/or accelerated due to work activity. Additional issues to consider include:

Did an injury occur as a result of the work activities?

Was the employee performing work activity consistent with the claimed injury?

If there was, in fact, a work injury, what body parts are actually involved? Defining an injury by ICD-10 codes may also be important given the reporting requirements for Medicare and Medicaid coordination of benefit

How long did the employee engage in the work activity for it to result in a work injury? Was it a substantial contributing factor in the disability and/or need for medical care and treatment/disability?

If not a specific incident-type injury, when did the injury culminate?

Questions regarding these issues may involve a medical director, nurse case manager, or someone with an advanced understanding of medicine.

Making Informed Decisions Regarding Primary Liability

It may be difficult for a member of the claims management team to make a legally defensible position when it comes to primary liability. This can be due to a number of factors beyond their control. If that is the case, utilize the service of a peer review physician or medical advisor to obtain further insight on an action plan for the claim.

Conclusion

Members of the claims management team are charged with a variety of tasks. Chief among them includes collecting applicable evidence and making reasoned decisions based upon the facts of the case and the law. This also involves seeking information on the mechanism of injury and determining if the claimed injury fits.

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