Compensability of Mental Health Claims in Workers’ Compensation

Properly Handling Mental Cases in Workers' CompensationPsychological and psychiatric injuries in workers’ compensation cases place many demands on members of the claim management team.  These demands include understanding issues of compensability of mental health claims, managing the claims to mitigate exposure, reduce program costs, and ensure the injured employee is paid all benefits they are entitled to receive.



Compensability of Mental Health Claim


Mental health-related workers’ compensation claims can arise in a variety of instances and injuries.  The compensability of the injury is driven by the statutory framework in place as jurisdictions vary on how such claims meet the statutory definition of a “personal injury.”  This requires an understanding of the law and facts of the case.


  • Physical/Mental Injuries: This is the most common type of case that jurisdictions accept as being compensable under a workers’ compensation act. This type of claim arises when the employee suffers a physical injury that produces sufficient mental stress or stimulus that results in physical symptoms that meet a threshold of being compensable.  The concept of physical “impact” is required, and mental health claims without such contact to the employee are deemed insufficient.


  • Mental/Physical Injuries: These cases are characterized by extraordinary mental stress that manifests, or culminates in a physical work injury.  Legal standards for this type of injury varies, but usually includes instances where the stress from the work injury is beyond the ordinary day-to-day stress from which an ordinary employee is exposed.  In layman’s terms, stress from the work injury culminates in a mental break down and can include stress over a period of time similar to physical workplace exposure cases.


  • Mental/Mental Injuries: This type of claim is generally not compensable, but is an emerging area of workers’ compensation law given our growing understanding of mental health and its parity with physical injury claims.  In these claims, there is a required mental stimulus that results in a mental injury.  Common examples of these claims are employees who witness a serious or stressful event such as the death or severe injury or a co-worker or bystander.  A frequent claim made by employees in mental/mental claims are Post-Traumatic Stress Disorder (PTSD).



Defending Mental/Mental and PTSD Claims


Experienced members of the claim management team know that these claims require hard work and a deep understanding of legal and medical issues.  This includes an understanding of the law, and willingness to peel back the layers and understand what is going on in the employee’s past, and present.


PTSD is best defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), which is published by the American Psychiatric Association.  Under the DSM-V, a true diagnosis of PTSD requires clinical observations and accurate documentation.  In general terms, the following findings are either required or need to be present in conjunction with other factors:


  • Documented stressor by either direct exposure, or second-hand information concerning a significant event;


  • Intrusion symptoms such as unwanted upsetting memories, nightmares, flashbacks, etc.;


  • Avoidance behaviors;


  • Negative alterations in cognitions and mood;


  • Alterations in arousal and reactivity;


  • Functional significance that creates symptoms of distress or functional impairment (g., social, occupational); and


  • Exclusion not due to a medical condition or some form of substance abuse.


It is important to investigate claims of mental health and PTSD-related injuries in an aggressive manner.  This includes a complete investigation of the employee’s prior medical history and their socio-economic and familial background.  It will also include the use of a reputable medical expert, preferably a psychiatrist, or neuropsychiatrist with clinical experience.





Work injuries that involve a psychological and/or psychiatric condition challenge members of the claim management team.  It is important they understand the law and complete a thorough investigation.  This includes knowing everything about the injured employee, and a willingness to leave no stone unturned.




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



Workers’ Comp Roundup Blog:


©2019 Amaxx LLC. All rights reserved under International Copyright Law.


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

Plan for a Happy New Year with Safety First

A safe workplace should be the hallmark of every successful workers’ compensation program.  Changes made to improve workplace safety should never be static.  Changes followed by monitoring and constant improvement must only boost workplace morale and reduce workplace injuries in the new year.  Here is a list of changes that can be made to improve safety and lower workers’ compensation program costs.


  1. Commitment to Safety by All Interested Stakeholders: Companies with lower work injury rates are successful because leadership has made a commitment to providing a safe workplace.  This commitment includes a message being delivered from upper management, and consistent implementation.  Leaders who practice what they preach see buy-in from the workforce.


  1. Constant Review of Safety Practices and Procedures: Policies are only as good as the piece of paper they are written on.  In some instances, a policy may sound like a good idea but is not practical upon its implementation.  All policies should be subject to review on a quarterly basis.  Input should also be solicited from the people who are impacted the most – the employee.  Allow everyone to be a part of the process.


  1. Review Workplace Ergonomics: Those interested in reducing workplace injury should have all work activities reviewed for proper ergonomics.  This includes a review of activities performed on the production line and front office.  While it might take an investment of money, the possibility of a profitable return in terms of lower workplace injuries pays dividends.  Simple fixes include having employees limit repetitive motions, installing proper flooring, mating, and lighting.  Cross-training also adds value to an employee’s knowledge and value.


  1. Install Proper First Aid Kits: All employees should have access to proper first aid kits.  They should be stocked to fit a variety of common work injuries and monitored to make sure they are replenished in a timely manner.  This should be done on a monthly basis when other safety equipment is checked, such as fire extinguishers.  Consider adding advanced life-saving equipment such as portal defibrillators in the workplace, and make sure everyone knows how to use and operate them.


  1. Review Workplace Safety Plan: All workplaces should have a safety plan in place.  This includes worksites that are not required to have them.  Start the new year off on a positive note to make sure it is updated, and all employees are aware of what to do.  This includes incidents such as fires, severe weather, and active workplace intruder situations.  All exits and egresses should be secure and properly marked.


  1. Review Workers’ Compensation Policies and Procedures: All employers should make their employees aware of procedures related to work injuries.  This includes basic information such as how to properly report a work injury, why it is important to report incidents in a timely manner, and contact information for the insurance carrier.  Managers should also receive instruction on how to report a work injury to the insurance carrier, along with other responsibilities.  Additional steps should also be taken to make employees feel comfortable when reporting a work injury.  Emphasize a zero-tolerance policy when it comes to harassment, intimidation, and discrimination when an employee reports a work injury.



Additional Steps for Workplace Safety


A safe workplace also includes proper instruction for management.  This includes providing managers with information on the following issues:


  • Common workplace injuries, and steps to take to prevent them from occurring;


  • Communication of safety-related issues at all team meetings; and


  • Points of emphasis when it comes to a safe workplace.





A new year is coming, now is the time to re-commit yourself and company to a safe workplace.  A commitment to safety starts from the top and trickles down to all employees.




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



Workers’ Comp Roundup Blog:


©2019 Amaxx LLC. All rights reserved under International Copyright Law.


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

The A B C’s of Workplace Safety

There are many ways interested stakeholders can reduce workers’ compensation costs in their programs.  Running a more effective program and reducing costs starts with a safe work environment that can be as simple as the A B Cs…


Avoid unnecessary risks in the workplace.  Educate all workers on how to be safe.


Be aware of common pitfalls that drain program costs.  This includes not making sure all employees are aware of safety.


Caution all employee’s to be careful during the workday.


Do not delay in reporting work injuries.  Provide resources for employees to report claims and provide appropriate First Aid.


Employers are usually the party required to complete the state-mandated First Report of Injury.


Falls in the workplace lead to serious work injuries.  Always make sure employees are provided with the proper safety equipment.


Get an ergonomic workplace assessment for all employees.  Repetitive use injuries are common in any occupation or job.


Help all injured employees in their return-to-work efforts.  Studies show the best way to reduce workers’ compensation costs is to get people back in the workforce as soon as possible.


Idiopathic work injuries are generally not compensable.  A careful investigation is required to determine if this is the case, so liability can be denied in a timely manner.


Just because an employee claims a work injury does not mean it is always compensable.  A proper investigation starts immediately after the injury occurs.


Keep your First-Aid kit properly supplied.  This can be the responsibility of a safety committee member to check safety supplies frequently.


Letting garbage sit around the workplace can result in injuries.  Encourage all employees to clean up messes – even if they are not responsible for it.


Making safety rules is important, and the first step to avoiding work injuries.  The next step is consistently enforcing them for all employees.


Never miss a deadline when it comes to filing a workers’ compensation document.  Failure to do so can result in penalties assessed to a workers’ compensation program, higher insurance premiums, and the payment of additional benefits.


Open blades and moving machinery are dangerous.  Make sure all safety equipment is in place and functioning correctly on a daily basis.


Prepare for all types of emergencies – think outside the box.  What is your company’s safety plan to deal with severe weather, workplace violence, harassment, or acts of God (e.g. – flooding, earthquakes or tornados).


Questions need to be asked constantly to improve workplace safety.  A safety officer or committee can be a great resource for employees wanting to learn more.


Required workplace safety posters alert employees to common dangers.  Some of the required posters are available to employers for free through state labor and industrial commissions.


Set up regular safety training.  While it is important for new employees to learn about the dangers of a workplace, it is especially important for even seasoned employees to be made aware of ongoing risks and dangers.


Talk about workplace safety at every company meeting.  This not only reinforces important messages, but it demonstrates a stakeholder’s commitment to safety.


Unlit areas and workplaces are dangerous.  This can include slips/falls and even eye strain.  Make sure that all employees have adequate lighting.


Violence in the modern workplace is an important issue to address.  This includes teaching employees how to recognize the signs of depression or isolation in a coworker.


Walkways and stairwells are common places for injuries.  It is important to make sure these surfaces are free of debris and have proper lighting.


Xerox machines can cause work injuries.  Yes, even paper cuts could be compensable.  Make sure all cuts and wounds are properly irrigated and bandaged.


You play an important role in workplace safety.  Never pass up the chance to improve your workplace.


Zzzzzzzzz.  Getting a good night’s sleep is important.  Countless work injuries are the result of employee drowsiness.


Everyone needs to make a commitment to workplace safety.  It not only reduces workers’ compensation costs but also promotes workplace morale.




Michael Stack - AmaxxAuthor 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 .



Workers’ Comp Roundup Blog:


©2019 Amaxx LLC. All rights reserved under International Copyright Law.


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

A Risk Based Approach to Business – Taking a Practical Approach to Business Success

Most people enjoy reading a good story. A good story is made up of 5 basic components that include CHARACTER(S), SETTING, CONFLICT, PLOT AND RESOLUTION. In a good story, there is typically a unique combination of the character(s), setting and conflict that makes for an interesting plot that feeds to the resolution.


All organizations tell a story that speaks to where the organization is, how it got there and where it is likely going. A good business story is one that speaks to success in the midst of the complex settings and conflicts.


In today’s business environments, the “Main Character” of the business story is “Risk”.  Risk is a very powerful and influential part of an organization. The path that organizations go down (storyline) is driven by the risks an organization TAKES that positively impacts them and the risks they AVOID or MITIGATE that can negatively impact them. Collectively, these decisions on “Risk” tell the story.


Good business stories are typically not a product of chance. They are strategic and purposeful about implementing a “RISK-BASED APPROACH TO BUSINESS” and apply logic and consistency to deal with the main character – Risk.



The Setting


Where does the character “Risk” live and what does it look like in an organization? The best way to think of the setting is to picture an “Organizational Risk Puzzle” that has many pieces.


When you hear the term “Risk” in organizations, most associate it with Traditional Risk Management. If you own or work in a business, the risk that typically comes to mind is liabilities associated with owning buildings, vehicles, and equipment or the risk associated with workers’ compensation programs. These risks, commonly known as “Pure Risks” typically get a portion of an organization’s attention (time & resources) with the goal of eliminating the risks and/or mitigating what happens.


The larger part of the organizational risk puzzle falls into the bucket of “Speculative Risk”. In this area, as opposed to eliminating risk, the goal is to find the right amount of risk that fits an organization’s appetite and enables them to be successful.


In short, the character known as risk is everywhere and resides in every business process area, organizational goal, strategic & geographic initiative, and compliance area and pretty much every part of an organization. In addition to what is in plain sight, organizations have emerging risks that expand the setting to new areas.



The Conflict


There are natural challenges that come when you put people inside the 4 walls of an organization. In a business story, the “Organizational Risk Puzzle” becomes even more complex because it appears to have “Mountains” and “Rivers” randomly running between and through the pieces of the risk puzzle.


What appear to be mountains are actually “Silos” and what appears to be rivers are “Politics”. Silos are groups of people put together for a dedicated purpose that move towards working independently. Politics are the people in organizations positioning for personal agendas that may not align with what is best for the organization. These are real obstacles and distractions that can divert from an organization’s vision and mission.


Organizations are generally good at developing silos but are not good at permeating them. The conflicts naturally expand because the siloed environments advance differing and non-aligned priorities, lack coordinated decision making, promote loan rangers, isolated groups, redundancies as well as unhealthy completion to mention just a few of the negative by-products. Of course, organizations typically do not have a good way to deal with the negative ramifications of politics other than in backroom conversations and through organizational noise.



The Plot


After organizations acknowledge that risk is the overarching theme and key to business success, the “Plot” is pretty straight-forward. IT IS TAKING A RISK-BASED APPROACH TO BUSINESS.


Within the story’s plot, the character known as “Risk” puts structure and accountability to the process. In a risk-based approach to business, risk takes on a new and more productive role. Risk works for you.


A very important part of evolving organizations is the ability to come together and develop “Plans” to deal with existing and emerging issues.  A Risked Based Approach to Business states that if you can develop a plan, you can identify the risk that can prevent the plan from playing out; and if you can identify the risk to a plan, you can put controls in place to make sure the risk does not play out.


The plot states that you cannot leave room for failure. You must be proactive and use identified risk to beat what could go wrong to the punch. The plot builds consistency to success by proactively mitigating what could go wrong. By doing this you are teeing up what can go right.



The Resolution


Figuring out how to pull all the pieces of the puzzle together in the midst of challenges are business defining moments. Successful organizations realize there needs to be consistency in cutting through the challenges and making the obstacles less relevant.


  • Part 1of the resolution is to figure out how to operate strategically. Operating strategically can be your biggest ROI. Organization executives have limited time & resources and a business to run and there must be a platform to operate strategically. Three essentials to operating strategically include your 3 Lines of Defense, a Risk Register, and a Baseline. The 3 Lines of Defense are about being strategic with your people; getting people on the same page going the same direction with motivation. The risk Register is about being strategic with your data and putting attention and structure to what is most important. The Baseline is about being strategic with your controls and making sure what you do connects to where you go.


  • Part 2of the resolution is a platform that puts logic to limited time & resources. This translates into a “Structured Plan” process. This speaks to having a practical, simple and repeatable “Blueprint” for all organizational process areas to use when dealing with their risk.


By putting structure to plan descriptions, structure to identifying risk that will prevent plans from playing out, structure to mitigation and rating processes and to monitoring as well as change management, your organization will get better.


Does your organization have a “Good Story”? Is there structure and logic to how the organization deals with its most plentiful character – Risk? Is there structure to identifying, assessing and either mitigating or taking advantage of the organization’s risks to capture a competitive advantage?




Author Mark Bennett, Founder of Risk Innovation Group (RIG), is dedicated to helping large employers face the complexities of risk through innovative Enterprise Risk Management (ERM) practices. ERM programs don’t just help large employers manage business risks more effectively; a well-developed ERM program can protect and create value as well as improve business performance and generate a strong competitive advantage.  Contact:

Using the Right Tools for Clinic Analysis

Efforts to maximize the value of an onsite clinic can often focus on utilization and communication: making sure that employees know the capabilities of their clinic and are taking advantage of scheduled events (like flu vaccinations or health risk assessments.) However, analysis of the data being gathered in the clinic on a day-to-day basis is sometimes neglected.



Robust Electronic Medical Record (EMR)


In the clinic, a robust Electronic Medical Record (EMR) should track a variety of metrics such as clinic utilization (i.e., number of visits, labs, other services), visits by type, and referrals by specialty. With the right tools, aggregated data from clinic activities can provide valuable insight into patterns of behavior or ongoing safety risks. While EMRs need to safeguard confidential patient information, a data portal can scrub relevant protected health information and other confidential material, preventing direct access to the EMR and ensuring security and HIPAA compliance. This type of technology should also allow multivariate analysis across a specific period, giving insight into daily clinic life.


With a data portal, departmental managers can view information about their teams and compare it to summaries from similar departments, while facility managers can access information from all departments in their locations, and corporate managers can view enterprise-wide data. Understanding cost drivers and the health issues that affect the covered population enables the setting of priorities, tracking KPls, identifying optimal benefits, and making other critical clinic decisions. From an operational perspective, identifying injury trends in a department can help safety managers modify sites or behaviors contributing to injuries.



Clinic Return on Investment


Another important analysis capability with data aggregation is clinic return on investment. This aggregated EMR data can be reviewed against other systems and financials. These KPls might include overall healthcare costs, reduced administrative and case management volume, productivity improvements, and employee benefits. With the proper technology tools, clinic data can be a powerful tool in improving employee productivity and safety.


Best-in-class providers provide a platform for clients to interact with their data, run reports, see trend analyses, request services, and securely exchange files and messages.




Author Chad Brunner, Medcor Advocate. Medcor helps employers reduce the costs of workers’ compensation and general health care by providing injury triage services and operating worksite health and wellness clinics. Medcor’s services are available 24/7 nationwide for worksites of any size in any industry. Headquartered in McHenry, Illinois, the company operates 174 clinics and provides triage services to over 90,000 worksites across all 50 states and US territories. Medcor’s triage methods are covered by U.S. & foreign patents, including U.S. No. 7,668,733; 7,716,070; & 7,720,692; other patents pending. Medcor is privately held. Learn more at

4 Quick Tips to Get Adjusters to Follow Account Handling Instructions

For more training, register for:


Registration: How to Script Winning Account Handling Instructions



A well-done set of account handling instructions can be the very foundation on which a highly successful employer and claims handling organization can work together as a partnership to drive positive injured worker outcomes and drive down workers’ compensation costs. Hello, my name is Michael Stack and I’m the CEO of AMAXX. While that statement is true about the account handling instructions, if they’re not followed, they’re not worth the paper they are printed on. If they’re not followed, they are not worth the paper they are printed on. So, the question then becomes, if you put in the time to create this great set of beautiful account instructions that no one is following, what good are they?



Adjusters Need to Follow Account Instructions


And then the second question is, how do you actually get adjusters to follow those account instructions? I’m going to give you a couple of quick tips here. To dial into some of this mindset of how to approach this and how to make them just that more effective so they can, in fact, be that foundation which we talked about earlier.


So I want to give you three quick tips here about how to design these and then how to get cooperation from those adjusters. Three things you want to make them clear, you want to make them concise. And number three, you want to make them easily understood, clear, concise and easily understood.


Many companies will have 10, 20, 30, 50, or 60 pages worth of account instructions. And when you are the one that wrote them and participated in writing them and you look at them and you’re overwhelmed and have a difficult sometimes understanding what the heck is in those, the chance of your adjuster team, being able to pick them up and understand and be able to execute on them effectively is very, very low.



Clear, Concise, and Easily Understood


So make them clear, make them concise and make them easily understood. When you’re designing those, take a look at what you have. If it’s this thick, you’re not going to be effective and you need to dial that in to sharpen it up and you need to take another look at it with these three things in mind.


And then the other question on this is if you are wanting to get participation from your adjuster team when you’re designing this, ask for their input, ask for their input. When you are designing these and finalizing them, if you can get some cooperation in the beginning of this partnership from that claims handling team, when you’re designing them, clear and concise and trying to make them understood, maybe there’s stuff that you think, Oh, that’s obvious as can be. But to them it just doesn’t, it just doesn’t make a lot of sense in how we would actually function.



Work Successfully Together


Get that input from your claims handling team, dial these things in together, and then you can build that partnership together and work successfully together. And again, my name is Michael stack. I’m the CEO of AMAX. And remember your work today in workers’ 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 - AmaxxAuthor 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 .



Workers’ Comp Roundup Blog:


©2019 Amaxx LLC. All rights reserved under International Copyright Law.


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

New Federal Guideline Aims To Clarify Safe Opioid Weaning Practices

The Centers for Disease Control and Prevention (CDC) was the first to sound the alarm on the U.S. opioid epidemic. For years, the CDC tracked the epidemic and shared the alarming statistics with the medical community in hopes that it would make an impact, yet opioid overdose deaths continued to rise. In 2016, this prompted the CDC to publish a comprehensive guideline for the use of opioids in chronic pain. The guideline was met with mixed reactions. Those who supported it saw it as a template for appropriate and judicious prescribing. Those who criticized the guideline feared that it would lead to the abandonment of patients who legitimately needed opioid therapy. This issue came to a head in March of 2019 when a group of more than 300 healthcare professionals and patient advocates pinned a letter to the CDC complaining of widespread misapplication of the guideline. The letter blamed the CDC guideline for inciting fundamental policy and practice changes that resulted in patients being subjected to involuntary dose reductions that caused unnecessary suffering and some patients to resort to suicide or illicit drug use.



Federal Agencies Respond to the Controversy


The CDC reacted by issuing a statement recognizing the evidence for misapplication and reemphasizing that the guideline neither supports nor recommends the abrupt discontinuation of opioids in any patient since it may result in harm. Last week, recommendations regarding when and how to discontinue opioids safely were formalized in a guideline published by the U.S. Department of Health and Human Services (HHS). The HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics warns clinicians that abrupt discontinuation can lead to significant opioid withdrawal symptoms, worsening of pain, psychological distress and suicidal thoughts. The guideline also recommends against mandating dose reductions or discontinuation arbitrarily without considering the clinical circumstances. It also stresses to not interpret the CDC’s cautionary threshold of 90 mg morphine equivalence as a de facto limit. While the CDC Guideline does recommend avoiding or carefully justifying increasing dosages above 90 MED/day, it does not recommend abruptly reducing opioids in patients already taking dosages higher than 90 MED/day.


Fundamentally, the HHS guideline reemphasizes the message in the CDC guideline: opioids should only be used when the benefits clearly outweigh the risks. Medical care for patients with chronic pain should focus on therapeutic goals and not necessarily on any predefined restrictions. This essentially means that regardless of the dosage or duration of usage, it is appropriate to continue opioid therapy in patients who are progressing toward or have met therapeutic goals including pain relief, improved function and quality of life. So, if these therapeutic goals are not achieved and the risk-benefit ratio is unclear or unfavorable, consideration should be given toward tapering to reduce opioid dosage or discontinuation, says the HHS guideline.



Compassionate Risk Assessment for Opioid Dosage Reduction


Watching this controversy play out in the media, and speaking for the clinical team at myMatrixx, I can say that it all seems like absurd theater in which we are the enlightened audience. The CDC guideline has been under persistent criticism since it was first published — a guideline that was very carefully written and based on clear evidence. Any misinterpretation or misapplication should only be attributed to those who misused it. Nothing in the CDC guideline was wrong per se, just misapplied. The HHS guideline only reemphasizes guidance specific to tapering that was originally in the CDC guideline. We feel that it effectively conveyed the message to clinicians to be more careful with opioids, but not careless.


This is the same message and approach we take with clinicians when given the opportunity to collaborate with patient care via our CASE RX program. The majority of the cases we review through this program involve chronic pain patients on long-term, high-dose opioid regimens. In order to determine if the continuation of opioid therapy is appropriate, we perform a thorough risk-benefit assessment in which we compare the level of therapeutic benefit the patient is achieving from opioid therapy to the overall level of risk. When the risks clearly outweigh the benefits, we present the clinician with a recommendation to wean.


This type of assessment is consistent with both the previously released CDC guideline and the newly released HHS guideline. We have always promoted gradual dose reductions and provided individualized weaning schedules that clinicians can understand and use as a template for the entire weaning process. The ultimate goal is to gain agreement with the clinician and patient that opioid therapy that does not result in clinically meaningful improvement is only presenting the patient with risk.



Author Michael Nguyen PharmD, CPh, Director of Clinical Services, myMatrixx.  myMatrixx, an Express Scripts company, offers best-in-class pharmacy services for workers’ compensation programs that include: formulary and network management, utilization management, claims processing, home deliver and specialty pharmacy care and physician outreach programs. Working with the financial and risk management leaders of organizations, myMatrixx helps reduce the pharmacy cost associated with injured workers through innovative programs, business analytics and robust clinical protocols and expertise.


Michael Nguyen’s blog may also be found at:

CMS Expands MSA Amended Reviews & Modifies Consents To Release In Updated Reference Guide

CMS recently released Version 3.0 of its WCMSA Reference Guide, what we informally call the “MSA bible.”  The reference guide provides most CMS policy and procedures relating to its review of Workers’ Compensation Medicare Set-Asides.


The updated guide can be found here.


Notable additions or changes to this version are detailed below with takeaways and comments.



Amended Review Criteria Expanded to Six Years


CMS has expanded the Amended Review MSA lookback from one to four years to one to six years post the prior MSA approval.  As a refresher, the Amended Review process in Section 16.2 allows a new MSA to be submitted following a prior approval if all of the following criteria are met:


  • CMS has issued a conditional approval/approved amount at least 12 but no more than 72 months prior,
  • The case has not yet settled as of the date of the request for re-review.
  • Projected care has changed so much that the submitter’s new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.


Tower appreciates CMS expanding the lookback to six years as this should allow for more cases to be submitted through this process and potentially settle with an MSA that better reflects the claimant’s current and future course of treatment.  If your case may meet this criteria, please contact Tower to review and determine the feasibility of submitting an Amended Review MSA.



Claimant Authorization to Submit Added to Consent to Release Form


Longstanding policy requires any MSA submitted to CMS must include a Consent to Release form signed by the claimant.  The primary purpose of the document is to provide Medicare beneficiary authorization for CMS to communicate with the MSA submitter concerning the workers’ compensation claim.


Per the updated reference guide, effective 4/1/2020 a consent must include the following language:


Further, I have had the Workers’ Compensation Medicare Set-Aside Arrangement need and process explained to me, and I approve of the contents of the submission.

Beneficiary Initials: ____


As a result of the addition of this statement, CMS is effectively asking the claimant to approve the MSA along with supporting documents in the submission.  We anticipate two consequences as a result of this addition:


  • Claimants will sign the consent but forget to initial this section.
  • Claimants will not sign the consent until such time as they review the MSA and perhaps the supporting documentation, i.e. medical records, which are submitted with the MSA.


While we understand CMS wanting to ensure the claimant understands the purpose of the MSA, we would assert this is already effectively done, in most cases, as part of the settlement process.


At this time, Tower will continue to use the Consent to Release without the requirement that the claimant approve the MSA submission.  However, we will need to begin using the revised consent as we get closer to 4/1/2020.



Submission of Annual Attestations through the WCMSAP


As we previously discussed in CMS Adds Electronic Submission Option for MSA Attestations, CMS is now allowing MSA self and professional administrators to submit annual attestations through the Workers’ Compensation Medicare Set-Aside Portal (WCMSAP).  Section 11.1.1. of the guide was updated to reflect the addition of this feature and a new Section 17.6 “Electronic Attestations” was added which directs both MSA self and professional administrators to the WCMSAP User Guide for further information on submitting annual attestations electronically.



Policies Added to Address Opioid Epidemic


CMS has been very active in the past two years at addressing the opioid epidemic among its Medicare beneficiaries.  The exception to this has largely been the MSA program.


In an effort to address opioids in MSA CMS added the following statement to section 17.1 on MSA administrators:


CMS highly recommends professional administration where a claimant is taking controlled substances that CMS determines are “frequently abused drugs” according to CMS’ Part D Drug Utilization Review (DUR) policy. That policy and supporting information are available on the web at


CMS takes this further in Section 17.3 by stating:


CMS expects that WCMSA funds be competently administered in accordance with all Medicare coverage guidelines, including but not limited to CMS’ Part D Drug Utilization Review (DUR) policy. As a result, all WCMSA administration programs should institute Drug Management Programs (DMPs) (as described at for claimants at risk for abuse or misuse of “frequently abused drugs.”


While MSA professional administration is recommended for most MSAs, CMS is correct in asserting it is of special value for a claimant utilizing opioid medications.  MSA professional administrators like our partner, Ametros, can readily provide the type of drug management program expected by CMS.  We applaud CMS for implementing these guidelines addressing opioid use in MSAs.


If you have any questions regarding theses MSA updates, please contact Tower’s Chief Compliance Officer, Dan Anders, at (888) 331-4941 or




Author Dan Anders, Chief Compliance Officer, Tower MSA Partners. Dan oversees the Medicare Secondary Payer (MSP) compliance program. In this position, he is responsible for ensuring the integrity and quality of the MSA program and other MSP compliance services and products. Based upon his more than a decade of experience in working with employers, insurers, TPAs, attorneys and claimants, Dan provides education and consultation to Tower MSA clients on all aspects of MSP compliance. Contact: ((888) 331-4941 or

The Clear Indicator To Start Working on Settling a Workers’ Comp Claim


For more in-depth Settlement Training check out:





There is a point within the Thanksgiving dinner when you know you have had too much.


Hello, my name is Michael stack and I’m the CEO of AMAX and happy Thanksgiving to everyone. This Thanksgiving week as we celebrate this great holiday where we come together as a family, give thanks and also have a really great meal. But there is that point when you say, hey, I have had too much Turkey, too much stuffing, too much mashed potatoes and gravy, and your body gives you that very clear indicator that that’s enough and you need to do something else, some other course of action needs to happen.



Need to Have Clear Indicator to Start Settlement Process


Similar in workers’ compensation, we need to have these very clear indicators when we’re talking about settling a case. That’s the context of today’s training, settling a case. What does that clear indicator that we need to start thinking about it? So where’s that clear indicator we need to start thinking about, okay, boom, that’s enough Turkey. Okay, boom. That’s the indicator that my case is ready to be thought about going on this path towards settlement. And how many put some of those wheels in motion?


So I want to talk with you today about those very clear indicators of what they are so that you can start and have that very clear indication, that very clear trigger that now we need to start thinking about settling this case and the first one that I want to give you is that the individual is consistent and stable, so consistent and stable and this is in their medical treatment and in their prescriptions; and their pharmacy and how that treatment, that course of treatment is going. So, if there’s a surgery coming up or they just recovered from a surgery, not a great time to start thinking about settling. They’re still within this process. They’re still within what we have guaranteed in the work comp industry that we’re going to take care of these people to get them to this phase, to get them consistent, get them stable in their medical and in their pharmacy.



Consistent and Stable in Medical and Pharmacy


Indicator number one is that they’re consistent and stable and that is that same thing when you say, whew, that’s enough Turkey, that’s enough stuffing. It’s very clear for you. This should be very clear for your work comp cases as well that they’re consistent and they are stable within this bucket. I’m not even going to give you any more because I want to have this be such a very clear indication. This is also the time to start thinking about your Medicare Set Aside as well. Your MSA. This is the time when to reach out to your MSA vendor, have them start getting engaged in this process as well, and then as you start moving along this further process of settlement, you’re engaging your settlement advisors, you’re engaging your post settlement administrator, your professional administrator within this process.


There’s a lot more to this, this early identifier is just the tip of the iceberg in this four-step process to settlement, and I want to encourage you to check out this full-length training.






Successfully Settle More Cases


It’s very valuable to really get this consistent process cooking along called the process to successfully sell more cases. You’ll see a link below to order to check out that course. It’s a tremendous course dialing into this. This is the first step indicator that they’re consistent and that they’re stable. If you can have that clear indicator, then start the recipe and start that roadmap towards settlement.


You will drive more successful win-win outcomes for your work comp cases. My name is Michael Stack and I’m the CEO of AMAXX. Happy Thanksgiving to everyone. I hope you enjoy a great holiday this week!




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



Workers’ Comp Roundup Blog:


©2019 Amaxx LLC. All rights reserved under International Copyright Law.


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

Properly Designing and Implementing Transitional Duty Program Ensures Success

return to workThe biggest mistake employers make with a transitional duty program is having a “sorta” light duty program.  The employer recognizes a transitional duty program is an important way to reduce workers’ compensation cost and realize the importance of providing modified duty/light-duty work for an injured employee but does nothing about it until an injured employee is placed on light-duty work restrictions by the medical provider.



Big Mistake is Designing Program After Employee is Injured


For a transitional duty program to be effective, it needs to be properly established.  This does not mean identifying a light-duty job for the employee once an employee has been injured.  It means having a written policy on light duty work that is known to everyone in the company.  When there is a written policy of providing transitional duty work, every employee will know that a light-duty or modified duty job will be available and required of them, if they are ever injured on the job.  The supervisors and managers within the company should be educated on the details of the transitional duty program so they can properly explain it to any employee who is injured.


A transitional duty position should be designed for every current job within the company.  The transitional duty job does not have to be in the same department as the injured employee’s original job.  It can be anywhere in the company.  The placement of the employee in a transitional duty position outside of the employee’s regular department is beneficial to the employee by broadening the employee’s skill base and knowledge of the company.  Any training the employee needs to accomplish the transitional duty job should be provided during the first days on the temporary job assignment.



Transitional Program Should be Understood Throughout Company


All employees should understand that transitional duty jobs are temporary and are not a new permanent assignment for the employee.  If the transitional duty is going to last more than 30 days, the employee should be moved to a second transitional duty job that allows for increased physical assertion, but still within the work restrictions set by the medical provider.  The employee should be clearly told that as soon as the medical provider clears them to return to their regular duty job, they will be required to do so.


The business partners who are involved in the handling of the workers’ compensation claim need to understand that transitional duty is required of all injured employees who are able to work in some capacity. The nurse case manager and the designated adjuster or dedicated adjuster(s) assigned to your work comp claims should understand that your company will return all injured employees to work as soon as the medical provider states what work restrictions are necessary.


The medical provider, whether employer selected or employee selected, should be advised there is a transitional duty job available to the injured employee. The medical provider should be given both a copy of the physical requirements of the employee’s regular job and a copy of the physical requirements of the transitional duty job that will be available to the employee. If it is a non-emergency situation, the physical requirements or the regular job and of the transitional duty job should be given to the medical provider prior to the first medical visit.  When this is not possible due to the need for immediate medical care, the physical requirements of both the regular duty job and the transitional duty job should be provided to the medical provider prior to the employee’s second medical appointment.


The employer should never allow the transitional duty job to interfere with the employee’s medical appointments, physical therapy appointments or other medical treatment.  The supervisor in charge of the transitional duty job position should be provided the date of the next medical appointment immediately following the most recently completed medical appointment to minimize the interruption in productivity of the department where the injured employee is working.



Properly Designed & Implemented Program Ensures Success


The work comp coordinator within your company should coordinate the transitional duty position with the employee, with the supervisor of the transitional duty position and with the medical provider to be sure everyone is on board.  Any issue that arises with the employee working in the transitional duty position can be addressed timely by the work comp coordinator.  The work comp coordinator should also verify that the transitional duty job meets the work restrictions set by the medical provider.


The establishment and implementation of the transitional duty program before it is needed is the key to a successful program.  By designing your transitional duty program to accommodate the needs of the injured employees, you will ensure the success of your transitional duty program.




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



Workers’ Comp Roundup Blog:


©2019 Amaxx LLC. All rights reserved under International Copyright Law.


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

Professional Development Resource

Learn How to Reduce Workers Comp Costs 20% to 50%"Workers Compensation Management Program: Reduce Costs 20% to 50%"
Lower your workers compensation expense by using the
guidebook from Advisen and the Workers Comp Resource Center.
Perfect for promotional distribution by brokers and agents!
Learn More

Please don't print this Website

Unnecessary printing not only means unnecessary cost of paper and inks, but also avoidable environmental impact on producing and shipping these supplies. Reducing printing can make a small but a significant impact.

Instead use the PDF download option, provided on the page you tried to print.

Powered by "Unprintable Blog" for Wordpress -