Quite Possibily The Worst Workers Comp Claim Handling Ever

 

Candidate for the Worst Claim Handling Ever

 

A leading candidate for the worst claim handling everturned up in a workers compensation claim file audit.  A third party administrator (TPA) was handling claims for a statewide government self-insurance pool. And yes, all of the following mistakes were on one file!

 

 

Coverage

 

The TPA adjuster, upon receiving the claim, went to verify coverage.   The coverage had expired twelve days before the claim was reported. The date of loss was five days after the coverage expired. The adjuster wrote in the file notes that he would confirm coverage before making any payments.” However, before the adjuster had done so, the TPA switched adjusters and the coverage question was forgotten.

 

Mistake #1. Handling the claim before coverage was verified.

 

 

The lack of coverage wasn’t addressed again until the pool’s executive director contacted the adjuster over a year later. By then over $65,000 had been paid on medical and indemnity by the TPA from the pool’s trust fund. There was no coverage but the pool was in an estoppel situation, so the TPA continued to cover the claim.

 

Mistake #2. The second adjuster not reading the first adjuster’s file notes.(WCx)

 

 

 

Contacts

 

Best Practices for a TPA include making contact with the employer, the employee and the medical provider within 24 hours. The TPA had overloaded its workers comp adjusters with over 200 files each. The government pool’s contract did not contain any provision for the maximum number of claims to be assigned to an adjuster.   The second adjuster on the file never even saw the claim during the first three months it was assigned.

 

Mistake #3. Not reviewing the file when it was assigned.

 

Mistake #4. Timely contacts with the involved parties were not made.

 

Self Insured Mistake: Not having a contract stipulation on how many files could be assigned to one adjuster. 

 

 

 

Investigation

 

Since the second adjuster never contacted the insured, the claimant or the medical provider, there was no investigation of the claim. The Employer’s First Report of Injury reflected that “the employee (a painter) hurt her lower back when she tried to move a five-gallon bucket of paint.”

 

Mistake #5. No investigation of the claim.

 

 

Medical Handling

 

File note entries read “Received medical bill” or “Paid medical bill” with the name of the medical provider and the bill amount. One medical report summarized in the file notes stated, “employee continues to work with her low back pain and wrist pain.”   Three months into the claim a medical report stated “will need to do bilateral CTS (carpal tunnel syndrome) surgery.”

 

Mistake#6.  Not comparing medical reports with the reported injury on the claim.

 

 

The employee was an obese woman with diabetes – two factors that can bring on CTS without an injury. Even though the claim was reported as a back injury, at no time did the adjuster question the carpal tunnel syndrome treatment.

 

Mistake #7. Failure to separate a covered injury from other medical conditions of the employee.

 

Mistake #. Lack of medical knowledge that CTS is not always injury related.

 

Mistake #9. Failure to get a medical termination based on whether the CTS was work related. If it was it should have been handled as a separate claim.

 

 

Indemnity Handling

 

The first contact with the employee occurred over four months into the claim when the employee called the adjuster inquiring about when she would be paid for her Temporary Total Disability, as she was off work due to the right wrist Carpal Tunnel Syndrome surgery (the left wrist would be done a couple months later). The adjuster did not follow up on the Temporary Total Disability question and got another phone call from the employee. The first contact with the employer occurred almost five months into the claim when the adjuster asked the employer for a wage statement.

 

Mistake #10. No on-going contacts with the employee and the employer.

 

Mistake #11. Not obtaining the wage statement from the employer when it was first noted the employee was going to need CTS surgery.

 

 

The adjuster put the temporary total disability (TTD) checks on autopilot and forgot about them. After about six months, the employee returned to work. As the adjuster had not been in contact with the employee or the employer, the Temporary Total Disability checks just kept on going out. The adjuster did not know the employee was back to work until receiving medical reports stating that the employee was at maximum medical improvement on her wrists and had been given a 15% impairment rating for both wrists combined. The employee received an extra eight weeks of Temporary Total Disability after she was back at work. The adjuster stated in the claim file notes that the overpayment of Temporary Total Disability would be taken out of the permanent partial disability (PPD) settlement. However, it never was recovered.

 

Mistake #12.Not making any effort to get the employee back to work earlier or to return to work on light duty.

 

Mistake #13. Putting Temporary Total Disability checks on long-term automatic issue. (WCx)

 

 

Remember the low back pain?

 

The employee had only been back to work for two months when the adjuster contacted her about the overpayment of Temporary Total Disability and settlement of the Permanent Partial Disability claim. The employee advised the adjuster that her back still hurt and she needed to go to the doctor.   The doctor ordered an MRI of the low back. The employee had a herniated disc at L4-L5 and a partially herniated disc at L5-S1. The doctor scheduled surgery for the employee.

 

Mistake #15. Not having inquired about the lack of medical treatment on the low back for almost a year.

 

 

The adjusterfinally paying attention, refused to approve the surgery until an independent medical evaluation (IME) could be completed. The IME confirmed the need for the surgery. After the surgery, the employee was off work for another seven months before the doctor placed her at maximum medical improvement with a 25% rating.    

 

Mistake #16. Not making any effort to get the employee back to work earlier or to return to work on light duty.

 

 

Negotiations

 

The adjuster contacted the employee with an offer to settle both of her Permanent Partial Disability ratings based on her being 40% disabled. The employee argued that she should be considered 100% disabled as she was not able to go back to her job as a painter. The adjuster refused to consider the claimant as having permanent total disability (PTD). A week later, the adjuster received a letter of representation from the employee’s new attorney, who claimed the employee was PTD. The attorney requested an administrative law judge (ALJ) hearing. The ALJ reviewed all the medical records and agreed with the adjuster’s defense attorney. The employee’s attorney appealed. The Workers Comp Board (WCB) agreed with the defense attorney. The adjuster paid the 40% PPD rating.

 

 

Worsening of Condition

 

A year later the employee’s attorney contacted the claims office, but the second adjuster was no longer with the TPA. A third adjuster on the claim learned that the attorney filed a request for the WCB to consider a “worsening of condition.”

 

 

Index Search

 

The new (third) adjuster looks over the file and realized that an ISO Index had never been filed on the claim. Once the index was filed, it was discovered that the employee had a prior back injury claim eight years before this claim. The employee was represented by the same attorney for both claims. The prior insurance company already classified the employee as 10% Permanant Partial Disability for a non-operated herniated disc. The prior medical reports showed that the employee’s earlier claim was for an L4-L5 herniated disc – the same injury the claimant had surgery for in this claim.

 

Mistake #17. Failure to index the claimant resulted in the TPA/pool paying for a claim that should have never been paid.

 

 

Exacerbation vs. New Claim

 

It was now obvious that the present injury was not a new claim, but the exacerbation of an old claim. If the index had been done when the claim first was received, it could have been referred back to the prior insurance carrier. The defense attorney requested that the ALJ transfer the claim back to the original insurance company. This is after the TPA had already paid the employee a 40% award (15% wrist and 25% back) on top of the 10% award the employee had received for the earlier claim.

 

The ALJ stated that as the TPA had already accepted the injury as a new claim, it would not change it now. The WCB appeal was denied, so the current insurer was stuck paying for the claim although it was an exacerbation of a preexisting injury.

 

 

Back to the Medical

 

The employee’s disk fusion surgery had failed. The treating doctor recommended another surgery. The third adjuster was too inexperienced to be handling this type of claim.

 

Self Insured Mistake. Not having a stipulation in the contract requiring experienced adjusters to handle claims -especially high dollar ones.

 

 

The adjuster asked her supervisor what to do. The supervisor said to get another IME. The IME stated that the fusion had partially failed, but absolutely did not recommend another surgery.

 

 

Sympathy

 

The attorney gave the third adjuster a sad tale of how much pain the employee was in, that the employee’s marriage was falling apart due to her pain and she was desperate to have the surgery. The attorney played on the adjuster’s sympathy until the adjuster agreed to the surgery.

 

Mistake #18.  Allowing emotions instead of medical facts to make the determination on how to proceed on a claim.

 

 

The adjuster should have had denied the additional surgery and forced the employee’s attorney to have the ALJ or even the WCB make the determination.

 

 

Permanent Total Disability Granted

 

Following the second surgery, the employee’s attorney filed a petition for PTD.   The treating physician had given the employee a total 75% Permanent Partial Disability rating based on the bilateral CTS surgeries and the two back surgeries. The defense attorney arranged another IME and got a similar rating of 65% total. The ALJ looked at the total medical history and the employee’s 65% or 75% permanent partial disability rating following her two wrist surgeries and her two back surgeries. The ALJ gave the employee a PTD finding. The defense attorney appealed to the WCB.   The WCB agreed with the ALJ and the third adjuster paid the employee another 50% rating. (WCx)

 

 

Summary

 

The failure to do the simple things in the claim file handling resulted in the self-insured pool paying out over a half million dollars in medical, indemnity and legal expenses. Verification of coverage would have stopped this claim before any dollars were spent. A proper investigation at the start of the claim, including an index of the employee, would have shown that the low back claim was an exacerbation of a prior injury and would have eliminated that portion of the claim. The review of the medical reports would have resulted in a denial of the CTS or at least had it treated as a separate claim. Non-compliance with Best Practices changed what should have been zero dollars paid into a PTD claim.

 

 

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

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact:  mstack@reduceyourworkerscomp.com.

 
WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

VIEW SAMPLES PAGES

MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

 

There is Only One Reason to Close a Workers Comp Claim

 

The Only Reason to Close a Worker’s Compensation Claim
 
A workers' compensation claim should only be closed when all known activity on the file has been completed. If it is possible that another dollar can be spent on the claim, the file should not be closed.
 
 
If there is still activity on the file, it should not be closed. A claim should be left open in all of these situations:
 
1.   The employee has not completed all medical treatment
2.   All temporary total disability indemnity has been paid, but the employee is continuing treatment with a medical provider
3.   The employee has completed medical treatment, but all medical bills have not yet been paid
4.   The employee has temporary total disability benefits that have not been paid
5.   The employee has completed all medical treatment and all medical bills have been paid but the employee is still receiving payments for permanent partial or total disability
6.   The widow(er) is still receiving benefits
7.   All medical bills and indemnity benefits have been paid, but there are still outstanding bills for the defense attorney, nurse case manager or other service provider (WCxKit)
 
A Claims Manager’s Performance Should Not Be Evaluated by Numbers of Closed Cases
 
Best practices of the Third Party Administrator require that claims managers’ performance review criteria should not include the number of closed cases.  This leads to too high of an incentive to artificially close cases that should not be closed.
 
Examples of Improper Claims Closings
 
Claims Manager Evaluated on Number of Closed Files
 
One claims manager had several old files where employees had permanent medical problems and had occasional doctor visits. The claims manager had closed the files but was still making annual payments. During a claim file audit, the claims manager argued that the claims should be closed because all the indemnity benefits were paid, although there was on-going medical maintenance treatment.  In this situation the manager's performance was evaluated based on the number of files closed. 

 
TPA Gets in Trouble with Large Fortune 500 Client
 
In the following example, a large national third party administrator (TPA) got into trouble when a big client noticed major irregularities in the number of claim files that were closed and re-opened. (WCxKit)
 
The client’s risk manager found that the TPA had a salary bonus program for adjusters. One of the performance criteria was to close as many old claims each month as new claims received.  
 
The adjusters found a way to get around the intent of the performance measurement so their numbers looked good. At the end of the month, adjusters who had not closed enough old claims closed files in the computer system that had little current activity. The following week in the new month, the adjusters re-opened the claim files. Obviously, this improper handling of file closings was not in the realm of best practices.
 
 

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

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com Contact mstack@reduceyourworkerscomp.com

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

VIEW SAMPLES PAGES

MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

Legal Pad vs. iPad, How Workers Comp Claims Handling Has Changed

 

Two Big Changes in Claims Handling
 
20-30 years ago, a claims adjuster used to investigate claims a lot differently than they do today.  Back then, adjusters were given legal pads, a tape recorder, a pen, a company car, and a list of their claims. Some say that the technological trend we live in today has negatively affected the art of investigation for injury claims.  But how?  And what is so different today when compared to 30 years ago?   The answer to this is subject to argument, but there are a lot of clear differences when you compare today’s insurance adjuster to the one of yesteryear.  Here are the pros and cons on the two biggest changes in the way claims are handled below:
 
 
Field adjusters versus in-office claims adjusters
 
Back in the day, adjusters always did in-person statements.  This entailed going to the employer or house of the claimant and taking their statement along with gathering their pertinent information, and putting paper notes in a manila folder which consisted of the actual claim forms and information. [WCx]
Field Adjusters Meet You Face-Face
 
In the past, if you are the adjuster and you are sitting across from the claimant, it could be considered more difficult for the claimant to distort the injury or accident details when recalling what happened. In fact, seeing your claimant in their actual home environment was considered a good way of “sizing them up” when it came to their complaints of injury and how their actual behavior and activities of daily living were affected.  Since you are right there, you can look around the house and see what is actually going on.  Is the house neat and tidy?  Is the claimant wincing in pain or finding it difficult to sit still?  Does your injured worker have dirty fingernails which show they may be doing activities more strenuous than what they are telling their doctor they can do? Do they have a good family support system present to help them in their time of need or to tend to their daily tasks?  The answers to these questions could affect the outcome of the claim, and what the future could hold for where the claim is going to go in the future.
Today Adjusters Work Almost Exclusively by Phone
Today, the role of a field adjuster is about gone.  Some insurance carriers still have field adjusters to do accident investigations and so on, but it is nowhere near the capacity that it used to be.  Claimants can “hide behind their phone” and essentially make any allegation they want, since they do not have to put on an act with their adjuster sitting right there. 
Since the claimant rarely if ever sees their actual adjuster, a personal relationship is really not made, be it positive or negative.  By keeping the adjuster in an office, the carrier eliminated large overhead costs with company vehicles, drive time, mileage, and so on.  This also allows the adjuster to carry a larger caseload.  Since they are chained to the office they are capable of handling a lot more than someone who is on the road.  This again can be seen as a positive or negative.  The point is that the actual in-person investigation that all adjusters used to do is no longer a factor.  Whether or not this is a negative in regards to the actual investigation is tough to prove.  Adjusters nowadays have had hours of training about how to interview, and what verbal and nonverbal cues to pick up on when they are talking to their injured parties.  There is more in-depth training involved now than there used to be years ago, both in investigation tactics and in medical terminology training. So the difference really lies in the adjuster, and how good they are at doing their job.  There were good adjusters and bad adjusters 20 years ago, and there are good adjusters and bad adjusters now. [WCx]
 
 
“Start to Finish” claims handling versus ascending levels of adjusters
 
In the past, adjusters were assigned to certain employers or insurance agencies, and that sole adjuster was the one to handle claims from either of those two parties.  Not only did they get every claim those parties produced, but the adjuster of the past handled those claims from start to finish no matter what the level of severity.  This lead to the adjuster forming a great relationship with those agencies or employers, and several positives came of this relationship. The adjuster knew an employer in and out, toured their facility and knew the job tasks demanded of their workers.  The adjuster knew a lot more about the employer than the injured worker may think they knew. 
Pro of Single Adjuster is Level of Employer Knowledge
If the adjuster knows the job titles, responsibilities, layout of the floor, the risk managers, and the executive staff, then an in-depth relationship is made, and it is hard to put a price on that.  A single adjuster could be saving this employer a lot in insurance expense and premium cost, just by the simple fact that the adjuster knows the employer’s demands and what goes on at this employer on a daily basis.  
Nowadays, it may be considered a luxury if the adjuster that handles your claims is even in the same state as the employer.  Out of state adjusters miss out on local politics, stereotypes of local doctors and clinics, and the overall work ethic of people in one city versus another.  Even more disconcerting, the adjusters start to bounce files to other adjusters in other states depending on the financial exposure or reserves allocated by the carrier. 
Con is Unspecialized Claim Experience
This can be considered a pro or con.  If one adjuster specializes in severe injuries, and you incur a severe injury for a comp claim, then it would make sense that you want that adjuster to handle the file versus the entry-level adjuster who doesn’t have the experience or background in dealing with severe injuries.  But, negative issues can come attached to those carriers who bounce claims around, namely the main issue that this new adjuster has not handled the claim in the very beginning.  A lot can go on early in a claim, and every adjuster has their own style of claims handling in general.  So what if some factors were missed early on that could affect the outcome of the claim?  What if certain questions were not asked that could have affected the compensability of the claim, had they been asked the day after the injury versus being asked months later? 
This is what can frustrates claimants the most.  Just when they get comfortable and start to trust the first adjuster, their file is moved to another adjuster.  They have to essentially repeat the whole process over again, possibly including taking another statement and trying to form another relationship with this new adjuster.  Maybe this new adjuster doesn’t return calls as quickly as the first adjuster.  Maybe the new adjuster is not as verbose as the first adjuster, and the claimant feels that this new adjuster is not paying them the attention they feel they were paid before.  Whatever the case may be, there are again pros and cons to each argument about which way is best.
Summary
These two issues have only scratched the surface between how claims are handled now versus how they were handled 20-30 years ago.  Which way is better is best left up to the parties having this discussion. As you can see, even with these two changes, it can open the door to hours of discussion.  The fact is that it is 2012, and with the technological advances that have been made, both in the insurance industry and in industry in general, we have to adapt to these changes and provide what we think will be the best info to help the adjuster make the proper decisions handing their claims. 
Let’s face it, claims are not going anywhere.  How we handle those claims is a constantly changing atmosphere, and you have to adapt to change.

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

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com Contact mstack@reduceyourworkerscomp.com

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

VIEW SAMPLES PAGES

MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

If the Shoe Fits, Make Sure The Responsible Party Wears It in a Workers Comp Claim

If someone Else is at Fault, They Should Pay For It

 
Subrogation is the process and the right of the workers’ compensation insurer or the self-insured employer to recover the money paid on a workers’ compensation claim from another party when the other party is responsible for the injuries to an employee.  In civil law, the principle of negligence guides and determines who should pay for damages caused to another.  Basically, the simplest way of putting it “if someone else is at fault, they should pay for it.” [WCx]
 
The most common situation where the insurer or self-insured employer can recover the amount paid from another party is the automobile accident where the employee is injured due to the carelessness of another driver.  While automobile accidents give rise to a significant number of workers’ compensation subrogation claims, there are many other events that can produce a subrogation claim. 
 
Some examples are:
  • Factory machinery that malfunctions injuring an employee
  • Factory machinery that does not incorporate standard guards and safety systems
  • Ladders and scaffolding that fails or is defected
  • Any piece of equipment that malfunctions causing an injury
  • Delivery people injured due to a defect at the delivery location (for example a trip and fall due to a pothole in the parking lot)
  • Injuries caused by the faulty workmanship of a third party
Subrogation in workers compensation can arise from any event that would create a claim in automobile liability, products liability, general liability, construction defect liability, homeowner’s liability, medical malpractice, or any other types of liability insurance.
 
Every Claim Should Be, But Isn’t Being Reviewed for Subrogation
 
Every workers’ compensation claim should be reviewed for subrogation potential when it is reported.  Unfortunately, most workers’ compensation adjusters are experts in workers’ compensation but have little or no knowledge of liability claims.  This results in the work comp adjusters frequently missing opportunities for subrogation.
 
The workers’ compensation adjuster should be taught to incorporate into the initial investigation of workers’ compensation claims to ask these questions:
 
  1. What caused the accident?
  2. How did the employee get injured?
  3. If someone else had done something differently, would the injury have occurred?
  4. What object was the employee in contact with when he/she was injured?
  5. Did the object function correctly?
  6. Was there another party involved?
    • Individual
    • Manufacturer?
    • Business?
    • Creator of a defect?
The answers to these questions will assist the adjuster in the determination of the opportunity for subrogation. [WCx]
 
While the workers’ compensation adjuster can be instructed to ask themselves the above questions, the work comp adjuster will still miss some opportunities for subrogation. There are a couple approaches the insurer or self-insured employer can take to improve the number of qualified subrogation opportunities.
 
 
Develop Subrogation Department
 
One approach some workers’ compensation insurers and large self-insured employers use is to develop their own subrogation department staffed with liability adjusters and subrogation specialist who can analyze each claim for subrogation potential.  A cost benefit analysis of this approach should be undertaken to verify that the additional personnel cost are more than offset by the additional subrogation recoveries.
 
A different approach to maximizing subrogation recoveries while minimizing the associated cost is to outsource the identification of subrogation opportunities.  This is accomplished by hiring an outside, independent claims auditor who has an extensive background in both liability claims handling and workers’ compensation claims handling. An independent claims auditor with multiline claims handling experience will be able to maximize the number of files identified to have subrogation recovery potential.  The independent claims auditor should review not only the open claim files, but also all closed claims files still within the tort statute of limitations for the jurisdiction.  If you would like assistance in identifying an independent claims auditor to assist you in maximizing your subrogation recoveries, please feel contact us.
 
 
 

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

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com Contact mstack@reduceyourworkerscomp.com

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

VIEW SAMPLES PAGES

MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

Fix Workers Comp Misunderstandings Before They Get Out of Hand

 

Misunderstandings Need to Be Address ASAP
 
Work comp misunderstandings are not a puzzle to be solved by the curious – they can be deadly if not properly addressed as quickly as possible. A complaint site to which people can report problems with insurance companies had the following anecdote:
 
“A NY employee was injured while out of state and received local treatment. The facilities were never paid, although bills were submitted. The worker called the carrier and was told that medical reports were never submitted. The employer had verified the injury and had no problem with the claim.”
 
The editor of the complaint site suggested that the worker file a complaint with the Workers Comp Board (WCB) in NY.
 
Employers hear similar stories all the time. What should have been done? (Filing a complaint with the WCB is possible, but few life expectancies are long enough to make the choice viable.)
 
 
Get the Facts
 
First, the story has many loose ends. How does the worker know what an out of state medical office submitted? Was it just a bill? Was there a medical report which clearly indicated relationship to work activity? What does it mean to say that the employer had no problem with the claim? Did the worker see the employer’s First Report of Injury (C-2)?
 
 
Make the Call, Be Proactive
 
The correct plan is for the employer to call the medical facility and discuss first. Then, with a HIPAA from the worker, ask for a copy of the file. Inform the facility that the employer will try to resolve this matter. In the meantime, advise that the medical bill should be submitted to the group health plan. They will be reimbursed by the carrier when the matter is resolved. (The NY WCL has provisions for group health plans paying when such snags occur.)
 
Why should he employer make the call? Because the problem will only drag on if they don’t. A recent study of smaller comp claims shows that when small claims encounter snags the worker will eventually get a lawyer (90 days into the claim) and the small claim grows into a mid-size claim, or larger.
 
The problem may not be solved immediately, or at all, but a worker seeing that the employer is doing something to help will almost always eliminate the need for a lawyer on a small claim.
 
Next, the employer should call the carrier to find out if no medical reports were received, or if reports were sent which lacked sufficient information. Or, perhaps, the reports describe something which cannot be considered work-related. None of these would warrant filing a complaint against the carrier with the WCB.
 
Employers should remember – it’s their claim too.
 
 

Author: Attorney Theodore Ronca is a practicing lawyer from Aquebogue, NY. He is a frequent writer and speaker, and has represented employers in the areas of workers’ compensation, Social Security disability, employee disability plans and subrogation for over 30 years. Attorney Ronca can be reached at 631-722-2100. medsearch7@optonline.net

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com Contact mstack@reduceyourworkerscomp.com


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

If My Workers are Hurt Why Do They Not Tell Me

It is always an interesting issue when talking to injured workers that have late-reported claims – very late reporting is the beginning of NOT reporting.  Similar to turning in homework late while in elementary school, the list of excuses can be lengthy.  The usual response is “I did tell my supervisor three times who must have just ignored me.”  Then of course when talking to the supervisor, it is learned the worker never told them about any type of injury at all. 

 
 
So these claims can spiral into a “he said-she said” argument where the blame will shift back and forth. The burden of proof is on the claimant to prove a work injury was sustained while  completing a work-related task. And as we discussed before most of the claims that come about are legitimate in nature. [WCx]
 
 
Delays in reporting injuries can greatly affect whether or not this worker will receive benefits or not, even if said injury is to be legit and compensable.  But with every day that ticks by, the story will hold less merit.  Even great workers sometimes are not going to run to you after an injury.  So here are some common responses as to why an injury is reported late.
 
 
1. The injured worker is a new employee
Nobody likes to be the new person on the job.  It is like starting at a new school. The new worker knows no one and does not know where to go. The worker may feel the need to have to prove skills right off the bat.  But even worse than being the “new guy,” is being the “new guy that injured himself on the first week of work.”
 
 
With the economy low, people are waiting longer periods of time between jobs.  This leads to general deconditioning, since workers are no longer working but rather living sometimes sedentary lifestyles.  It is very common to see recent new hires injured very quickly, as a result of this deconditioning.  The new worker wants to grab the ball and run with it just like they have not missed a step.  And that is possible, but it can also lead to injury. General deconditioning is the physical factor, but the psychological factor is far greater.  And , the worker may not to admit that anything is wrong.  The worker may have been unemployed for several months and has a family depending on the worker’s income or possibly bill collectors.  Due to these factors, the worker will not jeopardize the job or easily admit that an injury has happened.
 
 
2. The injured worker is a veteran employee with a good track record
On the opposite side of the table is the veteran worker.   The veteran has worked here for 25+ years and never had an incident.  It is a great source of pride to the veteran worker.  The worker has great job skills, and a good work ethic.  So they may have some aches and pains, but these resolve with time.  The worker has no history of a comp claim, and does not go to the doctor unless absolutely necessary.  So, these workers have the opposite versus our new workers listed above, but mainly stubbornness is the factor for not reporting an injury. These claims will be reported  a day or two before the veteran worker is heading in for surgery.  These workers will be the first to say they never had any incidents at work before this one, so there is no question that this is work related.  They feel as if they are entitled to workers comp, and sometimes can be difficult to deal with.  But the adjuster will complete an investigation, and if it is compensable, then the claim will be paid. 
 
 
3. A supervisor dropped the ball
Maybe the worker tells the supervisor he is hurt, and wants to report a claim.  The supervisor tells the worker he should tell HR so they can get a claim called in.  Then the supervisor went to lunch and forgot about it.  If the process for reporting claims is not very streamlined, this is a scenario an employer will see quite often. Time is the biggest factor in any claim, and the more time that goes by before the adjuster can get control of the file, the worse the outcome on the claim could be.  So make sure the supervisors know the importance of reporting the claim, if one of the workers claims an injury. And make sure to have some sort of discipline in place for those supervisors that fail to report a claim to the appropriate people within a timely fashion.
 
 
4. The injured worker had a bad experience on a prior comp claim
Some workers carry around a lot of baggage with them, from employer to employer.  This means if the worker has past workers comp claims, they have dealt with multiple carrier/TPA companies, and different adjusters, all with different styles and different ways of doing things. The worker may have had very bad experiences with these adjusters, and this has soured them on the whole compensation experience.  The worker says “I would rather go through my own insurance then have to go through that again.”   This will not help the employee in the end, because insurance will deny it. And the worker will have to go through comp whether they like it or not creating more problems.  But a lot of workers have this bad prior experience, and they do not trust the comp system, not the carrier/TPA, and will do whatever they can to avoid having to turn a claim in for an injury.
 
 
5. The worker thinks delaying reporting the claim will make it seem more legit
Some people think that waiting a few months to report a claim will make it appear they have a great work ethic, that they hoped not to have a claim to report. The worker will tell his boss “I was trying to save you some money; I did not want to report a claim.  I feel bad you have to call a claim in now.”  But this may not be 100% true.  Some people think that injury duration is a substitution for compensability.  But even if claiming to have the same shoulder problem for 2 years, it will not make a claim any more compensable than having the injury for 2 days.  Age is not a factor in the overall compensability of a claim.  Many other outside factors have to be taken into account, not just age of injury. (WCxKit)
 
 
Summary
We listed 5 factors in why an employee would avoid reporting a claim.  There are probably dozens more, but these 5 are generalizations of what we see a lot in workers comp.  It again comes down to communication, so all parties know what their responsibilities are.  The HR person, the supervisor, the worker, everyone has a job to do when an injury occurs, and the compensability of the claim can only be determined by the adjuster.  So if any of your workers try to pull any of the 5 items listed above, it doesn’t mean that their claim is not compensable and cam be denied.  Leave that work up to your adjuster.
 
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20%-50% www.WCManual.com. Contact: RShafer@ReduceYourWorkersComp.com.
 

Our WORKERS COMP BOOK:  www.WCManual.com
 
WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php
 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact  Info@ReduceYourWorkersComp.com.

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18 Arrested in New York for Workers Compensation Fraud

Benjamin Lawsky, superintendent of the Financial Services, recently reported that 18 people in 13 New York counties have been arrested in the latest effort to save businesses money by cracking down on workers compensation fraud.
 
 
The arrests were the result of a series of joint investigations led by the Department of Financial Services (DFS). Joining DFS in the investigations were the Office of the Inspector General (OIG) of the New York State Workers Compensation Board, the New York State Insurance Fund (NYSIF) and other insurers. (WCxKit)
 
 
The 18 arrests included:
 
Albany County — Charles Foster, 48, of Hoosick Falls, collected $22,800 in benefits after hurting his leg when cutting down a tree while employed by the Village of Hoosick Falls in February 2010. However, investigators found that he was managing a storage facility and running a scrap metal business while collecting the benefits from NYSIF. He is charged with workers comp fraud.
 
 
Schenectady County — Lee Kittle, 49, of Scotia, collected $22,600 in compensation from NYSIF after suffering an injury while employed at a mill in 1993. He was found to be working at Schenectady County Community College as a tutor and the Saratoga Race Track as a teller. He gave authorities a written confession. He is charged with offering a false instrument for filing in the first degree and workers comp fraud.
 
 
Erie County – John Czechowski, 45, of West Seneca, collected $12,000 from NYSIF after he was classified as totally disabled for a back injury he suffered working as a roofer. However, investigators discovered he was working off the books for a contracting company while collecting the benefits. He is charged with third degree insurance fraud, grand larceny, offering a false instrument for filing and workers comp fraud.
 
 
Onondaga County — Kemberlei Senke, 44, of Liverpool, is accused of claimant fraud for collecting $26,000 in benefits issued by NYSIF between June 2009 and January 2011. She reported suffering a knee injury while employed by Artistry in Wood. The investigation disclosed that she falsified reports to the NYSIF to inflate her wages and employment status. She is charged with insurance fraud in the third degree, offering a false instrument for filing in the first degree and workers comp fraud.
 
 
Onondaga County — Cheryl LaQuay, 62, of Calcium, is accused of fraudulently collecting $53,000 in benefits from the NYSIF between Oct. 2006 and Sept. 2011, while working as a home health aide. She is charged with insurance fraud in the second degree, offering a false instrument for filing in the first degree and workers comp fraud.
 
 
Oneida County — Aaron McElhinney, 26, of Vernon, is accused of collecting $11,600 in benefits from Chartis Insurance Company after falsely reporting that he suffered a work-related injury. Investigators found that he told his girlfriend and her mother that he was going to fake the injury so he could go to Florida. Co-workers corroborated that he did not hurt himself. He is charged with insurance fraud in the third degree and workers comp fraud.
 
 
Oneida County — William Ellis, 43, of Utica, admitted working for a construction company from 2004 through 2007 doing roofing, siding, plumbing and masonry while collecting $15,000 in benefits from NYSIF for an injury he suffered while working for a paving and excavating company in 1993.
 
 
Oneida County – William O'Neil, 30, of Rome, is accused of collecting $1,790 in benefits from 21st Century North American Insurance Company while working for a moving company. He was collecting benefits after suffering an injury while working as a carpenter. He is also accused of giving false testimony at a workers compensation hearing and causing a false independent medical examination report to be prepared and filed as part of his claim. He is charged with perjury in the first degree and workers comp fraud.
 
 
Ulster County — Sergio Cortez, 37, of Rosendale, collected $6,800 in benefits from NYSIF after claiming he suffered a slip and fall injury while working as a carpenter for ABD Stratford LLC in September 2009. However, investigators found that he was working as a landscaper while collecting benefits. He is charged with insurance fraud in the third degree and workers comp fraud.
 
 
Ulster County — Willie Dixon, 47, of New Paltz, collected benefits from NYSIF for an injury he reportedly suffered while working for the New York State Office of Family and Children Services in May 2010. An investigation revealed he failed to disclose on work activity reports that he was employed as a coach while collecting $4,700 in benefits. He is charged with insurance fraud in the third degree and workers comp fraud.
 
 
Ulster County – James Roy, 51, Hyde Park, is accused of attempting to collect benefits after falsely reporting that he suffered a work-related injury while employed by a tool-making company. He claimed that the injury occurred when he slipped on ice in the company’s parking lot, but witnesses contradicted his claim. He never received compensation because his claim was discovered to be false before benefits were issued. He is charged with workers comp fraud.
 
 
Otsego County — Susan Gridley, 61, of Schuyler Lake, started collecting benefits after an injury she sustained while working at a horse farm in 1986. She later failed to disclose on work activity reports submitted to the NYSIF that she was working as horse boarder and trainer while collecting $4,700 in benefits.
 
 
Oswego County — Kimberly Harrington, 53, of Lacona, is accused of cashing her dead husband’s workers comp benefit checks totaling $2461.90. The checks were issued by the NYSIF. She is charged with grand larceny in the fourth degree.
 
 
Warren County — Jeffrey Hamblin, 45, of Glens Falls, reportedly suffered a knee injury while employed as a truck driver for HR Logic/Doberts Dairy in November 2001. An investigation revealed he was employed as a general contractor for Painters Plus and worked for a doctor while collecting $7,700 in benefits from Liberty Mutual Insurance Company. He is charged with falsifying business records in the first degree and insurance fraud in the third degree.
 
 
Chenango County – Patricia Wilcox, 60, of Oxford, started collecting benefits from NYSIF after claiming she suffered a broken ankle while working as a teacher’s aide at the Chenango County Head Start program. Investigators found that her injury actually occurred at her home. She fraudulently collected $12,900 in benefits. She is charged with falsifying business records in the first degree and workers comp fraud.
 
 
Tompkins County – Steven Odum, 65, of Ithaca, is accused of failing to disclose work activity as the lead guitarist with the “Steve Odum Trio” on reports he sent to the NYSIF while collecting $11,300 in benefits after suffering an injury in 1988 while working at a residential child care institution. He is charged with offering a false instrument for filing in the first degree and workers comp fraud.
 
 
Clinton County – Leonard Drown, 63, of Morrisonville, is accused of collecting $25,500 in benefits from Pennsylvania Manufacturers Association Insurance Company after claiming that he was not working because of an injury. Investigators found that he was, in fact, working while collecting the benefits. (WCxKit)
 
 
Broome County – Olga Shelestovsky, 43, of Johnson City, is accused of working as a waitress while collecting $2,200 in benefits from NYSIF and claiming that she was unable to do any physical work. She is charged with offering a false instrument for filing in the first degree and workers comp fraud.
All of the accused are innocent until proven guilty.
 
 
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He recommends the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com. See www.LowerWC.com for more information. Contact: Info@ReduceYourWorkersComp.com.
 
 

ABC;s of WORKERS COMP:  www.WCManual.com
 
WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php
 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact  Info@ReduceYourWorkersComp.com.

No News is NOT Good News, When Managing Work Comp Claims

Work comp operates under certain presumptions, one of which is that unless an employer provides information to the contrary there is a near certainty that the workers will have every issue resolved, eventually, in their favor. Even if the information is provided it may be arriving too late to change a judge’s opinion about a claim, if the other side gets its info in first. And there remains the nagging question about why an employer would withhold information that was to its advantage.
 
The answers lie in the fact that most employers, after they complete a report of injury, think the active role is over. Surely, the carrier or Board will inform them if more is needed.
 
Almost always, much more IS needed and the employer is the best and/or the ONLY source of such information. But if no one asks, why should the employer volunteer information? Silence in such cases is golden – but not for the employer.
          
An employer must first realize           that every comp claim belongs to it and it alone. A carrier is paid to assist and is a surety for payment – but all expenses will ultimately be borne by the employer – sooner, later and often both.
 
An employer is not expected to be an expert in comp law or procedure – but they can and should be curious and concerned. Calling the carrier and discussing what documents are available that shed light on an employee’s past known history of claims and injuries or illness is invaluable to a defense, especially if the documents are sent ahead to the carrier in a timely fashion. “Timely,” in this case, means as soon as possible.

A Roman poet once wrote
: “words are treacherous companions, but silence is a faithful friend.” Very true, but the poet was writing for the benefit of someone who had something to hide. In work comp, silence is the best friend an incorrect decision against an employer could ever have.
 
Author: Attorney Theodore Ronca is a practicing lawyer from Aquebogue, New York. He is a frequent writer and speaker, and has represented employers in the areas of workers compensation, Social Security disability, employee disability plans, and subrogation for over 30 years. Attorney Ronca can be reached at 631-722-2100.
 
 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Info@ReduceYourWorkersComp.com.

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