• Home
    • Workers Comp Audit Stress Reducer – Use It For Your Next Premium Audit
  • About Us
    • Cutting Workers Comp Costs – About Our Company
    • President – Expert James J Moore AIC MBA ChFC ARM
    • OSHA Risk Manager – Glen DuLac – Added To Fulfill Customer Service
  • Work Comp Consultants
  • Free Info
    • Definitions
    • Free Speech
  • Testimonials
  • FAQ
  • Free Manuals
  • Six Secrets
  • Blog
  • Contact Us

J&L Risk Management Consultants

Work Comp expert witness reserve reviews premium audits for employers

icons
Call us today! 1-800-813-1386
WORKERS' COMPENSATION PREMIUM REFUNDS POSSIBLE.
Home » Archives for October 2019

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.                                 

graphic of workers comp claim action plan global

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. 

  1. Injured Worker Name
  2. Adjuster Name and Contact Info
  3. Date and Time of Action Plan
  4. Diary Review
  5. POA 
  6. Indemnity Benefits
  7. Medical Benefits
  8. Maximum Medical Improvement Date
  9. Anticipated Return to Work Date
  10. Released from Medical Care Date
  11. File Closure Target Date
  12.  Any outstanding forms that need to be filed with the State
  13. Any outstanding issues that may affect any target dates 
  14. Current Status – very important to avoid phone calls 
  15. Payment of benefits
  16. Addressing Modified Work availability
  17. Injured employee contact information – usually an email address
  18. Supervisory Review – great to see in files, not always there – usually a re-review of the adjuster’s workers comp action plan
  19. Communication between supervisor and adjuster on diary dates
  20. The adjuster’s description of accident in their own words – important 
  21. Compensability – another very important question answered
  22.  Reserves – Why are the amounts on the file (Total Incurred) 
  23. Amounts of Indemnity Total Incurred and Reserves on the file.
  24. Amounts of Medical Total Incurred and Reserves on the file.
  25. Amounts of Expense Total Incurred and Reserves on the file.
  26.  Amount of Rehabilitation that may be spent on the file – think Rehab Nurses
  27. Are Medical Networks being used properly?
  28.  Was the coding of the claim variables input properly?
  29. Full Medical Update including recent physician visit and the physician’s note
  30.  How and if Medical notes address light-duty ad full Return to Work
  31.  Work/Employment Status – this is covered often in most files 
  32.  How Average Weekly Wage was calculated and Anticipated Temporary Total Disability TPD,  and PPD payments 
  33.  Alert to all parties – Analytics data such as background of employee, such as the personality of the injured employee, drug or alcohol use, etc.
  34.  Current litigation status
  35.  Settlement Value – if applicable 
  36.  Social Security considerations/Medicare
  37. Results of the Index Report – usually do not see this in a Workers Comp Action Plan
  38. Subrogation – one of my big concerns in Workers’ Comp claims
  39. Coverage – the correct policy applied?
  40. Any special reporting requirements for the employer/client insured?
  41. Settlement reserve authority 
  42. 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. 

 

©J&L Risk Management Inc Copyright Notice

Filed Under: Online Claims Access Tagged With: Anticipated Temporary, permanent disability, POA, Six Hours of Worked, TPD

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.  

 

©J&L Risk Management Inc Copyright Notice

Filed Under: medical networks Tagged With: amputation, capabilities, Duke University, representative kicks, white-listing

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. 

 

©J&L Risk Management Inc Copyright Notice

Filed Under: subrogation Tagged With: aware increases, litigate, NCCI, policy dramatically, subrogate, unfettered

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.  

Pic of pill box value based care

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.

 

©J&L Risk Management Inc Copyright Notice

Filed Under: medical, workers comp costs Tagged With: Centers of Excellence Model, pharmaceutical, recycled topics, traumatic, WakeMed

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. 

 

©J&L Risk Management Inc Copyright Notice

Filed Under: Workers Comp System Tagged With: CSoE, Excellence balk, MegaClaims, sparse amount

Email Subscription

Search this website:

Work Comp Premium Audit Work Comp Mod Expert work comp expert witnessWork Comp Expert ReservesWork Comp Claim File Audit ExpertWork Comp Expert Witness

About Me

My Photo

James J Moore
Raleigh, NC, United States

James founded a Workers’ Compensation consulting firm, J&L Risk Mgmt Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:
• Risk and Insurance Management Society (RIMS)
• Entrepreneur Magazine
• Bloomberg Business News
• WorkCompCentral.com
• Claims Magazine
• Risk & Insurance Magazine
• Insurance Journal
• Workers Compensation.com
• LinkedIn, Twitter, Facebook and other social media sites
• Various trade publications

 

Archives

  • March 2021
  • February 2021
  • January 2021
  • December 2020
  • November 2020
  • October 2020
  • September 2020
  • August 2020
  • July 2020
  • June 2020
  • May 2020
  • April 2020
  • March 2020
  • February 2020
  • January 2020
  • December 2019
  • November 2019
  • October 2019
  • September 2019
  • August 2019
  • July 2019
  • June 2019
  • May 2019
  • April 2019
  • March 2019
  • February 2019
  • January 2019
  • December 2018
  • November 2018
  • October 2018
  • September 2018
  • August 2018
  • July 2018
  • June 2018
  • May 2018
  • April 2018
  • March 2018
  • February 2018
  • January 2018
  • December 2017
  • November 2017
  • October 2017
  • September 2017
  • August 2017
  • July 2017
  • June 2017
  • May 2017
  • April 2017
  • March 2017
  • February 2017
  • January 2017
  • December 2016
  • November 2016
  • October 2016
  • September 2016
  • August 2016
  • July 2016
  • June 2016
  • May 2016
  • April 2016
  • March 2016
  • February 2016
  • January 2016
  • December 2015
  • November 2015
  • October 2015
  • September 2015
  • August 2015
  • July 2015
  • June 2015
  • May 2015
  • April 2015
  • March 2015
  • February 2015
  • January 2015
  • December 2014
  • November 2014
  • October 2014
  • September 2014
  • August 2014
  • July 2014
  • June 2014
  • May 2014
  • April 2014
  • March 2014
  • February 2014
  • January 2014
  • December 2013
  • November 2013
  • October 2013
  • September 2013
  • August 2013
  • July 2013
  • June 2013
  • May 2013
  • April 2013
  • March 2013
  • February 2013
  • January 2013
  • December 2012
  • November 2012
  • October 2012
  • September 2012
  • August 2012
  • July 2012
  • June 2012
  • May 2012
  • April 2012
  • March 2012
  • February 2012
  • January 2012
  • December 2011
  • November 2011
  • October 2011
  • September 2011
  • August 2011
  • July 2011
  • June 2011
  • May 2011
  • April 2011
  • March 2011
  • February 2011
  • January 2011
  • December 2010
  • November 2010
  • October 2010
  • September 2010
  • August 2010
  • July 2010
  • June 2010
  • May 2010
  • April 2010
  • March 2010
  • February 2010
  • January 2010
  • December 2009
  • November 2009
  • October 2009
  • September 2009
  • August 2009
  • July 2009
  • June 2009
  • May 2009
  • April 2009
  • March 2009
  • February 2009
  • January 2009
  • December 2008
  • November 2008
  • October 2008
  • September 2008
  • August 2008
  • July 2008
  • June 2008
  • May 2008
  • April 2008
  • March 2008
  • February 2008
  • January 2008
  • December 2007
  • November 2007
  • October 2007
  • September 2007
  • August 2007
  • March 2007
  • February 2007

Recent Posts

  • Home Ergonomics Advice Reduces Workers Comp Costs
  • Workers Comp Predictive Analytics Changed Loss Run Reviews Forever
  • Workers Comp COVID-19 Vaccinations – Part of Return To Work
  • Workers Comp Test Audits – Pain or Preventative Measure
  • WCIRB 8871 Webinar – What California Insureds Need To Know
  • Workers Comp Website – 10 Things To Know When Switching Providers
  • Workers Comp Zoom Presentation – Top Four Hard Lessons Learned
  • Experience Mod Increases While Loss Runs Show No Changes – WTR?
  • Workers Comp Allocated Expenses – Who Pays For Which Bills?
  • Workers Compensation Presentations Kawasaki Technique
J&L Risk Management Consultants Inc
14460 Falls of Neuse Road,
Suite 149305
Raleigh, NC 27614
(800) 813-1386
▲Return to top of page
Copyright © 2021 J&L Risk Management Consultants, Inc.

Website Design by Redwood [ Design - Print - Web ]