Archives for October 2019

Workers Comp Claim Action Plan- Online Access Answers 100+ Questions

October 31, 2019 By JL Risk Management Consultants

Workers Comp Claim Action Plan – Online Access Answers 90% of Questions

Most Workers Comp Claim Action Plans cause the adjusters to have to do a ton of work. Long ago, when I was a full-time adjuster, I looked forward to closing out a file so that I did not have to do any more claim action plans.

Public Domain – Wikimedia

Workers Comp claim action plans still result in a large amount of work for the adjusting staff, even with the advances in technology.

Any outside parties to the claim (agent, consultant, employer, reinsurer, etc.) should relish the plan of action. Why?

Any of the persons in the above parentheses can avoid calling an adjuster by simply getting online and look for the workers comp action plan to find answers to their questions.

I did not want to copy a recent workers comp claim action plan as too much data had to be redacted due to privacy concerns. Below is a list of questions you can answer from a POA (Plan of Action). Most Workers Comp Action Plans originate with a template.

Injured Worker Name
Adjuster Name and Contact Info
Date and Time of Action Plan
Diary Review
POA
Indemnity Benefits
Medical Benefits
Maximum Medical Improvement Date
Anticipated Return to Work Date
Released from Medical Care Date
File Closure Target Date
Any outstanding forms that need to be filed with the State
Any outstanding issues that may affect any target dates
Current Status – very important to avoid phone calls
Payment of benefits
Addressing Modified Work availability
Injured employee contact information – usually an email address
Supervisory Review – great to see in files, not always there – usually a re-review of the adjuster’s workers comp action plan
Communication between supervisor and adjuster on diary dates
The adjuster’s description of accident in their own words – important
Compensability – another very important question answered
Reserves – Why are the amounts on the file (Total Incurred)
Amounts of Indemnity Total Incurred and Reserves on the file.
Amounts of Medical Total Incurred and Reserves on the file.
Amounts of Expense Total Incurred and Reserves on the file.
Amount of Rehabilitation that may be spent on the file – think Rehab Nurses
Are Medical Networks being used properly?
Was the coding of the claim variables input properly?
Full Medical Update including recent physician visit and the physician’s note
How and if Medical notes address light-duty ad full Return to Work
Work/Employment Status – this is covered often in most files
How Average Weekly Wage was calculated and Anticipated Temporary Total Disability TPD, and PPD payments
Alert to all parties – Analytics data such as background of employee, such as the personality of the injured employee, drug or alcohol use, etc.
Current litigation status
Settlement Value – if applicable
Social Security considerations/Medicare
Results of the Index Report – usually do not see this in a Workers Comp Action Plan
Subrogation – one of my big concerns in Workers’ Comp claims
Coverage – the correct policy applied?
Any special reporting requirements for the employer/client insured?
Settlement reserve authority
All information collected on employee including address and contact information (a large amount of background data from claim inputs)

I have combined many of the answers to the questions that anyone may have about the workers’ compensation claim. Now, I think we can see the value of online access. The above Workers’ Comp Action Plan covered six pages for an injured worker that was out of work for four weeks and will have no permanent disability.

Calling the adjuster vs. online access to the Workers Comp Action Plan = Six Hours of Worked saved.

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Workers Compensation Medical Networks – Are You A Drive-by User?

October 16, 2019 By JL Risk Management Consultants

Workers’ Compensation Medical Netwks – Discounts Not Being Useord By Employers

Workers’ Compensation medical network usage tends to be the drive-by type. What do I mean by drive-by?

drive thru workers compensation medical network

Wikimedia Public – Digimint

PPO/MPN/Cost-Savings Network

Most employers have an agreement with their carrier or Third Party Administrator (TPA) if your company is self-insured. Drive-by medical treatment originates with the employer or claims staff just using whomever they find convenient for post-accident treatment.

The discounts used provided by the medical networks never see the light of day. By luck, the injured employee treats with a provider that is in- network. The savings can be significant with Workers’ Compensation Medical Networks. The usual PPO discount pegs at 15% or higher.

Many networks exist in the marketplace. Some are whitelisted by a carrier, TPA, or other networks as their own group of providers. The white-listing should not be a cause for concern. Use the network you have in front of you regardless of the source of the providers.

Emergency Services vs. Workers’ Compensation Medical Networks

Please note one exception to the networks. If an injured employee needs emergency medical care or incurs a serious injury, make sure the injured employee receives immediate medical care. Do not worry about medical networks on this type of claim.

Attempting to have an employee with severe injuries stay in-network ends up costing insureds more than any network savings. I designed a walk-in clinic medical network for a very large (now defunct) home builder. The injured employee had a thumb amputation. He showed up with his supervisor at a walk-in medical clinic.

The supervisor said he stayed in-network. I was horrified and told them to go to the nearest hospital emergency room. The walk-in physician had already made the referral. The hospital reattached the thumb – Duke University Medical Center – whew!

Adjuster and Claims Department Concerns

Rightfully so, the claims adjuster and departments raise concerns about staying in the Workers’ Compensation medical network while assuring that the injured employee receives treatment from industrial-minded physicians.

Adjusters like to use certain physicians in certain areas for certain types of injuries. When I adjusted claims and now consult on them, I always carry a list of medical facilities in my head for a certain state or area. I think the main attribute was a “successful return to work” with the employee’s capabilities returned to enable them to do their jobs in full. The other attribute by physicians and medical providers was the bedside manner.

WCRI performed a host of studies on the main attribute that employees possessed with a successful return to work. The word TRUST of the employer before the injury and the medical care resulted in better returns-to-work.

The Second Key

The second key of my Six Keys To Workers Comp savings was written in the order of the claim. If I had to rank the Six Keys on savings potential, medical networks would rank the highest. Creating a network for injured employees seems complicated. Being prepared ahead of time make the task much easier.

At the time this article was published, approximately 41 states allow the employer to choose the medical network or to provide the injured employee with a panel or list of providers. Even if the employee retains the right to choose the treating physician (nine states?), the injured employee will treat with a suggested physician.

Preparation and Teamwork for the Workers Comp Medical Network

The upfront preparation pays off with the proper medical treatment at the lowest cost. The team members should be:

Claims adjuster or staff
Providers in the area
Medical network access for all involved – should be online with the carrier or TPA
Employer representative
Rehabilitation nurse – can be the hub to set up the network
Original treating physician – in-network referrals for more complicated cases.
Trust – see WCRI study referenced in a previous section

The employer representative kicks the medical network into gear by checking with all the above mentioned other parties. When looking for providers in your area, make sure they know that you use a certain network. Many medical providers signed up with medical networks once they learned local employers use a certain workers compensation medical network.

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Waiver of Subrogation Endorsement – Excellent Analysis Chart

October 11, 2019 By JL Risk Management Consultants

Misunderstood Waiver of Subrogation Endorsement – Why You Should Read Your Workers Comp Policy

The Waiver of Subrogation Endorsement appears in almost all workers’ comp policies. Almost all workers’ comp personnel and insureds do not ever read any policies. Who wants to read 40 pages of droning on when the Dec Page covers everything one needs to know concerning a policy? Please think again on that point. Endorsements can change the face of a policy dramatically.

picture waiver of subrogation insurance office

Wikimedia – François GOGLINS

Many articles appear in this blog on Subrogation. The search for those articles can be found here.

If you check out a few articles written on endorsements, the need to be aware increases for any Endorsements which insurers add at the time of policy inception (start) or during the policy period. Check out this article on the parts of a policy and this one on Endorsement.

The Waiver of Subrogation Endorsement always meant (in my opinion) the carrier desires to retain the right to bring a lawsuit against any third parties. The insured employer signs over those rights at the time the beginning of and during the policy.

The insurer wants an unfettered ability to recover any claims monies spent out with adjusting a claim. Of course. the insured would receive a credit for any recovered subrogation funds. The carrier is Supposed To file correction reports with the rating bureaus (NCCI, WCIRB, etc.) that may result in a lower E-Mod for the employer.

Each employer willing to waive their right to recover from or litigate receives a credit. Pull out your current policy or an old premium audit bill or statement. The credit appears in both, along with a nominal refund of sorts.

Understanding and applying the waivers may be of great benefit to employers. Some states do not allow the carrier to bring suit against a responsible third party directly. The carrier must ride on the coattails of the injured employee instead of moving the employee out of the way and litigating the responsible third party directly.

A great multi-state law office MWL and Counsel Gary Wikert, combined all the Workers’ Comp Waiver of Subrogation considerations in all 50 states. Adjusters and their supervisory staff should keep a copy of the Waivers of Subrogation at their fingertips. Insured employers should understand their rights under a Waiver of Subrogation. Download that PDF file here.

Their introductory paragraph reads as:

Most state workers’ compensation laws, or cases construing them, allow the employer and its carrier to waive its right to subrogate against a third party that caused or contributed to an employee’s injury. The purpose of a subrogation waiver is not well understood and is a subject of some confusion in the marketplace. Most frequently, contracting parties agree to contractually require the inclusion of a waiver of subrogation endorsement in a workers’ compensation policy simply because the requirement is contained in the form contract, and has been for many years.

A recent NCCI Symposium in Virginia covered Workers Comp mega-claims. The number one mega-claims by far were automobile accidents. Auto accidents remain the easiest claims for a work comp claims adjuster to subrogate the funds paid on a claim.

Sending a letter to the auto adjuster to retain the carrier’s lien is very easy. Monitoring the status of the subrogation lien becomes critical. I have reviewed more than a few files where the workers’ comp adjuster notifies of the lien and then lets it go at that point. The injured employee’s liability claim attorney may not pay one-third of the funds because of one letter.

Many WC adjusters tend to just specialize in one line of claims. The specialization is fine except when subrogation potential appears in a claim. When I started my insurance career in the 1980s, adjusters were almost exclusively multi-line. In other words, the adjuster knew just exactly how to pursue a third-party Workers’ Comp matter as he/she had adjusted claims outside the Workers’ Compensation arena.

Download the above PDF. You can thank me later.

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Value Based Care and Centers of Excellence Matched Pair for Work Comp

October 4, 2019 By JL Risk Management Consultants

Value-based Care and Centers of Excellence – A Winning Combo for Injured Employee, Employer, Carrier/TPA and Medical Provider

If a provider mixes Value-based care and Centers of Excellence, the result may be what Workers Comp has been searching for in the last 40 years. WCRI hosts a webinar next week on Centers of Excellence.

Feel free to read my article on Centers of Excellence from earlier this week.

Public Use License – E2405

Two of the up-and-coming areas of medical treatment in Workers Compensation fills a great need for:

Better communications
Specific treatment to a certain population
Better cost projections <<critical for adjusters setting reserves
Enhanced outcomes
Instills trust of Work Comp and medical treatment systems – check out the WCRI injured employee results surveys-wow! They won the vaunted Comp Laude award this year for those studies.
Controls cost
More industrial-based medicine

The above list considers on a few points of what I think the newest and best trend in medical treatment for injured workers. The Centers of Excellence Model has sustained high-levels of very specific care for specific serious injuries (Burn Centers, Brain Injury Center, etc.).

One caveat – not all traumatic injury treatment providers are considered Centers of Excellence.

Centers of Excellence Concept

The one very expensive yet needed Centers of Excellence are closed head injury treatment centers. Those medical and rehab providers, while expensive,produce amazing results. I referred quite a few patients to them and have recommended them in my claims consulting practice often for the very serious cranial and upper spinal injuries. The work they do often reaches the miraculous level.

One drawback remains the cost of out-of-state treatment in Workers’ Comp claims. Fee schedules are gone when the treatment moves across state lines. Please do not mistake that as a critique.

One of the considerations is the cost. One of the main criticisms of the staff at any Centers of Excellence comes from the paperwork required by Workers Comp carriers/TPA’s. The staff wants to spend every second of their time improving the injured workers’ lives, not getting multiple authorizations every week. I find that hard to criticize in such serious cases.

The local Center of Excellence, which I referred seriously injured workers to is Duke University Medical Center. One cannot forget the University of North Carolina Medical Centers or WakeMed Centers of Excellence. All three help keep Raleigh as one of the top places for medical care in the nation.

Value Based Care Concept

The new medical treatment term that has gained traction in health coverage originates from outcomes and cost as the determining factors. For the mega-claims, the Centers of Excellence could be considered as value- based care.

PBMs (Pharmaceutical or Pharmaceutical Based Management) systems became a natural beginning for the value-based care model in Workers Comp. Last year, I attended a session at the NWCDC Conference on value-based care. I realized the significance of what the session covered after-the-fact.

I said at the time of the NWCDC session – this will not work in Workers’ Comp. I now say that I was a little hasty in my decision. WCRI also presented a webinar on value-based care. Dr. John Lea presented earlier this year on value-based care and now will present a webinar on Centers of Excellence on October 12th.

Combination of Both

A combination of both concepts would allow for:

Reduced paperwork for Centers of Excellence
Keep injured employees in-state for the fee schedules
Instill trust in injured employees <<critical
Very specialized industrial medicine clinics in a certain area
Payment providers (carriers/TPAs) more readily make payments
Avoid injured workers having multiple Independent Medical Exams and external Second Opinions
The list could go on for a long time

Please do not consider this one of those recycled topics that appear in workers comp every few years. Value based medicine and especially Centers of Excellence wield a unique concept.

Workers Comp Centers of Excellence – Exciting New Medical Trend

October 3, 2019 By JL Risk Management Consultants

Workers’ Comp Centers of Excellence Treat The MegaClaims

The Workers’ Comp Centers of Excellence may reach beyond just MegaClaims. Let us look at the definition of a center of excellence.

pic of DNA Workers Comp Centers of Excellence

Public Domain

Researching the term uncovered the newness of the term and concept. According to a recent Risk & Insurance article

even the definition of centers of excellence remains not a very well-defined area of medical treatment.

According to Ann Perkins, COO, R&Q Health, there is no one set definition of a center of excellence.

But, “one way to look at them is as a center engaged in research. These centers are making contributions to patient health and health care at large. Typically, they treat a large number of patients with the same injury and the results are published and benchmarked with other similar centers,” she said.

In other words, a center of excellence is a team or facility that provides leadership, best practices, research, support and/or training in a specific area, like addiction, spinal cord injuries, heart-related illnesses and the like.

One of the most recognizable centers of excellence seen the most often in claims is the head injury treatment centers or burn centers. The results from those two types of medical treatment centers rise above just being successful.

According to the R&I article, Centers of Excellence balk at the amount of paperwork involved with Workers’ Comp. Can anyone debate that point? (No!) Workers Comp Centers of Excellence want to treat their patients and not be involved with the denial and approval process involved with what can sometimes be a contentious line of insurance benefit.

The centers of excellence concept hammered out a place in Workers’ Comp over the years. WCRI and the NWCDC Vegas set aside a webinar and upcoming sessions at their annual conferences on this topic. One cannot call this concept a fad. Some of the centers started doing business in the mid-1900’s or earlier.

One could call Workers Comp Centers of Excellence value-based care for the extremely large claims. Could these medical providers also treat only Workers’ Comp claims over $250,000 (or maybe less?).

A few carriers and big-house agencies borrowed the term over the last two years. Their concept centers around claims-handling. No names mentioned here.

If you Google the term, you will notice a sparse amount of articles on CSoE. Remember that acronym. WC Centers of Excellence (for medical treatment) will show up in the news within the next year. I guarantee it.