How To Make Your Workers Comp Claim Adjusters Dream Come True

Workers compensation claims adjusters run into all kinds of different accounts– from large to small; from the manufacturing field to the professional field; from the safe to the unsafe, and everything in between. Maybe there is no such thing as the “perfect” workers comp account for the adjuster to handle, but there are many things adjusters look for including:

 

1. Their main contact is involved in the claim
Every claim warrants a call to the insured or client. Sometimes this call is more beneficial than others, based on the client. Some accounts have a dedicated workers comp contact, usually someone in the HR department, who can help with the gathering of facts on the claim.  However, this person may not always have all of the information the adjuster needs.{WCx]
 
The perfect account will have a dedicated person who knows ahead of time what the adjuster needs and will readily share this information. This person knows to send the wage records and the personnel file, as well as knows about the injury details while having witness information and statements already taken. This contact knows what is needed, and knows not to put a personal “spin” on the details of the claim. This is all very helpful information for the adjuster, and it is something that the adjuster will request on every single claim that comes from that particular employer. The adjuster has one person to deal with while eliminating the need for countless phone calls to people at the employer who are all equally unhelpful.
 
 
 

2.  The contact responds timely

One thing that is sure to bother the adjuster is leaving messages and sending emails with no response from the employer. Face it; the adjuster is not making the effort to contact the employer just for fun. The employer holds very key information needed to make a compensability decision on the claim.
 
The perfect workers comp contact for the employer responds on the same day, preferably within the same hour as the adjuster left a message or sent an email. This helps the adjuster move forward on the claim, since typically the first phone call the adjuster makes is to the employer for accident details before the employee is called.
 
 
 

3.  The employer has a dedicated medical clinic that treats injured employees.

Too often employers allow injured workers to run to their own doctor, which will complicate the claim right away. The employee really does not know any better and just wants to get treatment for their injury.  It will automatically create an air of mistrust if the injured worker goes to a personal doctor, and then the employer or adjuster forces them to go to the occupational clinic.  Right away the employee will also adopt the “me versus them” attitude which does not help the claim. 



4.  The medical clinic knows the employer, and knows there are light duty work options available.

All too frequently, doctors are quick to place people out of work since they believe the only work available is the job they were doing at the time of the injury.  It is very common, especially early on in a claim, that injured workers cannot perform all of those job tasks. This creates lost wage exposure and increases the overall cost on the claim.
 
The perfect clinic knows the employer has light duty work options and will list medical restrictions that are useful to the employer and the adjuster. The doctor details lifting restrictions, and durations, and is quick to schedule a follow-up within 7days from the first appointment. Adjusters hate it when a doctor puts a person on a monthly follow-up appointment regimen since that means four weeks will go by before work restrictions or an “off work” status is changed or updated. The more the clinic physician knows about the employer, the more helpful it is for both employer and adjuster.
 
 
 

5. The employer is involved just enough to be helpful

Adjusters love to count on an employer to help provide information. But, too much information may not be helpful to the claim. Just because the employer has tons of information does not mean that it helps the adjuster. The informed employer has to know what to provide, what to elaborate on, and what not to provide. The same is true with employers who do not provide enough information. Some adjusters might prefer to have more information versus not enough, but the employer has to know where to draw the line. Adjusters do not need to know about certain industry issues, or what competitors are doing, or how past carriers used to handle claims. The perfect account provides the perfect information.  This can be established by meeting the adjusting team and going over what is and is not needed. In the end it saves all parties time and makes everyone more efficient. [WCx]
 
 
Summary
There may not be any such thing as the “perfect” workers comp account.  However, if employers and adjusters work together knowing what information is needed and take the time to create personal interest in all of the claims, the whole process runs a lot smoother and is more efficient. 

 

 

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.

Buffalo is in New York

I just got off the phone. I had been trying to call the insurance company’s Buffalo office but I could not find a current number, so I called the NYC office.

 
The operator at the insurance company's NYC office answered and I told her that I needed a number for their Buffalo office. She said, “But you called NYC.” I said, “Yes. I know, I just need the Buffalo number.”
 
 
She started going through a list. “Arizona…Colorado…. Connecticut… Delaware…Florida……I do not see Buffalo.”
 
I said, “You are looking at states. Buffalo is a city.”
 
She said, “What state is Buffalo in?”
 
I said, “New York.” Then, I just hung up in exasperation….
 
 
Gathering Information

Information is the most essential ingredient in compensation claim management, but where does information originate?
 
 
The employer tends to see itself as a source of information more than a recipient, believing, or hoping, that the carrier makes all necessary efforts to gather useful facts. But is the carrier doing its job? The answer is a phone call away.
 
 
Carriers are equipped to obtain information contained on mandatory forms, such as reports of injury, and to a lesser extent information obtained by investigators. But what about information which appears unannounced and unexpected? That is the sort of information which is often the game changer in difficult claims, especially those involving fraud or undue exaggeration of disability.
 
 
Such information comes from sources close to a worker like co-workers, acquaintances, neighbors, and relatives. These sources are understandably cautious in reporting suspicious behavior but sufficiently upset by it to make an effort to report it. A single phone call from such sources can save an employer hundreds of thousands of dollars but only if the phone call can get through. Social Security and IRS go to great lengths to move such calls into dedicated hot lines but does an employer’s carrier?
 
 
An employer should find out by making a call to its carrier, avoiding the inside numbers and calling the general numbers found on websites or in phone books, the very places an unconventional source will seek them. What usually follows will in most cases leave an employer troubled, especially if it has a suspicious claim in progress.
 
 
Carriers, for nearly two decades, have relied on phone systems which delay a caller in reaching a live employee. Even then, it is usually an operator who directs the call to an answering machine on which a recorded message informs the caller that if they leave a name, phone number and purpose of the call someone will call back.
 
 
An employer should test how long it takes to receive a call back when the caller is identified as someone who “has important information” and is reluctant to leave a full name. Most callers with sensitive information are reluctant to do even that, much preferring to hang up as soon as they are connected to an answering machine. If the employer leaves a name and phone number on an answering machine and never receives a return call the employer is only experiencing the same reception given to the most valuable calls.
 
 
An employer, therefore, must consider itself the guardian of its claim info and take special steps to see that it is transmitted to and acted on by proper units within a carrier. If the claim has been in progress and the carrier has appointed counsel, then counsel should also be copied with a request for counsel to call the employer to discuss the info. (WCxKit)
 
 
An employer should not hesitate to request a conference with the claims supervisor to discuss unanswered calls or claim material which is ignored. Nor should an employer be kept distant from the “carrier’s” attorneys. (The attorney’s primary client is always the employer ,not the carrier, even when the attorney is selected by the carrier.)
 

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
 

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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 RShafer@ReduceYourWorkersComp.com 

Unexpected Benefits From Government Regulation

Since WWII, many new programs, state and federal, regulating disability have been added to workers compensation. In some states, short term disability is required for most businesses. All have to comply with OSHA and ADA. Social Security Disability Benefits claims involve many employers, directly and indirectly.
 
With the laws have come statutes, rules and regulations – at times overlapping other laws or even contradicting them. The wealth of material that must be read to deal with interactions is enormous – and well worth reading. (WCxKit)
 
Many situations which are confounding if a solution is sought by staying within one law can be solved by searching the provisions of other laws. For example, obtaining an early independent medical examination shortly after an incident has been reported.
 
An independent medical examination under, say, New York compensation law must be done by the carrier in such a way as to comply with numerous requirements. Miss a single step and you must start all over – which makes the first exam unlikely in less than three to six months. Some states restrict the number of independent exams on a claim, resulting in hoarding opportunities for an exam until late in a claim.
  
But other laws, free from the oversight of a comp board, often require exams doc compliance. OSHA, in 29 CFR 1904.5, lists a variety of reported conditions that do not need to be listed on the OSHA Form 300. However, in order to comply, an independent medical exam would often be required, since only a medical professional, with access to prior records, could decide if an incident is one of the conditions subject to exclusion. 
 
In such cases, an employee could be required to attend an exam and, in addition, provide HIPAA releases for prior records. And, the exams are not subject to local work comp laws or oversight. The report of the exam can be used in a comp claim if proper discovery procedures are followed – and the exam does not count as a work comp exam. 
 
ADA can also be used for return to work examinations, again, with HIPAA releases. “Reasonable accommodation”, an ADA requirement, may often depend on the results of the exam. Again, the exam report can be used in the comp claim and the exam does not count as a comp IME.
 
Perhaps the most extreme example of expanding opportunities for additional exams is found in the New York Disability Benefits Law, Sect 217, where an employer is given the right to have an employee receiving short-term disability benefits attend an examination once a week for the period of disability ( for the maximum of 26 weeks of benefits). Short-term disability benefits are often paid while a comp claim is being contested. In such cases, a number of examinations could be scheduled and none would count as a comp IME. (WCxKit)
 
These are but a few of the examples of how the myriads of laws already in force can, with some searching, provide new solutions to old problems. Searing outside the comp law is truly searching “out of the box”.

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.
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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.

Florida Workers Compensation Basics 101

Workers Compensation Laws change frequently. This is only a summary; a complete copy of the most up-to-date version can be found at: www.WorkCompResearch.com an excellent service.

In Florida, every employer who has four or more employees, whether full time or part time is required to carry workers compensation insurance. [Corporate officers who have elected to exempt themselves from work comp coverage do not count as an employee]. There are a couple of exceptions to this rule. If you are in the construction industry and have one or more employees, you are required to have work comp coverage. Florida farmers who have more than five regular employees, or twelve or more seasonal workers who are employed for 30 days or more, are required to have work comp coverage.
 
Obtaining Coverage:
To obtain workers compensation coverage in Florida, the employer has several options including:
1.      purchasing a workers compensation insurance policy from a state approved insurance company
2.      qualifying as an approved self-insured employer
3.      contracting with a professional employer organization [employee leasing] that has a group workers compensation policy
4.      purchasing a workers compensation insurance policy from the Joint Underwriting Association, a Florida state agency that sales workers compensation insurance  coverage to employers who are unable to obtain coverage in the open market (WCxKit)
 
Claim Reporting:
The employee must report the injury to the employer within 30 days of the occurrence. If the injury is not reported timely, the insurance carrier has the option to deny the claim. The employer is under a strict time limit of 7 days to report the claim to the insurance carrier. The insurance company then has 3 days to send to the employee an informational brochure which outlines the employees rights and responsibilities under the workers compensation statutes.
 
Medical Benefits:
The employer selects and authorizes the initial medical provider. All subsequent medical treatment must be at a medical provider approved and authorized by the workers compensation insurance carrier. All authorized medical care and associated expenses (prescriptions, prostheses, mileage reimbursements) are covered by workers compensation.
 
Temporary Total Disability Benefits:
The temporary total disability (TTD) benefits are calculated as two-thirds of the employees average weekly wage over the 13 weeks prior to the injury, not counting the week the injury occurred. The maximum amount of TTD benefits that can be paid weekly changes every January 1st. The maximum TTD benefits per week for accidents occurring on or after January 1, 2010 is $772.00 per week. The state minimum weekly benefit is $20, which has not changed since 1972.
 
The first 7 days of disability (the waiting period) is not paid to the injured employee unless the employee is disabled for more than 21 days. TTD benefits can be paid for a maximum of 104 weeks. There is no provision in the Florida law that requires the employer to hold open a job for an employee who is unable to work due to the employee being unable to work. (Holding the position for the employee is the smart thing for the employer to do in most cases).
 
Temporary Partial Disability Benefits:
Florida work comp also provided for temporary partial disability (TPD). An employee will receive TPD if the medical provider releases the employee to work with restrictions on the number of hours the employee can work. If the employee is unable to earn 80% of his wages prior to the injury, the insurance carrier will pay TPD benefits on the hours the employee is unable to work per week.
 
Impairment Benefits:
When an employee reaches maximum medical improvement, the medical provider will determine whether or not the employee has any permanent partial disability. If the employee receives a disability rating, the employee is entitled to Impairment Benefits (IB).   The amount of IB is one-fourth of the TTD rate plus 1 cent. For example if the weekly TTD rate is $600.00, the IB rate would be $150.01. The number of weeks of IB is determined by a disability scale. A 10% rating on the scale is worth 20 weeks of IB; a 25% rating is worth 85 weeks of IB, while a 50% rating is worth 235 weeks of IB.
 
Permanent Total Disability Benefits:
Florida has a unique way of determining if an employee who has reached maximum medical improvement has a permanent total disability (PTD). If the employee can be placed in a sedentary job within 50 miles of his residence, the employee is not PTD, unless he has a severe injury as defined by the Florida work comp statutes. Some of the severe injuries include spinal cord injuries that involve paralysis of an arm, leg or the trunk; amputation of a hand, arm, foot or leg; severe brain injury; and, second or third degree burns over 25% of more of the body. If the employee is classified by the Division of Workers Compensation as PTD, the employee will receive PTD benefits which are the same as TTD benefits until the age of 75. If an employee is drawing social security benefits, the PTD benefits are reduced to the point where the social security benefit plus the PTD benefit equals 80% of the average weekly wage earned prior to the injury.
 
Death Benefits:
If an employee dies as a result of an on-the-job accident within one year of the date of the accident, or if the employee dies as a result of an on-the-job accident within five years with continuous disability, funeral expenses up to $7,500 is covered by workers compensation. The spouse is entitled to 50% of the average weekly wage, not to exceed $772.00 (for calendar year 2010). The spouse plus one child is entitled to two-thirds of the average weekly wage, not to exceed $772 (year 2010).   If the employee leaves behind one child as the only beneficiary of death benefits, the child receives one-third of the average weekly wage, not to exceed $772 (year 2010). There is no time limit on how long benefits can be paid, but the maximum amount of death benefits is $150,000 (not including funeral expenses). If the spouse remarries, the spouse receives a lump sum payment of 26 weeks (as long as the $150,000 cap is not exceeded. The spouse is also eligible for tuition benefits at a vocational technical center or community college. (WCxKit)
 
 Vocational Benefits:
If due to the employees on-the-job injury the employee is unable to return to work because of permanent work restrictions, the employee is entitled to assistance from the Workers Compensation Vocational Rehabilitation Section of the Florida Department of Education. At no cost to the employee, the employee can receive vocational counseling, transferable skill analysis, training on job-seeking skills, job placement, on-the-job training and formal retraining. 

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 or 860-553-6604.

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

©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.

Take A Survey – Of Your Own Company

There are a million ways to ask questions in a survey. However, the style of your questions will drive the quality of information you gather. You want to get good answers leading to good results. 

Think of workers’ compensation surveys as an opportunity to audit, assess and educate.  Some examples of the types of questions likely to advance your cause:

  1. Quantitative — find out the percentage of employees who return to work within four days.
  2. Direct – Do you have written step-by-step procedures for supervisors to follow in the event of an employee injury?
  3. Informative – Do you know what a positive Waddell test is? It is a sign of possible dishonesty. If you don't know this medicalese, or your adjusters don't know medicalese, you need to consider a medical director.

Discussions coming from this type of survey help you educate your team on the actions truly driving costs. It’s also a great chance to address things such as a manager’s perception that most claims are fraudulent.

How to get your answers:

DO

  1. Ask quantitative questions.
  2. Ask direct questions.
  3. Ask informative questions.
  4. Give and get information.

DON’T

  1. Ask trick questions.
  2. Ask reverse questions.
  3. Ask attack questions.
  4. Ask subjective questions.

There’s nothing  worse than participating in an audit or survey and then being left in the dark when it comes to results. Ask “How did I do?”

It’s important  to be sure you have a structured process for reviewing results with participants. Have the material and insights on hand to provide clarification there and then including concrete recommendations for improvement. (workersxzcompxzkit)

Feedback: So how did I do?

  1. Review results with participants.
  2. Provide recommendations.
  3. Educational material.

Author Rebecca Shafer, J.D, Consultant, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. She can be contacted at:  RShafer@ ReduceYourWorkersComp.com or 860-553-6604.

Podcast: KNOW the New OSHA Recordkeeping Rules — OR Risk Fines and Criminal Penalties. Click Here:   http://www.workerscompkit.com/gallagher/podcast/Non_Compliance_with_Recordkeeping_Standards/
 

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.
 
©2009 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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