The Right Way and Wrong Way to Deny a Workers Comp Claim

 

There are a lot of ways to deny a workers comp claim. The easiest way is if the case is not work related at all. The reality is that most injuries are work related, or at least they arise out of the course and scope of doing the job.
 
 
But there are a lot of ways that an adjuster can suspend or deny a claim, even though it may be compensable in the beginning.  Injured workers have to follow certain legal statutes held up and reinforced by the Statutes within the jurisdiction.
 
 
Below, we discuss a few ways that claims can be suspended or coverage can be terminated, and what you should look for within each one:
 
 

 

1.  The injured worker avoids treatment or is trying to treat with non-conventional means

There has always been a negative stigma with the occupational clinic that works with employers.  Injured workers feel that these clinics do not have their own needs in mind, but rather the demands of the employer.  These clinics often have long wait times to see a physician, and by the time you actually get into the exam room the doctor spends two minutes with the patient and says the injury is not work related.
 
 
This may be the case, but with certain jurisdictions a person can treat with whomever they wish.  Sometimes the medical diagnosis given by a chiropractor is held in the same regard as the diagnosis given by an orthopedic surgeon.
 
 
Adjusters are quick to pull the trigger on filing a suspension once an injured worker bails out of the occupational clinic in favor of their own primary care doctor.  As stated above, however, this may not be against the rules at all.  If you see this happening on your claims, be sure to discuss the rights workers have with your claims adjuster to ensure you are not missing information.  Maybe the primary care doc is not providing medical records, and this is the cause of the suspension.  Or maybe the primary care doc is not treating the actual comp injury and they are sending the bills to the comp carrier for treating another condition.  In any case, be sure that you have all of the details before rushing to judgment.
 

 

2.  Terminating wage benefits when a worker does not show for light duty work

If an injured worker has medical restrictions, the employer should take every chance they have to find work within those restrictions.  This limits wage loss expense, and keeps the worker doing something worthwhile for their employer instead of sitting at home and collecting a paycheck. 
 
 
Adjusters are quick to hit that denial once a worker does not show for this light duty work.  You have to be careful here, however, as some statues have a clear definition of how a light duty work assignment is given to an injured worker.  A voicemail may or may not be sufficient.  The offer could have to be made in writing and delivered via certified mail with the employee given enough notice to show for the work assignment.  Sometimes the work tasks and hours have to be clearly stated, and if any of this information is left out it voids the work duty assignment.  If you have questions about these light duty work assignments,  discuss it with your claims adjuster and legal counsel to be sure you are doing it correctly on every claim.
 

 

3.  The injured worker misses their IME appointment

If a worker is sent for an IME by their claims adjuster and they do not show, this doesn’t mean that their claim can be totally denied.  Most jurisdictions will allow the adjuster to suspend benefits until the claimant attends their IME, but rarely will it allow a full outright denial just based on the worker not showing.
 
 
This may not be true if the worker misses several IME appointments.   It is important to make sure that the claimant is being notified of the IME properly.  Sometimes it will have to be with a certified letter delivered and signed for by the claimant.  If this is not done properly, the suspension that was filed is rendered worthless. Do your homework and make sure these cite letters are being sent correctly.
 

 

4.  The presence of pre-existing conditions

Perhaps the most common reason for a suspension or denial is the presence of pre-existing conditions where the injury is located.  Let’s use a back strain as an example.  If a worker injures their lower back lifting a bag, they may sustain a strain.  If the strain doesn’t resolve in due time, an MRI may be performed.  If this MRI shows arthritis in that same area, adjusters will commonly file a denial saying that pre-existing conditions are present and that the injury is not work related.
 
 
This may be true, but that may not mean that the claim is not compensable.  The worker still lifted the bag, and may have sustained an exacerbation on top of that pre-existing condition.  If the worker needs surgery, a case may be made where the surgery is not entirely due to the work incident and is not covered as part of the comp case. That may be true, but the carrier is still probably on the hook for the strain. Some jurisdictions may or may not allow this, so be sure you know what you are dealing with when it comes to pre-existing conditions and workers compensation.
 
 
Summary
The common theme for the above items is that even though you see an alley to dispute a claim, it may not be as strong as you think.  Be sure to discuss your concerns with legal counsel, and know the proper way to do tasks, cite letters, and make sure all adjusters are following the rules properly.  It will save a lot of headaches down the road.


 

 

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

  


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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.

How to Manage Independent Medical Examinations to Control Costs

 

Independent Medical Examinations (IME) [also known as Independent Medical Evaluations in some jurisdictions] is a major tool used by workers compensation adjusters and defense attorneys to control medical treatment cost. An IME is the utilization of a medical specialist to examine the employee, to review the employee’s medical history, to provide a diagnosis, and to provide a prognosis. The medical specialist will give an unbiased opinion as to the nature and extent of the employee’s injury. An IME will establish the true level of the employee’s disability and permanency level. This makes the IME an important method of controlling medical treatment cost as well as a way to limit unnecessary lost time.
 
 
The states vary in the number and type of IMEs that can be had. In some jurisdictions, the employer/insurer is limited to one IME throughout the entire course of the claim. In other jurisdictions, the employer/insurer can have as many IMEs as they are willing to pay for. With an IME costing $500 to $1500 depending on the location and the specialty, the employer or insurer does not want to waste money having needless IMEs performed. [WCx]
 
 
The IME doctor will need all the available information on the medical condition of the employee. The IME doctor needs to be provided all medical reports from prior medical providers, all diagnostic testing results (MRIs, CT scans, EMG studies, x-rays, etc.), a complete job description of the employee’s duties including all physical requirements, and the employer’s first report of injury stating exactly how the employee was injured. If the employee has aggravated a preexisting condition, all medical records for treatment of the preexisting condition should be obtained prior to the IME and provided to the IME doctor.
 
 
The adjuster, employer, or defense attorney requesting the IME should draft a letter to the IME doctor stating the concerns about the employee’s medical situation, and outlining the medical questions that need to be answered. The letter should be kept objective, clear, and to the point, as in some jurisdictions it can become a part of the evidence in the claim.
 
 
The various industrial commissions, workers compensation boards, departments of labor, and bureaus give different levels of credence to the opinion of the IME. In some jurisdictions the opinions expressed in the IME hold equal weight with the medical opinion of the primary treating physician.  Other jurisdictions consider the IME but normally give greater credence to the primary treating physician, as the primary medical provider has normally seen the employee many more times than the IME doctor has.
 
 
Overcoming the bias of the commission / board / labor department / bureau requires the selection of a highly skilled and well respected doctor. Many adjusters (and employers on self-insured programs) make the mistake of using the same conservative doctor over and over for every IME. The opinions of these well qualified, conservative doctors, while often are accurate, are discounted by the hearing official because the hearing official knows the reputation of both the plaintiff attorney’s favorite doctors as well as the reputation of the adjuster’s/employer’s favorite doctor.
 
 
To be successful in the use of IME, the employer or adjuster should select a doctor in the appropriate specialty that has a reputation for telling it exactly the way it is. The hearing official will pay closer attention to the medical opinions of the doctors known to be unbiased.
 
 
As an employer, if the reputation of the possible IME doctors is not known, ask an experienced workers compensation defense attorney who has attended hundreds of hearings for IME doctor recommendations. Stress to the defense attorney that you are not looking for the most conservative doctor around, but for the doctor that has the reputation for being the most objective.
 
 
Of course, there are exceptions to the rule on finding the most objective IME doctor. In some jurisdictions like Georgia and New York, the administrative official hearing a contested disability rating will normally split the difference between the disability rating the claimant has been given by his chosen doctor and the disability rating given by the employer’s IME doctor. In those situations, where it is assumed the employee’s doctor will be providing a high rating and the IME doctor will be providing a lower rating, the use of a conservative IME is the better approach. Therefore, it is very beneficial to know how the system works in your state. (See our state by state guide for Laws and Regulations Here.)
 
 
After the IME, if there are still questions about the employee’s medical condition that have not been answered, it can be beneficial to follow-up with the IME doctor and ask those questions. Also, the IME doctor may be able to direct you to research on the particular medical condition of the employee that can be used at the administrative hearing.[WCx]
 
 
In order for the IME to be used as evidence in the claim, you must share it with the employee and/or employee’s attorney. Consult with your defense attorney as to the best time to share the IME information.
 
See also our Insurance Dictionary of Terms and Abbreviations Here

 

 

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 at Amaxx Risk Solutions, Inc. is an expert in employer communication systems and a part of the Amaxx team helping companies successfully reduce Workers Compensation Costs by 20% – 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com   Contact:mstack@reduceyourworkerscomp.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.

5 Reasons Why Reserves Need to be Higher than You Think

As a Risk manager, claims coordinator, agent, human resources representative — whatever your title may be, the name of the claims game comes down to reserves. Reserves are the tangible part of what an injury costs you, either directly out of budget, or as potential future increased premium costs. A lot of speculation and estimation goes into reserving a file, but a good percentage of the time when you try and come up with a number for a file you find yourself way too low. Why are the numbers that your adjuster recommends so high? What exactly do we have to cover as future medical cost, even though this claimant may no longer work for you? How do adjusters learn how to reserve?  
 

1. It is the cost of the claim for “life”
When you think about reserving a file for the long term, you have to think long term. Not long term as in 10 years. Long term as in for the rest of that person’s life. In most states, if an injured worker needs long-term reasonable and necessary medical treatment for their injury, and the doctor relates  treatment specifically back to that injury, then your company is probably responsible. You can get an IME (Independent Medical Review), or record review to fight why the recommended treatment is not related but, typically, the burden of proof is just causal relationship. If the patient can show the need for treatment relates back to the injury of 20 years ago, they have met their burden of proof. This is when these injuries can come back to bite you. Instead of settling 10 years ago because you thought the number was “too high,” now you are going to have to scramble to come up with a defense and, if it is indeed related, not only will you have medical costs but you may have wage-loss costs as well. (WCxKit)

 
 
The future is your biggest enemy in surgical claims with long-term exposure. Once surgery is performed, nothing is ever the same. Scarring, nerve issues, accelerated arthritis symptoms, the need for ongoing medication and doctor evaluations, diagnostic testing, etc. These things all lie in wait for the future. Sure, right now in 2011 the claimant’s demand of $100,000 may seem like a lot. But you have to break the file apart, and this is what the adjuster does. If your injured worker is 30 years old, you potentially have  55 years of exposure. If back surgery was  in 2011, and the claimant is  30 years old, you have a ton of problems sitting there waiting for you. The claimant may be fine now and the surgery was a success. But what about 5,10,15 years from now? Will be needed another surgery? Maybe that one will not go as well. So consider the long term: The life of the claim, the life of your claimant, and the need for future medical treatment.
 
 
2. The injury requires potential future surgical risk
Surgical cases are major red flags for future problems, especially when some sort of hardware is implanted. Most of the time these people return back to doctors due to pain, usually due to hardware or screws becoming loose. Then this person has to undergo a procedure to have it removed. Then, they have to rehab from that, and then they can return to work. But, again, the issue here is when will the person need that hardware out? Some can live with it forever and never come back. Some come back in a year or two. Some have constant problems with it and it creates problems preventing them from making a full recovery from surgery.
 
 
Back surgery is especially risky. In the world of workers comp you do not hear about many success stories with major back surgery. It may lessen the pain, but it can create a ton of future issues. When you evaluate these claims and costs of settling them, be sure to account for future surgical risk. It is very costly, and very risky, and maybe you better get rid of that risk now if you can versus adopting a “wait and see” attitude.
 
 
3. The costs ongoing medications
If you pick up any newspaper you will run across a story about the costs of medications and how they are dramatically increasing. Each drug manufacturer has their reasons to increase price but, whatever the reason, the bottom line is prices are always going up. And if you have a claim where a claimant has to take ongoing medication for pain or nerve issues, those meds are typically not the cheapest ones. Sometimes generics are available and worth looking in to, but its still an ongoing monthly cost that can drag on for years. You can find out from your IME doctor if it is necessary for your claimant to continue taking these meds, how often they should be taking them, etc. That way you can properly estimate the future cost. But keep in mind to add in a percentage for inflation over the years, since prices show no indication of decreasing.
 
 
4. An MSA may be needed
Perhaps the biggest roadblock to settling a claim is the need for a Medicare Set-Aside (MSA). The MSA breaks down future cost for those who require future treatment while also being on Medicare or of retirement age. If your veteran worker sustains a major shoulder injury a year before retiring that is not good. Not only do you have to cover surgery and rehab on a veteran worker in your shop, but also, the chances for a good recovery are guarded, which means ongoing treatment could last for years. An MSA is needed if you want to move this case to settlement. MSA numbers are not small. There are several vendors who specialize in MSA reports and submissions, and they will tell you they are very costly once approved by CMS (Center for Medicare/Medicaid Services).
 
 
MSA’s are costly, speculative treatment estimations. And the key word here is “estimates.” There is no guarantee the claimant will need another surgery. But they may estimate it for you, and make you pay for one just in case. So maybe that is a scenario where you should not settle. It is something to discuss with your adjuster. The point is, be aware if an MSA is needed it is going to financially cost you to settle and resolve your risk involvement in this case.
 
 
5. The age/general health of the claimant matters
Obviously if a 22-year-old worker falls and breaks his neck, you have about 63 years of medical exposure. If your 67-year-old, part-time janitor falls and breaks his ankle, you have maybe 16 years of exposure. Age matters. The younger the claimant, the more severe the injury, the more costly it is going to be.  Reviewing employees  personal health histories correlates to cost as well. The healthier the person, the speedier the recovery and the less it may cost to get them  back to full duty work.
 
 
It is hard to control genetics. Everyone is different and heals differently, but you can get a good idea about if someone is “healthy” or not. If you have seen your claimant in the past eating fast food and chain smoking during  daily breaks or lunchtime, you know quick healing is probably not in that person's future.
 
 
Summary
The art of reserving a file for life expectancy is part science, part estimation, and part experience. Adjusters see the same injuries day in and day out. Sometimes they deal with poor healers and sometimes they deal with those who make a speedier recovery than planned for. This is why reserving a file for probable outcome is an art form. All you can do is look at the evidence and what the future may hold. If in doubt, aim for a higher rather than lower reserve figure.(WCxKit)
 
 
For your long, large claims, utilize the help of a life care manager or an MSA company. Talk about future medical needs and costs with your adjuster. Roundtable the file with your peers and see if you are missing anything. Ask your adjuster during your weekly roundtable meeting. If you don't have a weekly roundtable, it might be time to ask for one. It is complicated to think about every cost an injured worker may need between now and 40 years from now, but if you use the tools at your disposal you should be able to get an accurate, effective reserve for the life of the file. If you want to outsource this – and many do – to a an expert, consider the Life Care Planner services of your TPA or MSA company. Also, ask your adjuster for the Reserving Worksheet – this can clear up any problems.
 

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.
 

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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.
 
©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.

Eight GREAT Techniques to Control Workers Compensation Medical Costs

The cost of medical care is the largest part of the total cost of workers compensation. Finding ways to control and manage these medical costs is important to maintain and control workers compensation cost. There are numerous techniques to use to control medical costs.
 
Let us look at the ones providing the most benefit to the employer:
 
 
1. Nurse Case Managers
The most important person in the control of workers comp medical costs is the Nurse Case Manager (NCM). The NCM is responsible for planning and coordinating medical care to assist the employee in returning to work as soon as physically able or when the employee reaches the maximum medical improvement (MMI). The NCM role can either be in the office handling most communications by telephone — a telephonic case manager (TCM); or the nurse can spend most of her (or his) time away from the office — a field case manager (FCM) who attends medical appointments with the injured employee.   (WCxKit)
 
 
Whether the nurse is referred to as a NCM, TCM, or FCM, the role is to make sure the employee receives all necessary medical care as quickly as possible. The responsibilities of the NCM include:
 

1.      Consulting with the medical providers on the best options for treating the employee.

2.      Coordinating the medical care between the different medical providers.

3.      Preventing the over utilization of medical care while ensuring the employee receives all needed care.

4.      Acting as a liaison between the employee, employer, physician, therapist, insurer, and other parties.

5.      Facilitating the communications between the employee, employer, and adjuster.

6.      Arranging the employee's return to work either in modified duty with the necessary accommodations or full duty without any accommodations.

7.      Keeping the adjuster and employer informed as to the employee's medical status.

 
2. Medical Provider Networks
When various medical providers including doctors, hospitals, physical therapists, and others join together for the purpose of providing medical care to a specific group (employees), a medical provider network is formed. In exchange for sending all injured employees to the medical provider network, the employers or insurers receive a group discount on the cost of medical care. California and Texas are the two biggest states where medical provider networks are utilized to control the cost of workers compensation. Follow the rules exactly, and you can direct care for the life of the claim in California. In California, these are called MPNs.
 
 
3. Medical Triage
Medical triage is the process of having a trained nurse arrange the medical care for any employee who reports an injury. The triage nurse coordinates the medical care for the employee, arranges for the initial medical visit and any follow up visit, and advises the adjuster on the nature of the injury and the type of initial care received by the employee. Approximately 40% of your claims will be "self care" claims, which means you'll have 40% fewer claims, many of which would have ultimately become lost time claims. It's a way to stay on the claim from Day 1. Nurse triage can even direct the employee (and supervisor) to the nearest PPO in your network – if allowed by state law.
 
 
4. Utilization Reviews
Utilization review is the review of medical care by another party other than the medical provider to ensure the appropriateness of the medical care. There are three types of utilization review.
 

1.      Pre-certification: the requested medical service whether hospitalization, surgery or diagnostic testing, is reviewed by a trained nurse or doctor, to verify it is the best medical approach for the injured employee's medical care, before the medical care is provided.

2.      Concurrent reviews: occurs when the employee is in the hospital is having any other medical care that takes enough time for the medical necessity to be checked before it is completed.

3.      Retrospective reviews: verifies the need for medical services already provided.

 
 
5. Medical Fee Schedules
In an effort to control medical costs, most states place a dollar cap on each type of medical service an employee can receive following an injury. A medical bill review company compares all medical bills submitted against the fee schedule to insure only appropriate services are billed and billed for the correct amount. Most states have their own fee schedules – which is generally a very large, complex list (like a phone book) of codes for each injury/illness and treatment.
 
 
6. Pharmacy Benefit Managers
Pharmacy benefit managers (PBM) specialize in providing the employee with needed prescription medications. The PBM arranges for the employee to obtain prescriptions at drug stores within the network, or provides to the employee, by mail, any maintenance medications the employee will take over an extended period of time. PBMs can help control the overuse of prescription medication and curb opioid abuse.
 
 
7. Medical Panels
Several states allow the employer to designate a list of medical providers the employee can select from when the employee is injured. This panel of doctors includes a variety of medical specialties and/or medical facilities. The medical panel is normally posted at the employee's work site for the employee to chose from. This is sort of a blend between employee selects their own provider and employer selects the provider. Which ever state/s you are in make sure you know how medical provider selection is done.
 
 
8. Independent Medical Evaluations (IME)
An independent medical examination is a second opinion from a doctor selected by the insurance company to confirm the diagnosis and treatment of the employee. It can also be used to verify the disability or impairment of an employee when the employee finishes medical care. (WCxKit)  Have an MD write the IME cover letter and point out to the IME doctor relevant causation issues and/or mechanism of injury issues that make be disproportionate to the injury. Why get an IME if it's not going to be preceded/set up with an effective cover letter?
 
 
These 8 approaches are not the only ways to control medical costs in your workers compensation claims. There are various other techniques that can be used to limit medical costs and additional approaches are being developed as more and more employers look for ways to control these costs.
 

Author Rebecca Shafer
, JD, President of Amaxx Risks 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. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com or 860-553-6604.
 
 
ABC's of Workers Compensation Cost Containment Book: www.WCManual.com
 
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.

Key Reasons Workers Compensation Claims Take So Long to Close

Given recent economic turmoil, many are having a hard time meeting financial obligations. This especially rings true for injured workers, who already have a strike against them — they are receiving workers compensation wage loss benefits at 66 percent to 80 percent of their previous income, and they are injured.

 

The situation worsens when an injured worker faces situations such as elimination of their job, permanent physical restrictions, or a long recovery after a major surgery. These factors mean pending workers compensation claims are being held open much longer, inflating claims counts for adjusters across the board.(WCxKit)

 

 

Below, are five situations that contribute to delays in closing workers compensation files:

 

  1. Claimants trying to milk the system.

In the minds of most injured workers, having some money coming in is better than having no money coming in. The injured worker may not have a job to return to or may fear termination because of an on-the-job injury, so they maximize the symptoms of their injury; this is called malingering.

 

 

Whatever the reason, a current trend involves injured workers stretching claims out as long as possible. Some purposefully take longer to recover by doctor hopping, trying non-conventional forms of treatment, and exaggerating pain complaints. The length of time out of work must be proportionate to the degree of disability.

 

 

Most physicians will catch this and mention something in medical records, which should alert the adjuster to set an independent medical evaluation (IME) or to do some surveillance on the file. Using the MDGuidelines is also helpful; since that offers a range of times a worker should be approaching maximum medical improvement (MMI). If the worker is not back to work within the guidelines, it is time for an IME. Be proactive on the claim or the months will continue to go by and the claimant will achieve their goal.

 

 

  1. Injured workers have no job to return to for light duty, let alone full duty:
    As mentioned above
    , a common scenario for an extended compensation claim is when the position the worker was in is eliminated, or when the employer does not have a transitional duty program. Since the job market is tight, some injured workers let their accepted workers compensation claim go on as long as possible.

 

 

Employers should alert adjusters before job cutbacks so they can discuss strategy on who will be affected. The adjuster can form an action plan to get the claimant back to full duty without letting him or her slip through the cracks.

 

 

  1. Claimants choose to litigate because they have no other choice and nothing to lose:

When claims are denied, workers may think they have nothing to lose by filing for a hearing or seeking counsel. This causes the claim to be open for several months or years while the litigation ensues and parties work toward an eventual settlement. The wheels of the legal system often move slowly, and this contributes to the number of open claims out there. If you take a slow-moving legal system and overload it with everyone filing for a WC claim hearing, you get a backlog of claims and the system barely moves. Stay in touch with counsel to make sure he or she is trying to settle the claim and move negotiations forward. The very best way to avoid litigation is to communicate with the employees. Have an employee brochure, a written transitional duty policy, have employee’s acknowledge receipt of the policy, have a brochure for your network physicians, and most importantly have an Injury Treatment Medical Information Form, a/k/a Work Ability Form. THIS gathers information from the injured employee’s doctor at the first medical visit. Employees contact attorneys because they can’t get information from their employers about their claims or their medical bills are not paid.

 

 

  1. Claimants have severe injuries:

Due to company cutbacks as mentioned above, one worker may be doing the work of three. This leads to employers trying to do more with less. Injuries are bound to happen, especially in more heavy-duty, manual-labor positions. Employees working longer hours and doing more strenuous activity are leading toward a musculoskeletal injury and a probable surgery, if not worse.

 

 

These workers may be reluctant to report an injury for fear of losing their job. So they try to work thorough the pain, until the injury gets so bad it needs immediate attention. Workers need to know to promptly report injuries no matter what the circumstance, so they can be treated before it gets worse. Workers with wrist pain wait until they have full-blown carpal tunnel before reporting the pain; whereas if it had been reported sooner, full recovery would have been more rapid and less traumatic; waiting is prevalent when pay is conditioned on production-based pay.

 

 

  1. Some injured employees wait for the Centers for Medicare and Medicaid Services (CMS) to approve the Medicare Set-Aside (MSA):

The dreaded MSA. If an injured worker is eligible for Medicare and the case is in litigation or parties want to settle, in order to settle the claim, an MSA is necessary. This will pay the employee what Medicare would have paid for the continued treatment of the injury. The employee then pays for future treatment from this account. He or she then files paperwork with CMS that tracks the claimant’s continued medical treatment long after the workers compensation carrier settles.

 

 

Getting CMS to approve an MSA can take from eight months to two years as there are numerous payment issues to be ironed out. Carriers and CMS employees are adjusting to this new system and, so far, it has not been a smooth transition, according to Gould and Lamb, experts in MSA issues. An adjuster or counsel can further explain how this works in individual jurisdictions.(WCxKit)

 

In summary, workers compensation claim closure rates have slowed nationwide with multiple forces to blame. But, with a good action plan, some persistence, and a bit of patience, these issues can be resolved and the file can eventually be closed for good.


Author Rebecca Shafer
, JD, President of Amaxx Risks 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. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.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.

 

©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.

 

Four Useful Tips Can Go a Long Way in Managing Workers Comp

When you have a high-exposure file that turns out better than you had expected and costs come in way under what you had budgeted for, it is easy to see the cost-savings that are associated with that loss. If you saved $50,000, that’s a nice lump of savings for your balance sheet. 
 
But those little savings you make throughout the course of a year add up as well. It’s difficult to see it in the short-run, or by the month, but looking at it over the course of a year, it can really add up to a nice savings in your budget. We discuss some ways those little savings can add up below. (WCxKit)
 
 
1-Using quality vendors to get better results:
Sometimes the better vendors just cost a bit more than others. This is usually due to the fact that they have better talent working for them, and there are associated costs included with that. However, if these more expensive vendors get your workers back to you ready for work quicker, then you save again on the wage loss issue. This means that these vendors have already paid for themselves if you weigh their costs versus the cost of wage loss for your injured worker.   Talk with your carrier about who the best vendors are in your area for IMEs, surveillance, and nurse case management. Don’t shy away from them just because their costs are a tad higher than their competition. They can save you money in the long run by providing you with excellent service, and by getting those injured workers back to work quicker than their counterparts.
 
 
2-Enhanced communication with your TPA/Carrier:
Lack of proper communication can lead to increased claims expense. If the adjuster doesn’t know that you have light duty work available, they may not be pushing hard enough to get work restrictions for your injured worker. Maybe the adjuster doesn’t know you have a dedicated medical clinic and/or physical therapy facility and failed to direct the injured party to treat at those clinic locations. 

Maybe the injured worker took vacation time or sick pay for their time off of work, and they didn’t tell the adjuster that so they got paid twice-once by your company and once by the Carrier. Although most times the adjuster will catch this, sometimes they do not. This leads to an overpayment that the carrier must try to recoup, and if they fail to do so the cost of that ultimately gets pushed to you in the result of a higher premium due to increased claim costs. Whatever the event may be, you need to be in regular contact with your adjuster.   

Perform claims reviews and ask the adjuster on each claim what their plan is for getting the claim resolved.  The more you discuss the claim, the more ideas you both can come up with, and that may be what is keeping your worker off of work. By working together, you will save costs. Most adjusters would prefer too much communication versus not enough, plus this will keep the adjuster on their toes and they will be keeping a close eye on your claims, preventing one from falling through the cracks which will further waste claims dollars.

 
 
3-Using the other departments your TPA/Carrier has to offer:
Most Carriers/TPAs have multiple departments that will work with you to reduce your exposure. Loss prevention, ergonomics, dedicated adjusters to your account, medical/nurse resources, medical bill review, etc.   All of these services may be provided free of charge by your Carrier/TPA, and the end result of utilizing these services will be lower claim cost to you. Implementing the action plans that these departments come up with is designed to lower your costs. So talk with your Carrier/TPA and find out what resources they have to help you reduce cost. They will be happy to work with you, and you will be happy since your claims expense will decrease over the course of a year.
 
 
4-Utilizing a 3rd party company for all of your RX needs:
Pharmacy costs are constantly rising. Almost every injured worker comes out of their doctor's appointment with a prescription for some medication in their hand. There are a lot of 3rd party pharmacy companies out there willing to work with you to reduce these costs if you funnel your injured workers to their pharmacy programs. Find out what kind of pharmacy management program they provide. The best sell their services unbundled.  Look for prospective as well as retrospective elements of the cost control program. This can lead to huge cost savings, even on the minor claims, and will help the most with the more severe claims, since those injuries usually require prescriptions that cost more, and they length of the prescriptions last longer. This is a significant way to reduce your costs, and you will see large savings at the end of the year. (WCxKit)
 
 
Summary:
There are a lot of ways to reduce your costs. Not only in the larger higher exposure claims, but in the small minor claims as well. If you think about it, every little savings you can make can add up to a lot by the end of the fiscal year. Remember there are ways to cut costs on every claim, no matter how insignificant the claim may be at the time. You have to think both ways, in the short term and long term. Whatever it may be, the end result is you saving money, and that is never a bad thing
 

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. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
 

ABC's of Workers Comp Management:  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.

17 Ways to Win Your Claims in Workers Compensation Litigation

 
Statistics prove litigated workers compensation claims cost the most. In this article we will use the broad definition of litigation to include any claim where the employee has hired an attorney, regardless of how the claim is settled, whether by agreement, workers compensation board decision, or in the courts. Here are some suggestions on how the employer and/or the insurer can have a positive influence on the overall cost of the claim.
 
 
The First Steps in Controlling Litigation:
Any time an injured employee hires an attorney, you should immediately begin to prepare for the possibility of a long, drawn-out process. Some of the steps you can take include:
 
1.      Employ the defense attorney early on as the employee's attorney will start maneuvering the claim in the most favorable direction for the employee if they are allowed to do so. Assemble your defense BEFORE the first hearing.  Yes, do it early!
 
2.      Assist the defense attorney in preparing to defend the claim by providing the defense attorney with the first report of injury, the wage records of the employee, the personnel records of the employee, any witness statements you obtained immediately after the accident, and any other information that you have that relates to the employee or the injury.
 
3.      Get over your reluctance to offer a modified duty job to the employee. By putting the employee back to work, you diminish the plaintiff attorney's arguments that the employee is unable to work, will never be able to work, etc. Also, if handled correctly, a modified duty job offer will make the employee feel more appreciated and less likely to hold out for a “big settlement."
 
4.      In states where an employer can request multiple independent medical examinations (IME), an IME should be scheduled immediately. Have an M.D. prepare the cover letter to the IME doctor. Yes, it's going to cost money, but in the end, it will save money.
 
In states where the employee selects the medical provider and you only get one IME, an independent medical examination should be scheduled immediately after the employee has reached their maximum medical improvement. I repeat, have your MD prepare the cover letter. This will provide medical documentation that the employee has recovered from their injury and to limit the exaggeration of the injury you can expect from the plaintiff attorney. 
 
5.      If you have any doubt about the validity of the injuries claimed by the employee, consider surveillance to verify or disprove the validity of the injuries. Have the employer review the surveillance.
 
6.      If you do not already have medical case management on the claim, add it if you can. Consider peer-to-peer medical review — this is a doctor who reviews the medical portion of the file.
 
7.      Another way to reduce future disability value placed on the claim is to hire a vocational rehabilitation specialist to assist the injured employee in returning to work. physical therapy networks may have rehab specialists. Consider using one.
 
8.      Do not let your feelings be hurt; the plaintiff attorney is in for the money, and the employee is thinking about his own welfare, not what is in the best interest of the employer or the insurer.
 
 
As the Claim Progresses:
The employer's involvement in claim defense continues after the initial flurry of activity at the beginning of the litigation process.
 
6 additional steps you should take:
1.      After the defense counsel has obtained all the initial information, but before the discovery process begins, review with defense counsel their initial evaluation of the claim. Is the claim one that should be denied and fought all the way, or is the claim one that should be settled? Know what you defense attorney thinks before a lot of money is spent on discovery. Get ALL prior medicals early, before the first hearing if possible. Subpoena them if necessary. Yes, you can do that in most states.
 
2.      If the defense counsel thinks you are going to lose based on his or her initial evaluation, do not be afraid to go ahead and settle the claim before the legal bills escalate.
 
3.      If the defense attorney recommends the claim be defended, or recommends discovery to clarify the defense of the claim, have him to proceed timely. 
 
4.      Do not delay the discovery process. This will only allow the employee to stay off work longer drawing indemnity payments and going to additional medical visits (even if the medical visits are not needed, the plaintiff attorney will encourage the employee to continue to treat to push up the settlement value of the claim).
 
5.      Keep in touch with defense counsel as the status of the claim dictates. More is better than less. If she/he isn't responsive or aggressive, get a new attorney.
 
6.      Always promptly cooperate with your lawyer. It will move the claim along faster.
 
When the Claim is Concluded:
Regardless of whether you settle the claim or the claim is adjudicated by the work comp board or the courts, there are certain steps you need to take including:
 
1.      Pay the claim quickly. Incurring penalties and attorney fees on top of the claim value does not do anyone (except the lawyers) any good.
 
2.      Only consider an appeal if the defense counsel thinks you have a viable chance at winning the appeal.   Appealing the board decision or the court decision simply because you do not like it is an expense you do not need.
 
3.      If the injured employee does return to work, either with or without work restriction accommodations, treat them the same as all the other employees and like nothing ever happened. If you treat the returned and litigated employee like they have the Black Plague, it won't be long before they understand they are not welcome. The employee attorney will be filing another petition for additional benefits claiming the employee is unable to work or the injury has been aggravated with the employee going back off work drawing additional indemnity benefits and incurring additional medical expense. (WCxKit)
 
Note: I usually fight long and hard before I settle if I have any inkling the claim is exaggerated. Settling quickly sends the wrong message. I always VERIFY the extent of the disability with surveillance before I settle. Seeing is believing.
 
 
By planning your involvement in the defense of the workers compensation claim, you can reduce the overall defense cost and possibly the settlement value of the claim. The employer should always take part in the defense, as the cost of the workers compensation litigation will be your cost eventually through your work comp insurance premium. Act now to control the long-term cost.
 

Author Rebecca Shafer
, JD, President of Amaxx Risks 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. See www.LowerWC.com for more information. Contact:RShafer@ReduceYourWorkersComp.com.
 
 

 
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

4 Types of Workers Comp Claim Leakage You Have Not Heard Of Yet

 
Errors in payments, usually referred to as "leakage," are a major issue for any insurance company involved in workers compensation claims. Generally “leakage” is classified into two types: hard and soft.
 
 
Hard leakage refers to erroneous payments made on claims without coverage, e.g., a claim is paid when no policy coverage or compensability exists.
 
 
Soft Leakage refers to overpayments to claimants in wage compensation, errors in medical payments, and errors in payments to medical providers after a claim is denied or disputed.
 
 
There is an area not often mentioned, however: vendor leakage.
 
 
Vendor leakage involves payments to various outside vendors used in investigation and claims handling such as nurse case management, surveillance, independent medical evaluation (IME) companies, and vocational assessments. (WCxKit)
 
 
1. Nurse Case Management Leakage
Many companies use outside vendors for nurse case management (NCM). Adjusters use these nurses to assist in gathering medical records, to talk over medical issues with physicians either onsite or telephonically, and to meet with claimants to get another view of the ongoing medical complaints a claimant may have.
 
 
Leakage can occur when NCM is used on claims where it is not necessary. Too often adjusters have a high claim volume and, to save time, they assign an outside NCM to assist on uncomplicated medical claims. This is not only expensive, but also not needed.
 
 
For example, if a claimant has a typical back strain with no internal structural damage and no pending surgery, there is no need to involve a NCM. But in order to keep an eye on the claimant’s medical treatment, an adjuster assigns a NCM to oversee the medical portion of the file.
 
 
Adjusters are known to assign NCM from time to time solely to gather medical records so they do not have to call the provider and request records. This is both a waste of claim expense and a sign of a lazy adjuster.
 
 
NCM should only be used when there is a complicated surgical case, when congenital medical issues could complicate healing after injury (e.g., a case with a claimant with severe diabetes or morbid obesity), or in scenarios when the same claimant has a number of similar complaints/injuries throughout years in the workforce, indicating the presence of a repetitive injury that could lead to a severe injury if the work duties are not corrected. Any other use of outside NCM is a waste of claims dollars and a waste of the nurse’s time and effort.
 
 
2. Surveillance Leakage
First of all, surveillance does have its place in certain claims and secondly, not all surveillance is a waste of time. However, in most cases surveillance does not greatly impact the outcome of the claim. Depending on the jurisdiction, videotape of a claimant walking around outside or running various mundane simple errands will not impact the compensability of the claim. A workers compensation claim does not disable someone from performing most general activities of daily living.

Keep in mind though that even though it does not influence the outcome of the claim, it may be very useful to build internal management commitment for your program or be a deterrent to fraud when others in the facility become aware that extent of injuries is verified via surveillance. In fact, we at  Workers Comp Resource Center are huge proponents of using surveillance to verify the extent of any injury before a settlement is offered. When one member of our staff was a litigation manager, he wanted to see with his own eyes that a claimant was really disabled before authorizing payment of a settlement. LowerWC.com is a stickler for detail.

 
 
Surveillance is typically costly, and unless an employers has an inside tip that the claimant has other employment, or is routinely breaking medical restrictions, it may not be useful. Surveillance without a purpose is considered leakage.
 
 
3. IME Leakage
Independent medical examinations (IME) are probably the most commonly used tool for adjusters. IMEs are used to make a medical correlation between the objective injuries a claimant may have, and how they relate back to the workplace injury. Inexperienced adjusters will send a claimant for an IME too soon, or too often. The results will shoot their defense of the claim in the foot because, depending on the scenario, the IME physician does not have a reason to terminate ongoing medical benefits. A typical strain can last up to eight weeks, and if the company does an IME at three weeks, the claimant is still in the healing stages and the company will either have to wait for the treating doctor to release the patient from care or perform another IME later and incur extra expenses. So, untimely IMEs are leakage. Using an M.D. to review timing of an IME can eliminate this type of leakage.
 
 
Depending on the jurisdiction, an IME may cost anywhere from $575 and $3,000, which often does not include medical record review, adding hundreds of dollars to the total bill. Plus, costs can vary on the specialty of the physician and the location of the IME. In our experience, which includes many claim audits by an M.D.,  about one-third of IMEs are unnecessary.
 
 
Often the treating physician can address any concerns an adjuster has regarding injury causation, and correlation of symptoms to the injury. This is usually free, and it only takes the time of the adjuster to draft a good letter to the treating doctor outlining the concerns. If the treating doctor will not respond, or it appears a claimant is over-treating for the injury, then an IME is warranted.
 
 
IME physician reputations are sometimes a greater factor than their actual report. There is a physician in Wisconsin who writes a good IME report, but when judges see his name, they disregard his opinions. Plaintiff attorneys and administrative law judges often see the same IME physicians again and again, and if these physicians have given poor depositions in the past or write overly-aggressive reports failing to support objective medical diagnoses, the IME report is not worth the paper it is printed on.
 
 
An IME is a fantastic tool when used properly, with the appropriate physician, with a cover letter written by an M.D. requesting specific medical information, at the correct time it is needed. Any overuse or improper use just leads to more expense sunk into the claim for no strategic benefit.
 
 
4. Vocational Assessment Leakage
When a claimant can no longer perform their pre-injury job, adjusters sometimes bring in a vocational expert to comb the job market for potential work based on the claimant’s experience and medical restrictions.
 
 
Similar to IME reports, the reputation of the vocational counselor is very important. In most litigated cases, a voc expert is used to show the injury and subsequent permanent medical restrictions the worker has doesn’t deter him or her from any future employment. But, this argument must be made correctly. Plenty of outside factors are taken into account, including geographical location, the current job market, the claimant’s transferable skills, and the overall chance that the injured worker will have gainful, long-term, satisfying employment within these restrictions. You usually can’t take a man who was a welder his whole life and turn him into a greeter at a grocery store, and expect a judge to be satisfied with that. This can be avoided by selecting a vendor that searches for jobs in the open market, sets up interviews, and follows up after the interview to make sure the employee attended the interview appropriately dressed, for example — making a real effort to get hired.
 
 
Adjusters know when a claimant sustains an injury resulting in the injured worker having permanent medical restrictions, the claim can go down several routes. First, the adjuster should go to the employer where the claimant was injured to try to either create a job within the restrictions and pay range, or to attempt to modify the worker’s position to accommodate medical restrictions. If this can be achieved a voc expert is not needed. Otherwise, vendor’s fees are spent on countless hours looking for jobs outside of the employer's facility.
 
 
In summary, leakage affects all insurance companies, third-party administrators (TPAs), self-insured employers, etc. Unnecessary outside vendor usage contributes to excessive claim costs and is known to be used more often than needed in day-to-day claims' practices. (WCxKit)
 
 

Consider on a larger scale the costs going into a basic, lost time claim. It is a good bet some of these costs can be eliminated with a more proactive adjuster who is open to getting the injured worker back to the employer by strengthening the adjuster/employer/worker relationship. Knowing your vendors, selecting your own vendors or becoming VERY WELL acquainted with TPA vendors, and specifying the triggers for use in your account instructions, can go a long way toward making your program more efficient.


Author Rebecca Shafer
, JD, President of Amaxx Risks 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. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
 
 
 
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

Top 10 Things You Should Know About Workers Compensation Second Opinions

In approximately half the states, the employer determines the medical provider who will treat the employee for a workers compensation injury or occupational illness. In the other half of the states, the employee selects the medical provider. In many cases, the employer or the employee who did not select the medical provider becomes unhappy with the lack of medical progress by the employee. In all states the employer or employee who did not select the medical provider has the right to a second opinion. (Some times to assert this right you may have to petition the Workers Compensation Board or Industrial Commission). (WCxKit)

 

  1. The employer is often not kept advised by the employee or the work comp adjuster or the nurse case manager – if there is one, on the medical status of the employee.   When the employer does have a work comp claims coordinator or is self-insured for work comp, the employer is much more likely to be abreast of the employee’s medical progress and known when a second medical opinion is needed.

 

  1. Some employershave the misconception that the employee has chosen the medical provider and there is nothing they can do about it. The employer is entitled to a second opinion in regards to the employee’s medical treatment. If the medical provider is keeping the employee off work after you have offered to accommodate any modified duty restrictions the medical provider feels are justified, than it is time to request a second medical opinion. Also, if the employer is not satisfied with the medical reports and diagnosis received from the employee’s medical provider, the employer should request a second opinion, especially if the medical provider is recommending surgery or other long-term medical procedures.

 

  1. If the employerrequests the second opinion and designates the doctor for the second opinion, in most states that will be counted as one of the independent medical examinations (IME) the employer can have. For a true second opinion, and not an IME, the employer should discuss with the employee the need for a second opinion and agree to a doctor of the employee’s choice for the second opinion, if they know the second opinion doctor has the expertise and will give an unbiased report. (If the employee is represented by an attorney, the arrangement for the second medical opinion will have to be made with the attorney). If the employer does not know the doctor the employee is requesting, before agreeing to the second opinion doctor, ask the claims adjuster or local defense attorney for an evaluation on the medical expertise of the second opinion doctor.

 

  1. In some states,the second opinion doctor will be selected by the Workers Compensation Board or Industrial Commission. When the employer and employee are located in one of these states, the employer should still pursue the second medical opinion if the employee’s recovery progress is longer than expected.

 

  1. The second opinionmedical provider should have expertise in the desired field of medicine. If the employee is treating with an orthopedic surgeon, the second opinion doctor should also be an orthopedic surgeon. If the employee is treating with several doctors, and multiple second opinions are needed, the second opinion doctors should be specialists in the appropriate fields.
  2. If you do not likethe results provided by the second opinion doctor, you can request a third opinion in some states. However, the employee or the employee’s attorney will probably resist a third opinion when they already have two similar opinions. If you press the matter before the Workers’ Compensation Board or Industrial Commission, you will get denied as it will appear you are doctor shopping. Remember the advice from above – know the second opinion doctor’s credibility before you agree on the doctor.

 

  1. The costof the second opinion doctor should be submitted to the claims office for payment. It is a good idea to advise the claims office and obtain their approval of the employee obtaining a second opinion before it happens, so that the claims office does not reject payment of the bill when submitted.

 

  1. Some statesdo impose time frames on when the employer can request a second medical opinion. The time frames for a second opinion vary considerably from state to state. Some states may impose a 90 day limit after the employee starts treating, while other states will have no time limit on requesting a second opinion. The employer’s work comp claims coordinator should know the time requirements for second opinions in the state(s) where you do business.

 

  1. Second opinionsare not limited to medical treatment. If the medical provider gives the employee a permanent partial disability rating that appears excessive for the limitations the employee exhibits, an IME is justified.

 

  1. One areaof second opinions the employer should stay out of is the recent trend for plaintiff workers’ compensation attorneys advertising they will give “free and confidential” second opinions on how the employee’s current attorney is doing in the handling of their work comp claim.   The shark circling the shark……(WCxKit)

 

 

Second opinions can be beneficial to both the employer and the employee. The second opinion can get the employee back to work that has been kept off work longer than necessary. The second opinion can often provide the employee with a different course of medical treatment that benefits the employee by providing a faster and higher degree of recovery, and benefiting the employer by returning a valuable employee to work sooner.

 


Author Rebecca Shafer
, JD, President of Amaxx Risks 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. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

 

Our WC Book: http://corner.advisen.com/partners_wctoolkit_book.html

WORK COMP CALCULATOR: http://www.LowerWC.com/calculator.php

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

WC GROUP: http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

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.

 

The Basics of Independent Medical Examinations (IME) for Workers Compensation Claims

An independent medical examination (IME) should be completed when an employee's recovery from an injury takes longer than normal, or when the employee is released from medical care, but receives  a higher than expected disability rating by the treating physician. The IME documents the employee's medical condition. An IME also provides the insurance company or employer with an independent verification as to whether the employee's medical condition is or is not related to an on-the-job injury.
While most treating physicians are honest and reputable doctors, some treating physicians rely on referrals from plaintiff attorneys for the bulk of their business. These doctors have a tendency to overstate the employee's disability and permanency level. They know the attorneys who provide them with patients use their medical evaluations to obtain the highest possible settlement for their clients. Therefore, the independent medical examination documenting the medical status of the employee is essential to the fair settlement of the workers comp claim. (WCxKit)
If the employee has more than one aspect of his/her health in question, more than one IME is necessary.   For instance, to evaluate properly the employees workers comp claim, it may be necessary to have IMEs done by an orthopedic surgeon, a neurologist and a physical rehabilitation specialist. Most states limit the number of IMEs to one, two or three in each area of medicine. While a few states allow the insurer as many IMEs as they want, the cost of an IME can quickly add to the overall claim cost. Therefore, use IMEs when needed, but do not abuse the process.
An IME should be performed by a doctor who specializes in the field of medicine routinely treating the type of injury the employee has incurred. The IME doctor should not have been previously involved in the employee's medical care either for the injury in question or for any other medical care. An IME does not create a doctor-patient relationship.
The purpose of an IME in a workers compensation claim is to determine the cause of injury and the extent of the disability from the injury. If the treating physician has not placed the employee at maximum medical improvement (MMI), the IME can be utilized to determine what further treatment the employee needs. 
By obtaining an IME, the insurer is better able to make fair decisions on how to handle the claim. The IME provides the workers comp adjuster with the necessary information to discontinue medical treatment, to continue medical treatment, to change medical treatment, and to determine the appropriate permanent partial disability benefit or permanent total disability benefit.
In most states the workers comp adjuster selects the IME doctor. In a few states the adjuster must petition the Workers Compensation Board to have the employee seen by an IME doctor. In some states the workers comp board selects the IME doctor. Whether the doctor is adjuster selected or workers comp board selected, it is imperative the doctor be a specialist in the field of medicine that involves the injury. The proper selection of the doctor results in high quality exams both accurate and medically sound.
To insure the IME is accurate, the adjuster or the nurse case manager assigned to the claim, provides the IME doctor with all the employee's medical records and diagnostic tests results (x-rays, CT scans, MRI reports, EMG studies, etc.). The information needs to be provided to the IME doctor well in advance of the employee's appointment to allow the doctor time to review properly the medical history of the employee. Also, the adjuster or nurse case manager also provides the IME doctor with a detailed job description obtained from the employer – the IME doctor should not have to rely on the employee's description of his/her work (which could overstate the physical demands of the job).
The IME doctor in addition to being provided the medical records, diagnostic test and job description, is informed of the reason the adjuster is requesting the examination — whether it is to establish what further medical care is needed, the level of permanent disability or other concern. By understanding why they are performing the IME, the doctor can then focus on answering the question(s) or concerns of the adjuster and/or the employer. 
When the employee is represented by an attorney, the IME is normally set by agreement between the parties. If the employee's attorney is uncooperative about having an IME it is usually a sign the employee's attorney questions or doubt's the veracity of the claim or the extent of the injury. When the employee or the employee’s attorney refuses an IME, an immediate petition to compel the IME is filed with the workers comp board. 
During the IME the doctor conducts an interview of the employee, performs the appropriate medical examination, observe the employee's general appearance, the employee's gait, how the employee stands, whether or not the employee has any difficulty climbing onto the examination table, whether or not the employee shows any signs of distress and the employee's weight. The doctor evaluates the employee's subjective symptoms and determines if they are consistent with the manifestations of the injury claimed. The IME doctor looks for any signs of exaggeration or deception by the employee and will include in the IME report if the employee is intentionally exaggerating his/her symptoms or if s/he feels the employee is malingering.
Also during the IME the doctor performs various test to verify the symptoms alleged by the employee conform to the normal symptoms for the injury claimed.   The doctor questions the employee about his/her ailment(s), the treatment the employee has had for the injury, whether or not the employee had a prior injury or an injury subsequent to the workers comp injury and discusses any underlying pathologies to the injury. The IME doctor determines if the employee smokes, drinks, uses illicit drugs or has other health or lifestyle issues that will impact the employee's ability to recover from the injury or the employee's level of permanent disability. (WCxKit)

The independent medical examination should be used by the insurer or the employer to document the medical status of the employee at that moment in time. The information obtained from the IME is used either to provide the employee with the full medical care needed, or to determine the employee's level of disability, or both

Author Rebecca Shafer, JD, President of Amaxx Risks 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. Contact:  RShafer@ReduceYourWorkersComp.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.
 
©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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