Chapters

Post-injury response procedures are a set of written guidelines detailing roles and responsibilities from when a work-related injury first occurs through the first 24-48 hours. The procedures map the steps employee, supervisor, and witnesses must take immediately following a work-related injury.

Using a consistent post-injury response procedure allows the company to exercise its management responsibility to ensure injured employees receive prompt medical care and then return to work quickly.

Written procedures include clearly defined best practices for:

• Employees
• Supervisors
• Medical providers, including onsite providers

Employers need to develop/implement these tools and documents outlining steps to take from injury to recovery:

• Post-Injury Response Procedure
• Employee Brochure
• Employee Instructions
• Work Ability Form
• And More

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A strong communication strategy is the key to a successful workers’ compensation management program. Both proactive and reactive communication is critical to saving money in a company’s workers’ compensation program by training employees before an injury occurs and reacting correctly after an injury occurs in the workplace.

Proactive communication is written/verbal communication the employer disseminates to employees about the company’s policies, programs, and procedures expected of them following a work-related injury.

Reactive communication is the post injury communication the company establishes and maintains with its injured workers so they remain psychologically connected during recuperation and focused on the final objective of returning to work as healthy, productive employees.

Workers’ compensation best practices include:

• Using a mission statement to outline the organization’s worker compensation policies and employee expectations.
• Outlining injured employee benefits and delivering those benefits on time.
• Using formal communication with injury response steps and written policies.
• Using informal communication such a “Get Well” card.
• And More

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Resolving and settling workers’ compensation claims is a complex process requiring adjusters, medical providers, attorneys, and workers’ compensation coordinators to have an in-depth knowledge of multiple areas of the law, including workers’ compensation, product liability, and general liability legal issues.

The effective adjuster develops the talent to negotiate the claim by emphasizing its strengths. Prior to starting the settlement negotiations, the adjuster outlines in an Action Plan the strengths and weaknesses of the claim, obtains settlement authority, and develops a strategy to stress the reasons the claim should be settled for the amount the adjuster recommends.

Establish Value of the Claim

As part of any negotiation, the adjuster must establish the value of the claim and a settlement range for the claim based upon the strengths and weaknesses evaluation. Establishing future medical costs and the degree of medical disability is critical to a fair settlement value. In some states, medical costs cannot be closed or settled but other parts of the claim can be.

Ability to Return to Work

Lack of future employment and the disabled employee’s inability to return to work increases the value of a claim. The longer the employee has been out of work, the higher the settlement range is likely to be. For this reason, adjusters and workers’ compensation coordinators must determine if there are other positions available for the employee with permanent disability restrictions. It is generally better to find a position within the organization, but there are times when employment must be found elsewhere. Try to find employment for the employee as close to, or higher than, the original wages because the settlement will be larger if the post-injury wages are lower than the pre-injury wages.

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Employers and risk managers need to know the services provided by their insurance company and/or their third-party administrator (TPA). If employers are not satisfied with the performance of the adjusters assigned to their account, they need to know how to correct the problem.

Cost Reduction Areas to Consider:

• Bundled services
  When the same insurance company provides the insurance and administers the claims.
• Unbundled services
  The insurance and claims adjusting functions are separate.
• Deductible affects control
  The higher the deductible, the more control the employer has over how claims are handled. Self-insured organizations have the most control over their claims.
• Communication and meeting with claim partners and handlers
  Best Practices require regular communication.
• Reviewing open claims regularly
  Discuss claims and transitional duty opportunities; assess employee return-to-work status; fine tune plans of action; check for fraud; and develop a time line for claim resolution.
• Account handling instructions address:
  

  Settlement authority Timing of status reports Subrogation waivers Recorded statements And More

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Keeping in contact with injured workers and the employee’s medical providers is an important step to integrating injury-related medical care. Employers and risk managers need to gain the cooperation of medical providers to convey how the company cares about its employees.

In order to take control of the medical process, risk managers need to be familiar with different types of physicians and medical advisors. Some of the most common are:

• Primary Treating Physician
• In-house Medical Advisor
• Preferred Provider Organization Doctor
• Independent Medical Evaluation Physician
• Specialists
• On-site Occupational Clinic
• Physician Peer Reviewers
• Remote Health Services

The employer must know how physician selection is handled in each state – primarily: Who may select the treating physician/clinic: the employer or the employee?

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Employers taking an active interest in the medical status of their employees have a far-reaching positive impact. Both employer and employee benefit by eliminating unhealthy lifestyle habits.

• The employer experiences lower insurance costs and higher productivity when the employee is on the job working.
• Employers offer incentives to encourage employees to attain acceptable ranges of body mass index, blood sugar, blood pressure, cholesterol and to attest to being tobacco free.
• The employee experiences better health and an enhanced lifestyle by participating in employer-provided wellness programs and gains improved return-to-work readiness if injured.
• An employee incentives can include cash payments equal to a percentage of the cost of an individual health insurance policy.

Negative Effective of NOT Having a Wellness Program

Comorbid conditions, such as obesity, smoking, poor physical condition, diabetes, migraines, chronic pain, and substance abuse often complicate injuries and, when surgical repair is involved, recovery can be longer and more expensive.

Types of Wellness Programs

• Weight Control
• Smoking Cessation
• Depression/Anxiety Awareness Treatment
• And More

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Before implementing a workers’ compensation management program, all employees must be made aware of changes, and senior management and supervisors must be trained in using new forms and procedures.

Key Training Activities

• Identify and catalog day-to-day responsibilities.
   
• Factor in new processes and procedures to develop an implementation strategy for existing and new responsibilities.
   
• Communicate new processes to all employees.
   
• Disseminate new policies and procedures.
   
• Promote the program via memos, brochures, posters, newsletters.
   
• Reinforce management commitment of top managers.
   
• Identify and document transitional duty jobs.
   
• Incorporate new policies/procedures into new hire packets.

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Federal employees injured on the job are entitled to workers compensation. There are several different federal workers compensation programs related to different populations of workers, but the majority of federal workers fall under the provisions of the Federal Employees Compensation Act (FECA).

FECA provides medical and wage loss compensation benefits to civilian employees of the United States for disability due to injury or disease sustained while in the performance of work duty. FECA also provides for the payment of benefits to dependents if a work-related injury or disease causes an employee’s death.
FECA Basics

• Who Pays for FECA Costs
• How is FECA Administered
• Selecting Medical Providers
• Medical Benefits
• Lost Wages Federal Employees Receive
• Permanent Disability or Death
• Registering as a Federal Medical Provider
• Cost Control Challenges
  1. Compensation
  2. Medical
  3. Legal
  4. Administrative
  5. Three-Level Claimant-Oriented Process
  6. Presidential Protecting Our Workers and Ensuring Reemployment
• And More

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Medical costs CAN be controlled or contained using a variety of strategies. Third-party administrators and insurance company claims administration teams offer various services to reduce medical costs.

Medical cost control is fee management achievable by either:

1. reducing the number of treatments,
2. reducing the cost of treatments, or
3. purchasing premium services.

This last option, costing more initially, reduces the length of time an employee is out of work.

The services available to reduce medical costs include:

The employer must understand how these services work and the value they bring to the company’s unique workers’ compensation situation. It is not a “one size fits all” solution for cost reduction. For example, telephonic nurse case management incurs certain fees, requires the nurse case manager to hold certain licenses depending on jurisdiction, and is used when claims are complex or in lost time claims where length of time out of work is disproportionate to the injury.

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Sometimes the extent of an employee’s injury requires a more hands-on approach to the return-to-work process. If an employee does not “fit” into a traditional transitional duty assignment, rather than let the employee remain at home over an extended period of time, consider other options.

These nine options can reduce the length of time the employee is out of work:

1. 1. Work Hardening: A reconditioning program usually takes place off-site in a job-simulated environment and is adapted to keep pace with the employee’s changing medical restrictions and used when an employee cannot return to the regular workplace assignment. Work hardening is especially useful when re-injury is the worker’s fear.
   2. Independent Medical Evaluations: Performed by an independent or neutral doctor to determine the employee’s medical status; evaluate testing; and move the claim forward. It is useful when there is a dispute about the employee’s medical status and recovery. The physician must be fully prepared before scheduling this procedure by reviewing all medical records and current tests, and discussing medical issues with the treating physician.
   3. Functional Capacity Evaluations: A physical or occupational therapist measures the individual’s range of physical abilities in the work environment. A functional capacity evaluation is used when there does not seem to be a legitimate medical reason for symptoms the employee is experiencing, it is believed symptoms are exaggerated, or the employee cannot perform a transitional duty position.
   4. Vocational Rehabilitation: Rehabilitation is a go-to option – employers should not WAIT until maximum medical improvement is reached BEFORE considering rehabilitation options. Use vocational rehabilitation when soft-tissue injuries do not resolve or the employee cannot return to work after three months of total disability.

Five More Options Available

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