Use Collaboration, Technology for ADA Compliance and Positive Return to Work Outcomes

collaboration and return to workReturning an injured worker to the job before he’s physically ready can be a nightmare. The last thing an employer wants to do is put the employee at risk of reinjury.

 

On the other hand, waiting to bring an employee back until he is 100 percent recovered prolongs the number of lost work days and impedes the worker’s recovery. Reinjuries, as well as extended disability durations both, add costs to the claim.

 

What’s needed is an accurate depiction of the physical requirements of a job, along with a deep understanding of exactly what the injured worker is physically able to do or not do. Armed with such information, the employer can make the best decisions for the injured worker and the organization.

 

 

ADA Considerations

 

One issue that may come into play when returning an injured worker is the Americans with Disabilities Act. Employers cannot refuse to let an employee return if he can perform the essential functions of that job — even if that requires reasonable accommodations.

 

Following return to work best practices will ensure compliance with the ADA. Return to work has even been described as the “ADA on steroids.”

 

Both return to work and the ADA involve a collaborative process between the employer, employee, and possibly, the medical provider. Whether the disability is work-related or not, the first question to ask is whether the person can do his original job.

 

In many cases, the worker may be able to perform the essential functions of the job with some modification or reasonable accommodation. That may involve an ergonomic change or schedule alteration, for example. As long as it does not impose undue hardship — either financially or operationally — on the employer, accommodations should be explored, both from a return to work and ADA standpoint.

 

Return to work best practices entail resuming work as soon as possible, both to help the worker heal and to reduce claim costs. A work accommodation or transitional duty that helps the worker get to the point where he/she can fully do the job is the best course of action.

 

If the worker cannot perform the essential functions of his job even with accommodations, providing a transitional job elsewhere within the company, or a position off-site would be the next step.

 

A key to ensuring compliance with the ADA and getting the best outcome from a return to work standpoint is to engage the employee in what is formally called the interactive process. This allows for an open and honest discussion about what the employee can do and how the employer can facilitate the process.

 

 

Defensible Return to Work Solutions

 

There have been new tools developed that can accurately match a person’s physical capacity with specific jobs, allowing for a solid decision as to what the person is capable of doing, whether with reasonable accommodation or not.

 

An example is a digital job profiles integrated with automated job-matching analysis, developed by MyAbilities, combining ergonomic research with artificial intelligence-powered software that allows for ADA compliance and RTW best practices. It addresses the employee’s physical degree of fitness for the current job and runs those capabilities against all the digital profiles in a company’s job bank. If the injured worker is unable to perform his job, even with accommodation, the tool can identify other positions within the company that he might be capable of performing within his physical restrictions.

 

Digital job profiles comprehensively describe the physical requirements and features of every possible job. Each job includes graphics and video profiles, which significantly help evaluate and depict its physical requirements. The company’s automated physical assessment used in conjunction with the job-matching tools can quickly and accurately provide a picture of the worker’s physical capacity for various positions.

 

Under ADA law an employee is required, with or without accommodation, to perform the essential functions of a job achieving the same work product as other employees. However, this same stipulation does not apply under workers’ compensation RTW best practices which take ADA requirements a step further.

 

The job-matching tool allows employers to leverage the digital job profiles and interactive process to modify the employee’s original position with or without accommodation or provide an alternative transitional duty position.  Exceeding ADA compliance requirements, this RTW best practice would be true even if the worker is unable to perform all of the essential functions of the job or their work product is less than comparable to other employees.

 

 

Conclusion

 

Getting injured employees back to work is a win-win for everyone — as long as the job involved is appropriate for the worker’s level of fitness. By collaborating with the injured worker and using sophisticated tools, such as the job-matching analysis developed by MyAbilities’ will ensure the best outcomes.

 

 

 

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 .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Social Security Disability Offset and Workers Compensation

ssdiSocial Security disability benefits (SSD) are paid through a government disability program for workers who have had enough earnings paid into the Social Security system, regardless of whether their injury or illness is work-related. Injured workers are only entitled to SSD if they have a long-term impairment that precludes any gainful employment. SSD is only payable to workers unable to engage in any substantial productive activity whose physical or mental impairment is expected to last at least a year or result in death.

 

 

Duplication of Benefits

 

When an employee is so seriously injured that they receive a workers’ comp rating that classifies them as permanently and totally disabled, the injured employee may be eligible to receive both workers’ comp permanent total disability benefits and SSD.

 

If they receive both workers’ comp and SSD at the same time, they may get more compensation on a weekly or monthly basis than what they would if they were still working.

 

 

Offset

 

To prevent this duplication and overpayment of disability benefits, Social Security and state workers’ compensation statutes have offset provisions reducing the amount paid to the disabled employee.

 

The offset counterbalances the amount that the injured worker would be overpaid. The intent of the offset provisions is to ensure that an injured worker does not receive excessive pay from the combined workers’ comp and SSD. However, the combined payments after the reduction will not be less than the amount of the total SSD before the offset.

 

 

Average Current Earnings

 

Disabled employees cannot receive more than 80% of what was their “average current earnings” pre-disability. The Social Security Administration (SSA) defines average current earnings as the highest of:

 

• The average monthly earnings from “covered employment and self-employment” (where Social Security taxes were paid) during the highest five consecutive years

 

• The average monthly earnings in the calendar year of highest earnings from covered employment during the five years ending with the year in which the disability began

 

• The average monthly wage on which the disabled employee’s unindexed disability primary insurance amount is based

 

Disabled employees who have second jobs where they receive payments “under the table” without paying Federal Insurance Contribution Act (FICA) taxes cannot collect SSD (or workers’ comp) on the undeclared/untaxed income.

 

 

Total Family Income

 

The maximum amount of benefits, instead of determined by average current earnings, may be determined by the total amount of SSD received by all members of the injured worker’s family in the first month that workers’ comp is received.

 

 

Who Is Affected By the Offset Provisions?

 

The offset of SSD applies to disabled workers under the age of 65 and their families. Benefits for a worker’s spouse or dependent children are offset before the offset is applied to the worker’s benefits.

 

 

Which Payment Is Offset

 

SSA defers to each state’s laws as to whether the workers’ comp or the SSD payment will be offset. In most states, the SSD is reduced to an amount that equals 80% of the average current earnings when added to the workers’ comp disability payment.

 

A few states have laws that require the SSD payment to be primary, so that the state workers’ comp disability payment is reduced to make up the difference between what the SSD payment would be and the 80% of the average current earnings. Take, for example, an employee under the age of 62 at the time the combined Social Security disability and workers’ comp disability payments began. The employee was earning $900 per week before the injury and is receiving a workers’ comp permanent total disability payment of $600 per week. Based on the employee’s SSA earning records, the employee is entitled to $250 per week after the SSA approves them as permanently disabled. Instead of collecting $850 per week ($600 from workers’ comp and $250 from SSD) the employee will collect a total of $720 per week (80% of the $900 per week earnings – assuming the employees earnings immediately prior to the injury were their highest “average current earnings”). Social Security pays their disability benefits monthly.

 

In most states, the employee in this example would still collect the $600 per week from workers’ comp and the equivalent of $120 per week from Social Security, for a total of $720 per week. In the states where the SSD payment is primary, the employee still gets $720 per week, but the workers’ comp payment is $470 per week ($720 minus the $250) for their permanent disability payment, and SSD pays their $250 per week equivalent on a monthly basis.

 

 

Other Disability Benefits

 

There is no further offset or reduction if the employee receives other types of disability benefits or other income including:

 

• Private disability insurance

 

• Federal, state or local government disability

 

• Veteran’s Administration disability

 

• Railroad Unemployment Insurance Act sickness

 

• Black Lung Part B

 

• Proceeds from a third party liability settlement

 

• Jones Act payments

 

• Payments from a tort lawsuit

 

• Unemployment

 

• Private pension or private insurance

 

 

Lump Sums

 

If the disabled employee takes a lump sum settlement instead of weekly payments for their workers’ comp permanent total disability benefits, SSA will consider it as an offset. When this happens, SSA will prorate the lump sum settlement over the period that weekly benefits would have been paid and reduce their SSD payment accordingly. If the lump sum settlement indicates that a portion of it is for future medical expenses, that portion will be excluded from their calculations.

 

 

 

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 .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

 

Selection Criteria for New Third Party Administrator (TPA)

third party administratorWhether you are just starting your self-insured claims program or have decided it is time for a switch to a new third party administrator (TPA), the selection of the new TPA is one of the most important decisions you can make in the administration of your self-insured program.

 

Employers switching TPAs often ask questions of potential new TPA partners that address the issues they have had with their current TPA. Employers frequently make the mistake of not asking the new potential TPA partner about areas where the current TPA performs well.

 

 

Areas that need to be explored with all potential TPAs before selecting the next TPA include:

 

  • Obtaining a copy of the TPA’s Best Practices to confirm their claim handling standards
  • Obtaining a list of the current clients and former clients to contact for their impression of the TPA’s abilities
  • Verifying the TPA has a claims office in each state where you have business locations
  • In large states, verifying the claims office(s) are located near your business locations
  • Verifying the TPA will assign dedicated adjusters to your account in areas where your claim volume is large enough to occupy all of one or more adjusters, and will assign a designated adjuster to handle all claims in locations where you have inadequate claim volume to keep one adjuster busy
  • Determining the claim reserving authority the adjusters will have
  • Determining the claim settlement authority the adjusters will have
  • Confirming the experience level of each of the dedicated or designated adjusters
  • Determining the frequency of the claim file reviews by the claim supervisors and the extent of the directions and guidance provided by the supervisors
  • Confirming the licensing of each adjuster and each claims office
  • Establishing the claims intake process
  • Establishing the maximum number of claims that will be assigned to each adjuster
  • Establishing who the legal defense firm(s) will be when defense counsel is needed
  • Establishing who the medical triage company will be
  • Establishing who the medical management company will be when medical management is needed
  • Establishing who the pharmacy benefit manager will be
  • Establishing who will provide the medical fee schedule reviews
  • Determining the capabilities of the claims management system used by the TPA
  • Determining whether your claims management system can be integrated with the claims management system of the TPA and who will be responsible for maintaining the systems integration
  • Verifying that the TPAs claim management system will be able to provide all the data and claim management reports needed to manage your claims programs
  • Determining who will be responsible for correction of data errors that occur
  • Determining the security measures the TPA will take to protect the confidentiality of your data and financial information
  • Determining the nature and extent of the financial data available on each claim file
  • Determining if the TPA data system will allow the creation of ad hoc reports
  • Verifying the TPA will allow annual independent claim file audits to verify compliance with Best Practices including the prevention of claim leakage

 

 

This list provides just some of the areas that need to be considered when selecting a new TPA. By addressing these issues during the TPA selection process, further problems with the new TPA can be reduced, if not eliminated.

 

 

 

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 .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

NCCI Report Highlights Early Identification of Prescription Drug Abuse

Prescription Drug AbusePrescription drugs continue to contribute to a significant portion of medical costs in workers’ compensation claims nationwide.  This is due in part to opioid addiction and its negative impact.  Gains are being made, which means proactive members of the claim management team need to be continually engaged and implement best practices to avoid addiction and reduce the portion of claims consumed literally by prescription drugs.

 

 

NCCI Report Highlights the Problem

 

The National Council on Compensation Insurance (NCCI) recently released a report regarding prescription drug costs in workers’ compensation case.  The report sets forth the following encouraging conclusions:

 

 

  • While the prescription drug share of medical costs in workers’ compensation cases is at 13.7%, this amount declined by 2% in 2015, and 4% in 2016; and

 

  • Main drivers in prescription drug usage include Lyrica, OxyContin, and Gabapentin, which account for more than 15% of prescription drug costs in 2016.

 

While some of these trends are positive, it should still be understood that more can be done by proactive claim handlers to control the costs of prescription drugs in workers’ compensation claims and run a more effective program.

 

 

Early Identification of Prescription Drug Abuse

 

All interested stakeholders should be on the look-out of for overuse and abuse of prescription drugs.  Signs of misuse include the following:

 

  • Identification of injured employee’s with risk factors that include past/present history of substance abuse, family history of substance abuse, and various psychological and/or psychiatric conditions;

 

  • Injured employees that specifically request prescription medications by their name brand and refuse to accept generics; and

 

  • Instances where someone regularly claims to lose their prescription drugs and is requesting a refill.

 

The existence of a pain management agreement is a common feature in most workers’ compensation laws in instances where an employee is using opioid-based drugs.  This agreement should be strictly followed.  There should also be a renewed effort on the part of everyone to direct an injured employee back to work, even if it is in a light-duty/sedentary capacity.  Studies suggest strong return-to-work efforts significantly reduce the medical spend on any type of personal injury claim.

 

 

Multi-Faceted Approach to Reducing Prescription Medical Expenses

 

Proactive stakeholders in the workers’ compensation system can advocate for change to reduce the cost and human toll prescription drugs – mainly opioid-based – take on injured employees.  This includes an effective three-pronged approach.

 

  1. Prevent new cases of opioid-based prescription medication abuse from occurring: This all starts with the use of a pain management agreement – and making sure it is strictly enforced.  This zero-tolerance approach will ensure powerful pain medications are not misused or abused.  Terms within the agreement should include exactly how the medications are to be used, random drug testing and consequences for false/positives, failed tests and missed testing, how replacement medications are to be dispensed and where all prescriptions are to be filled – avoiding physician dispensing protocols.

 

  1. Treat people who are addicted with compassion: No process is foolproof, and anyone can become addicted.  It is important to treat individuals who suffer from this consequence are treated with respect and dignity.  All reasonable and necessary forms of treatment should be made available; and

 

  1. Use drug utilization measures to better target prevention and treatment: This is one of the most effective tools available to members of the claim management team in combating the abuse and overuse of opioid-based prescription medications.  Drug utilization review (DUR) is the process of reviewing all aspects of prescription drug usage – prescribing, dispensing, and use of medication.  It examines the individual usage of someone against predetermined criteria based on evidence-based medicine to ensure an effective and efficient result.  The recent NCCI report also credited the effective use of DUR in driving down the amount of money spent on prescription drugs in workers’ compensation claims.

 

 

Conclusions

 

There are many negative consequences of prescription drug abuse and misuse in workers’ compensation cases.  Steps are being taken to hold these adverse effects in check and also reducing workers’ compensation program costs.  This can be accomplished by implementing an effective approach that includes drug utilization review in your 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 founder & lead trainer of Amaxx Workers’ Comp Training Center.

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Workers’ Comp Mediation – Getting to “YES”

workers' comp mediationWorkers’ comp mediation and other alternative dispute resolution methods can be effective in the settlement of workers’ compensation cases.  It also helps promote program efficiency that frees up funds set in reserve, which in turn can be used to settle other claims.  Notwithstanding the benefits of using dispute resolution mechanisms, it is important for members of the claim management team and other interested stakeholders to prepare.  Failure to do so can waste everyone’s time and energy.

 

 

Selecting the Right Mediator

 

In most jurisdictions, there are no specific requirements or training someone needs to have to serve as a mediator.  The result is the parties to the workers’ comp mediation have the unfettered right to select the person to serve as the neutral.  With this in mind, it is important to note every mediator brings a unique skill set to the table.  This should include someone knowledgeable in a particular workers’ compensation act, and have a reputation for being able to cut through the smoke and mirrors of contentious litigation and get everyone to “YES!”

 

 

Preparing for a Successful Workers’ Comp Mediation

 

A mediator may often ask that parties submit a confidential mediation statement in advance.  This document can serve as the framework for reaching a favorable settlement and avoid wasting time.  Each mediator may have their own preference as to what is covered in the mediation statement.  Common points that should be considered can include:

 

  • An itemization of the benefits claims/defenses and potential recovery/exposure: The value of a workers’ compensation case is the starting point for settlement.  This often includes calculations for the employee’s average weekly wage (AWW), exposure for various indemnity benefits (TTD, TPD, PPD, and PTD) and medical benefits.  Other items to consider include the need for vocational rehabilitation services and the possibility of retraining.  All parties should consider the strengths and weaknesses of defenses such as causation issues, the reasonableness/necessity of medical care.

 

  • Expectations regarding a reasonable settlement range: The goal of mediating a case is to find common ground.  This requires compromise on the part of the defense interests and injured employee.  Attorneys, settlement consultants, and other interested stakeholders need to evaluate their cases and have an understanding as to where this case may settle.  This will allow the mediator to work with all sides in reaching an agreement.

 

  • The status of any prior negotiations, offers, and demands: Any settlement needs to start with a settlement demand.  This information should be communicated by the employee or their attorney to the employer/insurer before mediation takes place.  In the same regard, the defense interests should obtain reasonable settlement authority.  A claim handler ideally will be physically present at the mediation and able to get additional authority if necessary.

 

  • An honest assessment of your cases that includes its strengths and weaknesses: All parties needs to be honest about settlement and participate in good faith.  Attending a mediation just to see how the other side views the case can be unproductive and delay settlement on other cases.  A good mediator will challenge the parties if there is a sense they are not negotiating in good faith.

 

  • Confirmation that all intervenors and/or interested parties have received proper notice. It is important that all interested medical providers, private insurance carriers, and government agencies such as Medicare or Medicaid be made aware of their potential right of recovery.  This should be completed well in advance of settlement negotiations so they can provide all parties with an updated benefit resume.

 

 

Conclusions

 

Reaching a settlement on every case is not practical given the contentious nature of workers’ compensation litigation.  Notwithstanding these barriers, all parties should consider workers’ comp mediation as a tool to resolve cases.   It can also deliver the “win” all parties are looking for as they work hard in resolving disputes.

 

 

 

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.

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Case Study: More than $1.5 Million in Savings Through Generic Substitutes

Generic drugs in workers' compensationThe latest Drug Trend Report from myMatrixx once again showed a substantial cost difference between brand-name and generic drugs. In fact, while the costs of brand name drugs are increasing, prices for generics are steadily decreasing. Unfortunately, some workers’ compensation stakeholders overlook this issue when preparing Medicare Set-asides.

 

Medications prescribed for the injured worker are expected to be included in the MSA to gain approval by the Centers for Medicare and Medicaid Services. There are exceptions; however; such as when it can be demonstrated the injured worker is no longer taking the medication. But switching from brand-name to generic medications is one of the most efficient and effective ways to reduce costs.

 

 

Generics vs. Brand-Names

 

Some people are concerned that generic drugs are of lower quality than brand-name medications. The Food and Drug Administration stipulates that all generic drugs must be equivalent to their brand-name counterparts. Additional FDA requirements include:

 

  • That generic drugs have the same active ingredient, strength, dosage form, and route of administration as the brand-name drug.
  • The generic manufacturer must prove its drug is the same (bioequivalent) as the brand-name drug.
  • All manufacturing, packaging, and testing sites must pass the same quality standards as those of brand-name drugs.
  • Any generic modeled after a single, brand name drug must perform approximately the same in the body as the brand name drug.

 

The FDA also points out that many generic drugs are made in the same manufacturing plants as brand-name drugs.

 

Are there differences between generics and brand name drugs? Yes, but as the FDA points out: “There will always be a slight, but not medically important, level of natural variability just as there is for one batch of brand name drug compared to the next batch of brand name product. This amount of difference would be expected and acceptable, whether for one batch of brand name drug tested against another batch of the same brand or for a generic tested against a brand name drug.”

 

Generic drugs are cheaper than brand-names because the manufacturer making the generic version does not have to go through costly clinical trials that new drugs do. Also, they don’t generally pay to advertise, market or promote the drug, since the brand-name maker has already established the drug in the marketplace. The competition created by multiple manufacturers developing a generic version of a brand-name medication further drives down the price of the medication.

 

The only reason for any patient to use a brand-name over a generic medication is if the generic drug causes unusual side effects to a particular person or, in rare cases, is less effective. In the vast majority of cases, patients do just as well with generic medications as with their brand-name counterparts.

 

The biggest difference between generic and brand name medications is the price. A case study of a recent MSA is a dramatic example of this.

 

 

Case Study (Provided by Tower MSA Partners): More than $1.5 Million in Savings Through Generic Substitutes

 

An injured worker who had been diagnosed with Post Traumatic Stress Disorder, anxiety and mood disorders was taking a variety of medications to treat his conditions. Among the more costly drugs were Wellbutrin, Klonopin, Rozerem, and Neurontin — all brand-name medications.

 

When discussions about settling the claim began, the initial MSA included $1,657,022 for medications and $30,058 for future medicals.

 

Total MSA Exposure — $1,687,081.

 

 

Solution

 

After identifying the brand-name medications as the key cost drivers in the initial MSA allocation, Tower recommended working with the injured worker’s attorney and the treating physician to switch to generic substitutes. The switch from brands-to-generics took several months to complete, to ensure the effectiveness of each.

 

When the conversion was completed, a physician’s statement was obtained confirming the switch from brand to generic, as well as an updated prescription history documenting ongoing generic use. Tower promptly submitted an MSA with an allocation of $112,572.

 

Results

 

CMS approved the MSA within eight days, allowing the parties to settle. The switch from brand-name to generic medications resulted in savings of $1,574,509 — and assured the injured worker would have enough funds for his future medicals and medications.

 

Conclusion

 

Developing and getting FDA approval for a medication is a long, complicated process. Drug manufacturers charge for a medication based on their expenses for creating and bringing the drug to market. Once the patent expires for a particular medication, other manufacturers are free to produce the same drug — as long as it meets the FDA standards for generics; i.e., it is the same drug.

 

The cost difference between generic and brand-name medications continues to grow further apart. By carefully looking at the medications prescribed for an injured worker and working with various stakeholders involved, an appropriate, cost-effective MSA can be created.

 

 

 

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.

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

11 Tips for Safe Use of NSAIDS to Treat Pain in Workers’ Compensation

NSAIDs in Workers' CompensationThere’s good news about the latest drug usage in the workers’ compensation, although it comes with a word of caution. The good news, according to the latest Drug Trend Report from myMatrixx is that the use and spend on opioids have once against decreased. Alternative medications treatments are being used more often to treat pain. While that’s good in the effort to prevent unnecessary use of opioids, one class of medications need to be taken with caution.

 

NSAIDs — nonsteroidal anti-inflammatory drugs— have become one of the medications of choice to treat pain. These can be very effective and don’t carry the risks of addiction or dependence of opioids. However, the problem is the potential negative effects on the cardiovascular system. Care needs to be taken when prescribing them, especially to older workers.

 

The situation is something of a Catch-22; older injured workers often have pain, but they are typically more vulnerable to problems of the cardiovascular system. Payers can help protect injured workers who are prescribed these medications by understanding the risks, educating patients and exercising caution.

 

 

NSAIDs and Cardiovascular Issues

 

NSAIDs are often used to treat mild to moderate pain. They are especially helpful for pain caused by inflammation, such as arthritis or a sports-type injury.

 

NSAIDs are drugs with analgesic, anti-inflammatory, and antipyretic activity. Some of the commonly used over-the-counter varieties are ibuprofen, such as Motrin and Advil; and naproxen sodium, or Aleve and Anaprox. Prescription NSAIDs include Celecoxib, or Celebrex; and diclofenac, known as Cataflam and Voltaren. Aspirin, which is an NSAID, does not pose a risk of heart attack or stroke and is commonly used to prevent those conditions.

 

Gastrointestinal problems associated with NSAIDs are well known. But researchers have also found that these medications can increase blood pressure and lead to congestive heart failure, as well as acute myocardial infarction.

 

The Food and Drug Administration warned of the potential risks of heart attack or stroke from NSAIDs in 2005. Ten years later the agency strengthened its warning, based on the advice of an expert panel that had reviewed additional information.

 

The risk was especially noted when the drug rofecoxib, or Vioxx, was on the market. It was removed in 2004, after being associated with as many as 140,000 heart attacks in the U.S. during the five years it was sold. It prompted further research about the risks of heart attack and stroke from NSAIDs in general.

 

According to the FDA:

 

  • The risks of heart attacks and strokes increase even with short-term use of NSAIDs and may begin within a few weeks of taking the medications.
  • The higher the dose of NSAID, the higher the risk. Also increasing the risk is the length of time the medications are taken.
  • People most at risk are those who already have heart disease, although others can also be at risk.

 

Patients taking diuretics may be at the highest risk of heart attack or stroke, especially during the first few weeks of taking NSAIDs.

 

 

Preventing NSAID Risks

 

Taking NSAIDs for a few days to relieve pain generally carries just a small risk, for most people. Employers and payers can help ensure injured workers are less at risk of developing heart attacks or strokes from the medications through the following strategies:

 

  1. Monitor for signs and symptoms of adverse effects.
  2. Educate injured workers and family members on the risks, especially those more at risk.
  3. Prescribe the lowest dosage possible.
  4. Prescribing taking the drugs for only a limited period of time.
  5. Try alternative remedies for people who have heart disease, if at all possible.
  6. Do not take more than one type of NSAID at a time.
  7. Try alternative medications, such as acetaminophen. Be aware, however, that this drug can cause liver damage if the daily limit exceeds 4,000 milligrams or if the person drinks more than three alcoholic beverages a day.
  8. Suggest week-long NSAID ‘holidays’ on occasion.
  9. Advise the injured worker to get medical attention immediately if he experiences chest pain, shortness of breath or sudden weakness or difficulty speaking.
  10. For muscle or joint pain, suggest hot or cold packs or physical therapy before NSAIDS, for those more at risk.
  11. Injured workers already taking aspirin to prevent a heart attack should talk with their physician first, as some NSAIDs may hamper the aspirin’s effectiveness.

 

Conclusion

 

The workers’ compensation industry has made inroads in curbing the unnecessary use of opioids. However, care needs to be exercised before giving an injured worker a blanket recommendation or prescription for NSAIDS, especially for people who have pre-existing heart-related conditions. As with all medications, moderation is key.

 

 

 

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 .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Tips to Get the Most from Your Workers’ Comp Adjuster

 

Hey there, Michael Stack here with Amaxx. So Happy Mother’s Day to all the mothers that are out there. Hopefully you had a lovely celebration over this past weekend celebrating Mother’s Day. We certainly did for my wife, the mother of my four children. We did coffee and pancakes in bed and taken out to a really nice lunch. We had a really lovely day, and hopefully it was the same for you or your mother as well.

 

But it got me thinking about this sort of this day of demonstration of gratitude for mothers and how really for the amount of work that they do, one day is just not enough. It pales in comparison to demonstrating that gratitude. It needs to be delivered on a regular basis.

 

 

Gratitude for Your Workers’ Comp Adjuster

 

And it got me thinking about this other group, sort of this other role within the work comp industry that’s the same way that doesn’t get even a day at all, and that’s your adjusters. For the amount of work that your adjusters do on a day in, day out basis, the importance of their role within the work comp industry, the amount of gratitude that they get is very, very low. There are no pancakes delivered to them in bed, there’s no taking them out to lunch to have a lovely day.

 

So two things I want to talk about and focus on getting the most out of these adjuster relationships in today’s video. First one is demonstrating gratitude. How to demonstrate gratitude and the second thing is about how to set these up. How to set up these adjuster relationships.

 

So very simple, when I talk about gratitude you’re asking your adjuster for a thousand different things every day. Send me this form, send me this recorded statement, I need this, I need this, did you do the investigation, did you the three-point contact, what was this, blah, blah, blah, and it’s coming out in rapid fire all day long via phone, email and now often times text messages. So all these different places that they’re getting demands to respond to regularly.

 

 

Say Please & Thank You

 

Say please, say thank you to your adjuster. May I please have that investigation report? Can you please send me that witness statement? Whatever it is that you’re asking your adjuster, and when they send it to you, say thank you. Say thank you. This is a lost art within our world today. Don’t just apply this to adjusters, apply it to your regular daily life.

 

We have gotten to be so bold in the way that we interact with people that this has been forgotten. Very simple, very necessary, and it’s going to demonstrate a little bit more of that gratitude for your adjusters. And oh, by the way, maybe take them to lunch every once in a while too. They always like that.

 

Second thing is I want to talk about your set up within your account handling instructions. So when you set this up when you’re with your TPA when you’re with your carrier, if you’ve been with them for a long time it’s worth revisiting definitely at least on an annual basis. But a lot of time we like to talk about your account instructions as a living document, something that you can alter or change as necessary throughout the course of your claims handling relationship.

 

 

Set-Up In Workers’ Comp Account Handling Instructions

 

So let’s talk about the set up. Couple of things that I want you to look for in your account instructions when you’re initially setting it up or if you’ve been with them for a while to potentially modify.

 

 

Dedicated vs Designated Adjuster

 

So you can have a dedicated versus a designated adjuster. Now this is about how to set this up as far as who is serving you and what it costs. So who is serving you and what it costs. So dedicated versus designated, I want you to look at their case loads and I want you to look at their experience.

 

So what type of adjuster, who is that individual who is going to be assigned to your case? Again, in your instructions as you’re setting this up or as you’re potentially modifying it on an annual basis.

 

A dedicated adjuster is one that only works directly for you. So you work with Jane Smith, Jane’s your go to girl. She’s there handling all of your cases, or Jane and John if you’ve got more than one. Designated means that Jane or John works only for you, but they also work for XYZ Company as well.

 

You can develop a relationship. We talk about having your adjuster so much as being this key part of your team, demonstrating them gratitude, bringing them along, really having them as a main cog in your wheel. Setting up these relationships is a great way to do this. You could spend more money on a designated or dedicated adjuster. It’s going to cost you more out of the gates, but it can save you a huge amount.

 

 

Adjuster Case Loads

 

Same thing as we’re looking at these case loads. So adjusters with lower case loads do a better job. Adjusters with lower case loads do a better job. You don’t need a lot of research to figure that one out. It’s just common sense. If you’re handling 50 cases versus 500 cases, you’re going to do a better job on the 50 then you are going to do trying to handle the 500.

 

So one little quick tip here, this is something that you can define within your instructions. Also, do they have an admin support? So does your adjuster have administrative support? They can have a higher case load and do an equally good of a job if they have an admin support helping them to process a lot of that paperwork.

 

So something to think about and look at and ask your carrier, ask your TPA if this is an option and then look at those outcomes of how you can really best set that up.

 

 

Adjuster Experience Level

 

Then your experience level, do they have five years, do they have ten plus years of experience? You can negotiate this in your contract. You can negotiate I want my adjusters to have ten years plus experience, or I want them to have ten years plus experiences on these certain types of cases, the lost time cases, the catastrophic cases, whatever it is. You can define that.

 

Another thing you might want to do is if you look at this and they say, “Sure we can that but it’s going to cost you action.” You kind of choke up on that amount. You could say, “We want a mix step. We want ten years plus experience to be working with some of the newbie adjusters on those medical only files so that they have that supervision, they can deliver those outcomes.”

 

So all different things to look at and think about as you’re setting up these adjuster relationships. Once you do, then show them that gratitude. Bring them that coffee in bed. Take them to lunch. Show them that gratitude for the work that they’re doing. When you do, they’re going to deliver much better outcomes.

 

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

 

So be great.

 

 

 

Michael Stack - 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.

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

 

Stop The Bleeding! Control Workers’ Comp Leakage

control hard and soft workers' comp leakageSelf-insured employers and insurers understand that workers’ comp leakage costs money.  The overpayment of medical cost, indemnity benefits and claim expenses is a waste of money and weakens the overall financial stability of the employer or the insurer.  What to do about workers’ comp leakage is a frequent topic of discussion.

 

When there is no doubt that a payment should not have been made (example:  a non-recovered duplicate payment), it is referred to as hard leakage.  When a payment is made that is questionable and is subjective (example: a higher than normal settlement), it is referred to as soft leakage.

 

Employers and insurers frequently attempt to mitigate both hard and soft workers’ comp leakage by providing additional training to the claims staff. Additional training definitely has benefits and will reduce leakage, but additional training normally addresses only the issues the work comp supervisor or claims manager has identified.  This approach will often continue to overlook different types of leakage that is not on the company’s radar.

 

 

Independent Claims Auditors Bring Perspective

 

To identify leakage that is being overlooked, companies have been turning to independent claims auditors who bring in an outside perspective when reviewing claim files.  Senior management often recognizes adjusters, supervisors and even claims managers have a built-in conflict of interest in identifying every source of leakage – the more leakage they identify, the lower their level of competency appears to be.

 

The independent claims auditor can be completely objective, as the independent claims auditor does not have to worry about the impression the results of a workers’ comp leakage audit will create. The outside auditor is looking for the financial mistakes (leakage) in an effort to assist the insurer or self-insured employer to lower its overall claims costs without the worry that senior management may be critical of the adjuster’s/ supervisor’s/claims manager’s performance.

 

 

Hard Workers’ Comp Leakage

 

The independent claims auditor will identify types of hard workers’ comp leakage including:

 

  • Payment of non-compensable claims
  • Payment of claims occurring outside of the insurance policy period
  • Failure to utilize the medical bill fee schedule for all medical bills covered by the schedule
  • Payment of the same medical bill, including overlapping medical bills, more than once
  • Incorrect calculation of the employee’s average weekly wage
  • Incorrect calculation of the employee’s indemnity benefit
  • Incorrect calculation of the number of days or weeks of indemnity benefits owed
  • Incorrect handling of the waiting period and the retroactive period
  • Erroneous payment of indemnity benefits after the employee has return to work
  • Failure to properly calculate the impairment rating value
  • Failure to utilize the pharmacy benefit management program
  • Failure to apply offsets including unemployment benefits, social security benefits, over governmental programs
  • Failure to identify and pursue subrogation
  • Failure to obtain Second Injury Fund recoveries
  • Failure to obtain reinsurance company recoveries
  • Failure to arrange for modified duty work when approved by the medical provider
  • Payment of temporary total disability benefits when temporary partial disability benefits are owed
  • Overpayment of medical mileage
  • Over reserving of the long-term claim resulting in a higher than appropriate experience modification factor with Underwriting

 

 

Soft Workers’ Comp Leakage:

 

The independent claims auditor will identify possible soft workers’ comp leakage including:

 

  • Failure to thoroughly investigate the claim prior to acceptance of compensability
  • Failure to complete the Insurance Services Office inquiry
  • Failure to properly evaluate future medical benefits when settling a claim
  • Poor settlement negotiations
  • Failure to properly manage defense counsel
  • Failure to properly utilize medical case management, either overutilization or underutilization
  • Failure to utilize medical triage
  • Failure to settle dispute claims at the optimum cost point

 

 

Controlling Workers’ Comp Leakage Can Mean Large Savings

 

Controlling leakage is frequently the difference between an insurer or self-insured employer making or losing money.  While no claims operation will eliminate all leakage, a five percent (5%) leakage factor on a small self-insured program with $20 million in paid claims each year is an extra $1 million dollars spent, and 3% leakage on a $100 million a year paid out by an insurer is an extra $3 million dollars spent.

 

The above lists of how leakage occurs in workers’ compensation are not complete.  There are various other ways leakage can occur.  For a workers’ comp leakage audit to provide the maximum benefit to the insurer or self-insured employer, an auditor with a high level of expertise in workers’ compensation is needed.

 

 

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 .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

Surveillance in Workers’ Compensation

Surveillance in workers’ compensation plays an important role in resolving claims and detecting fraud.  Given its expenses, there are various factors members of the claim management team need to consider before hiring a service provider to conduct surveillance.  If these issues are not considered, the bottom line of a workers’ compensation claims program will suffer.

 

 

Surveillance in Workers’ Compensation Basics

 

The purpose of hiring an investigator in workers’ compensation cases is to observe and document the movements of an injured employee.  This allows the defense interests to introduce first-hand evidence into a hearing on the merits to demonstrate what someone is doing and their functional abilities – when they do not think someone is watching.

 

The first and most important step in hiring a service provider to assist with this activity is to find someone who is credible, ethical, and experienced.  Failing to take these factors into consideration can result in adverse findings.

 

 

When Should Surveillance be Used?

 

Not every case requires the use of a private investigator.  Instances where surveillance in workers’ compensation can either be helpful or have an effective impact include the following:

 

  • Instances where credible information of fraud is received and the injured employee’s movements and activities need to be closely monitored;

 

  • Cases where the employee is working an unreported second job or engaging in “cash” driven business activities. This can include employees who might be more active in certain times of the year;

 

  • Claims involving employees with a long history of work and other personal injuries. “Frequent fliers” should always be given special attention;

 

  • Employee’s who exhibit signs of malingering or are presenting at their medical appointments with conflicting pain complaints; or

 

  • Injuries that occur under unique or interesting circumstances. Examples include the “Monday morning” injury, injuries that occur before or after lay-offs, or during times of labor disputes.

 

 

 

Getting the Right Background Information

 

Background information on the injured employee’s habits is important before using an investigator for surveillance in a workers’ compensation case.  Given the cost and time involved, it is important to know when someone will be at a particular location and at what times.  Information that can be useful and collected via discovery can include:

 

  • Dates and times of doctor appointments;

 

  • The date and location of the independent medical examination or various workers’ compensation proceedings;

 

  • Places where the employee frequents such as attending religious services, social events and clubs, and restaurants or sporting events; and

 

  • Hobbies and other activities such as gardening, other yard work, or coaching a sports team.

 

 

Other Sources of Free Information

 

The advent of the Internet has created a treasure trove of free information.  This includes where they were born, lived (including specific address), and photographing or postings commonly found on social media.  Members of the claim management team who use social media for background information on an injured employee should be mindful of some simple rules:

 

  • Research on information open to the public is generally fair game when it comes to access by an adverse party. If someone does not closely lock down their security settings on platforms such as Facebook, Twitter, or Instagram, the information in the public domain can be used;

 

  • Use of a third party or “straw man” to connect to an injured employee is generally unethical and can result in information obtained from the query to be inadmissible; and

 

  • Asking for passwords from an injured employee is illegal in some states. That does not prevent defense counsel from bringing a motion to compel to obtain a court order for passwords.  Case law in this area is developing.

 

Interested stakeholders should look beyond social media and access genealogy websites.  Again, if information is published online and not obtained via mischievous means, it will likely be admissible.  Any useful information online should be printed and/or electronically stored immediately.  This is because information can be deleted, removed, or locked down just as quickly as it is posted.

 

 

Conclusions

 

Surveillance in workers’ compensation will always be a part of strong defense. When used, it should be done in an ethical and legal manner.  It must also be used in a cost-effective manner to avoid excessive spending and preserving the stability of a workers’ compensation 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 founder & lead trainer of Amaxx Workers’ Comp Training Center .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

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