Chapters

Workers’ compensation injury claims MUST be reported IMMEDIATELY after an injury, since timely claim reporting procedures ensure:

• Injured workers receive immediate and appropriate medical care.
   
• Key personnel are involved sooner rather than later.
   
• Workers’ compensation benefits are initiated and paid quickly.
   
• Workers return to work sooner.
   
• The claim is investigated while details are fresh in everyone’s mind, especially witnesses.

Late reported claims have a negative impact on both employee care and the organization’s bottom line, i.e., workers’ compensation costs.

Effects of LATE reported claims:

1. Claim costs increase.
    
2. Indemnity payments are late and employees become angry.
    
3. Medical treatment is unmanaged.
    
4. Litigation rates increase.
    
5. Transitional duty employment is compromised.

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When an employee is injured on the job, the employer’s goal is to return the employee to work as soon as the worker is medically able, thus reducing the cost of lost-wage indemnity payments that can be more than 40% of the cost of workers’ compensation claims. Find a transitional duty job for each injured worker if an injury is serious enough to keep the employee out of work. The job is located as soon as medical restrictions are obtained. Transitional duty is a temporary assignment with increased capabilities each week.

The Transitional Duty Cost Calculator is a tool used to show the savings a company can achieve by bringing employees back to work sooner rather than later.

Transitional Duty Policy

A transitional duty policy is implemented in working instructions, guidelines, templates, and forms.

An effective transitional duty policy includes these elements:

• Purpose of the policy
• Termination of assignments
• Communication of expectations
• Type of jobs
• Eligibility
• And More

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Workers’ compensation claims are usually legitimate and companies are committed to paying compensable claims quickly; however, they have a duty to determine that each is legitimate. When fraud is suspected, employers must communicate their suspicions to the adjuster. Prompt reporting and thorough accident investigation are CRITICAL to reduce fraud.

Investigate a claim when the employer wants to:

• Verify the extent of the employee’s disability.
• Substantiate the ability of an employee to return to work or perform transitional duty.
• Verify whether the employee is engaged in outside employment.
• Prove insurance fraud.
• Reduce/increase the amount of a settlement.

Types of Investigation

1. General
2. Activity check
3. Sub-rosa
4. Virtual
5. Medical records

When to Use Surveillance

Request an investigation when a claim is thought to be suspicious or exaggerated. Fraud control actions are needed when:

1. Claimant claims total disability.
2. To verify information and tips.
3. The claim could be financially devastating to the company.
4. And More

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Drug costs are not only the fastest growing component of medical care but also one of the most neglected areas of workers’ compensation cost control. Proper utilization of pharmacy benefits management can result in substantial savings. There are steps employers can take directly to prevent misuse of medication, and they can also contract with a pharmacy benefits management vendor. Most TPAs and insurance companies are aligned with these pharmacy benefits management programs.

Employers can take these steps to avoid overuse and abuse of prescription medications by proactive management over the life of the workers’ compensation claim. Questioning medication overuse becomes more difficult after the employee is addicted.

1. 1. When employee is on narcotics 60-plus days and making limited medical progress: Ask the nurse case manager or the adjuster to inquire from the doctor’s office what else, besides medications, can be done to fix the cause of the employee’s pain or other problem(s).
   2. When the gentle approach fails: Ask for a peer review during which the carrier or third-party administrator’s staff doctor telephones the treating physician to discuss the appropriateness of dosage and impact the medications are having on the injured employee. If addiction is suspected, recommendations are discussed on how to wean the employee from these drugs.

And More

When retaining a Pharmacy Benefits Management vendor, consider these components:

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An effective employee safety program serves many purposes, among them being able to assess workplace hazards and comply with Occupational Safety and Health Administration (OSHA) regulations, and state and local laws. Because safety is a process REQUIRING complete management support and buy-in, an employer’s safety program must be equal in priority to quality control and production.

Goals of an Employee Safety Program:

• Reduces workplace hazards leading to injury or illness.
• Reduces direct and indirect costs of workplace injuries and illnesses.
• Complies with all local, state, federal, and industry-specific regulations.
• Provides OSHA-specific compliance rules and regulations.
• Protects the employer’s most valuable asset – employees.

Four Steps to Creating a Safety Program:

1. Conduct an assessment.
2. Set corporate and departmental goals.
3. Assign roles and responsibilities.
4. Create a recordkeeping structure to document injuries and/or illness.

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Three disciplines – physical rehabilitation, physical therapy, and occupational therapy – are individualized services used to reduce the degree of an injured employee’s disability and to facilitate a more rapid return to work. The optimum result is a model that delivers high quality medical treatment, superior treatment outcomes, and premium customer and patient service.

There are two approaches to managing physical therapy services: 1) using a traditional medical network; and 2) partnering with a therapy management firm. Usually there are increased savings from the latter approach because there is proactive management of all physical therapy cases in addition to a better-contracted rate.

Physical Rehabilitation

Physical rehabilitation is specialized medical care for the treatment of a disability resulting from an injury or illness.

Physical Therapy

Physical therapy is the practice of using therapeutic exercises to restore movement and functional ability following an injury.

Occupational Therapy

Occupational therapy teaches injured workers how to strengthen specific body parts using a set of physical movements to regain functionality so they are able to return to work.

Guidelines for Using Physical Rehabilitation, Physical/Occupational Therapy

 

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There are two reasons workers comp costs are high:

1. Too many claims lasting too long.
2. Employers fail to “take charge” of the process.

 

When employers fail to take charge,
the EMPLOYEES are in charge by default.

 

The adjuster is primarily responsible for administering claims. The employer is primarily responsible for managing the claim process within the work environment.

To remain out of work, an injured employee must substantiate an injury by providing appropriate medical documentation. In the documentation, the employer needs enough information about the injury to return the employee to work or find a transitional duty task.

The low-quality sample disability note (opposite) is a replica of a doctor’s certificate provided by an injured employee to the employer for a claim approved by the insurance company for a $100,000 settlement. This certificate does not contain any information useful to the employer such as a diagnosis, prognosis, estimated return-to-work date, treatment, or even the doctor’s phone number.

A useful work ability form must contain the following information:

• Employee name and contact
• Medical provider contact
• Injury type
• Diagnosis / prognosis
• Treatment plan
• Work ability at home and at work
• Next appointment
• Estimated return-to-work date
• Restrictions for a transitional duty job

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There are specific Best Practice standards the primary injury management team can implement to meet and surpass national standards. Briefly these standards are:

Injury coordinators:

• Implement a proactive post-injury response procedure.
• Develop a communication program.
• Bring labor unions on-board.
• Adopt a corporate-wide transitional duty program.
• Teach workers’ compensation concepts to management highlighting cost savings.
• Know the key indicators of malingering, fraud, and abuse.

Supervisors:

• Provide injured workers with all necessary forms.
• Obtain appropriate medical help for the injured employee.
• Train subordinates on rights and responsibilities in workers’ compensation.
• Know about and complete all forms concerning the worker’s accident.

Middle managers:

• Know the roles and responsibilities of employees, supervisors, and providers.
• Track and report lost workdays monthly to management.

Risk managers:

• Ask: Does claim volume require dedicated staff to handle and implement claims?
• Attend association seminars to learn about other workers’ compensation solutions.

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Workers’ compensation is required in all states (except TX), territories, and other developed nations for injuries and illnesses that occur in the course of employment. Under workers’ compensation:

• Injured employees are provided with guaranteed medical and wage loss benefits without proving the employer is at fault.
• Employees give up the right to sue the employer.

Companies pay for insurance according to the level of their risk. Premiums and deductibles usually increase when workers’ compensation is NOT handled efficiently.

Depending on company size and injury complexity there are many players involved in the workers’ compensation industry, such as:

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