Workers’ compensation provides coverage for injured workers’ lost wages and medical expenses.
Originally posted on Property Casualty 360 by Patricia L. Harman.
Worker’s compensation is administered at the state level – all 50 states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands have their own programs, as does the federal government for its employees. It is designed to provide coverage for injured workers’ medical costs, pay them for lost work time and even cover death and funeral benefits if necessary. Approximately 75% of workers who file a claim only require medical benefits coverage and benefits for replacement wages are determined by the severity and length of the workers’ disability. Benefits usually begin following a brief three to seven-day waiting period.
In order to file a claim, there are four eligibility requirements that must be met:
- The worker must be an employee of the company where the workers’ compensation claim will be filed.
- The employer must carry workers’ compensation insurance for employees.
- The injury or illness must be work-related.
- The employee must comply with the state’s deadlines for reporting the injury and filing a workers’ compensation claim.
Workers’ compensation provides six types of benefits:
Temporary total disability — This benefit covers approximately two-thirds of a worker’s pre-injury wages (tax-free) until the worker is able to return to work. The benefits end when the employee resumes full-time employment. The majority of employees receiving these benefits return to work.
Temporary partial disability — This benefit is paid to workers who return to work with reduced responsibilities and a lower salary and helps offset the loss in salary.
Permanent total disability — While few workers’ compensation cases result in permanent total disabilities, this coverage applies when an injury results in permanent impairment or the worker has reached his or her maximum for medical improvement from the injury.
Permanent partial disability — When an employee has permanent impairments that do not completely limit his or her ability to work, the permanent partial disability benefit kicks in until the employee has accomplished maximum medical improvement. These benefits are generally limited to a specific period or total dollar limit.
Death benefits — For workers who pass away from a work-related injury or illness, compensation for death benefits is based on a formula that calculates the worker’s earnings and the number of dependents who are determined to be eligible survivors.
Medical benefits — For workers whose cases do not extend beyond the three to seven-day waiting period, only medical benefits are paid.
Filing a claim
“The workers’ compensation system in the United States was built on a ‘grand bargain’ between employers and employees,” explains Desiree Tolbert-Render, Sedgwick AVP of national claims tech compliance. “Injured employees and their dependents gave up the right to sue their employers in civil court in exchange for assured and specific benefits, regardless of fault, provided by the employer. The employee’s rights and responsibilities under workers’ compensation, as well as the requirements and procedures for filing a workers’ compensation claim can vary from state to state.”
When a worker is injured, he or she should notify the employer as soon as possible, especially since each state has different timeframes for filing. By promptly filing a report, the injured employee can receive any necessary medical treatment sooner and the employer can address any safety issues to prevent additional injuries to co-workers.
Tolbert-Render shares some do’s and don’ts for injured workers considering filing a workers’ compensation claim:
- Do file a claim on a timely basis.
- Do take time to review the important information about your rights, responsibilities, benefits, and assistance available to you sent by the claims examiner and the state workers’ compensation agency.
- Do be honest and upfront about the injury and any prior injuries or accidents to the affected body parts.
- Do communicate with the employer and the claims adjuster about your medical status and work status to avoid delays in receiving benefits and the necessary medical treatment.
- Do follow the doctor’s orders.
- Do work within the established restrictions.
- Don’t delay in filing a claim.
- Don’t discontinue medical treatment before being released.
- Don’t work outside of the established restrictions.
- Don’t seek medical treatment from unauthorized providers in those states where the employer can manage medical care.
- Don’t delay returning to work and resuming a productive lifestyle.
In 2016, there were approximately 2.9 million work-related illnesses and injuries reported or approximately 2.9 cases per 100 full-time employees according to the U.S. Bureau of Labor Statistics. Interestingly, the areas of finance and insurance saw a slight increase in the number of illnesses and injuries, while the construction, manufacturing, wholesale trade and retail industries saw significant declines.
According to the federal government, benefit payments totaled $61.9 billion in 2015, a 1.3% decrease from 2014. Medical payments accounted for half of that spend, totaling $31.1 billion, while payments for lost wages were $30.7 billion.
Originally posted on Metropolitan Risk by Charlotte Ulehla.
What is a return to work evaluation form?
Employers can provide their employees with a return to work evaluation form to give to their physician when the employee suffers a work-related injury. The form can facilitate communication between the treating physician and employer as to the employee’s status and capabilities. Many employers miss this step.
We encourage employers to send the physician the employee’s current job description AND a job description for an alternative duty position for which the injured employee might be eligible.
What is the importance of a return to work evaluation form?
It’s difficult to action plan the claim and get the employee back to work when there is no clear understanding of the employee’s injury AND job duties. This form along with the job description helps establish the baseline so all stakeholders can work in concert. This will get the employee back in some productive capacity.
Why should an employer provide this evaluation form?
If an employee is injured, they may not be able to perform their original duties. This return to work evaluation form helps the employer create accommodations enabling the employee to come back to work at the best of their ability.
A frequent (and very costly) mistake employers make is bringing the worker back too fast without having them medically cleared to perform their duties. We recently had an employer tell us their worker was injured playing softball for his recreational team on his own time. The employer never noted the incident formally in their employment records creating an incident. Further, they never had the employee medically evaluated to see how severe the injury may have been. Nor did they have the employee medically cleared to come back in the same capacity. Instead, he took a day off, came back to work too early. Sadly, he threw his back out on the job further, exacerbating the injury. Had the employer properly recorded the incident and had the employee fill out an injury form this would not have become a comp claim.
The original injury was non-compensable as it did not occur at work. It became compensable when he returned to work too early and made the injury worse. Following proper procedures and utilizing a return to work evaluation form would have gone a long way in preventing this type of situation from occurring.
What’s the impact on your workers’ compensation premiums by using a return to work evaluation form?
It creates a formal process around employee injuries that accomplishes several cost savings benefits:
- Prevents employees from coming back to work too soon. This saves you from driving up injury rates and costs as the injuries usually become worse.
- Facilitates very productive communication between treating physician, the injured employee and your company’s HR staff person.
- The goal after every employee injury is to get them back to work in SOME capacity as quickly as possible. This cuts down on the ultimate cost of the claim. Too often we see employers simply file the workers’ comp claim with their carrier then walk away and go back to their regular scheduled programming. Then their experience modification factor gets re-calculated which may result in significant workers compensation premium surcharges.
Can employees abuse the return to work evaluation form?
Employees can abuse this only if the employer allows it to happen.
If the employer:
- Meets with the injured employee every 10 days to check in on their healing progress
- Makes it clear that the accommodations aren’t temporary
- Allows open communication to provide the best accommodations and transition phase possible
- Follows up with the physician
There should be no possible chance that the employee would abuse the return to work evaluation form. Truthfully, we see far more abuse when employers have no form and no process for getting the worker back on duty.
Originally posted on Business Insurance by Angela Childers.
Costly catastrophic claims are emerging in the workers’ compensation sector, partly driven by comorbidities and prescribing of expensive brand-name drugs, experts say.
Comp payers must quickly identify seemingly innocuous claims that have the potential to balloon out of control and proactively work to mitigate those costs, they say.
More than 80% of medical costs in workers comp are for claims between $10,000 and $500,000, according to Boca Raton, Florida-based National Council on Compensation Insurance Inc. And although overall comp claims are declining, the number of claims exceeding $10 million in comp jumped to 10 in 2016, according to NCCI, compared with just four during the prior year.
While catastrophic injuries affect those figures, comorbidities, lower-body fractures, back strains, and shoulder injuries can also lead to substantial claims in some cases, experts say.
Comorbidities, such as hypertension and diabetes, can increase the cost of an injury that seemed to be a $30,000 to $40,000 claim to six or seven figures, said Anita Jovic, vice president of operations at Home Care Connect LLC in Winter Park, Florida, which provides home health services for injured workers.
“The injured worker may not know they have an underlying diagnosis,” she said. “For instance, in a crushing injury, if you find out (the worker has) diabetes, that claim balloons. The patient may have a wound that may not be healing as quickly … that prolongs the care.”
“Comorbidities, in general, are something we keep at the forefront of our purview,” said Helen Froehlich, the vice president of case management services for Wayne, Pennsylvania-based Genex Services LLC. “What I have seen have a drastic impact on our claims has been very consistently high blood pressure, obesity and adult-onset diabetes. Being aware of where comorbidity is, whether it has a direct potential impact on that individual case … is imperative.”
Patchez Pirtle, the director of catastrophic services for Owings Mills, Maryland-based Restore Rehabilitation LLC, said she’s seen pelvis fractures, heel fractures, and rotator cuff injuries grow into very expensive claims.
Those injuries don’t “necessarily set off alarm bells, but do tend to become very expensive claims,” she said. Often complications from those types of injuries aren’t realized until the employee has been sitting home for months on pain medications, making it more difficult to get that claimant going in the right direction.
Brand-name medications can be a big concern, said Dan Anders, an attorney, and chief compliance officer for Tower MSA Partners in Delray Beach, Florida, which specializes in Medicare set-asides in workers compensation.
“If there’s a brand-name medication … that comes out during the course of their treatment that the doctor thinks is the next wonder drug, it gets placed on the claim and drives up the cost,” he said. “Opioids, for the most part, are available as generic and may not be too pricey, but it’s the long-term effects … they require a lot more management by a physician, which means more visits, and tend to have side effects. The side effects can increase such that there are more medications being prescribed that are nonopioids to deal with those side effects.”
Injuries like back strains or shoulder trauma, which at the outset seem like a standard claim, can also become catastrophic claims because if the initial treatment doesn’t work, “brand-name medications are prescribed and then pain management escalates into a psychiatric issue,” Mr. Anders said.
The key is identifying which claims could escalate, including those driven by expensive medications, said Amy Bilton, shareholder at Nyhan, Bambrick, Kinzie & Lowry P.C. in Chicago. For example, one of her current cases involves a man in his 20s who had a previously asymptomatic condition become symptomatic due to his exposure to fumes at work, ultimately leading to renal failure. His monthly infusion drug, Soliris — which was the only treatment option — costs $1 million a month. However, she said they’re constantly looking to see if any new drugs or treatment options are in the works.
“This is obviously an extreme example, but that’s what a lot of these (high cost) cases come down to — extreme examples,” she said.
Tracy Ryan, chief claims officer of global risk solutions at Boston-based Liberty Mutual Insurance Co., said in the past 10 years the company has used a predictive model for claims it designates as “slow developing medical” to help identify these types of expensive claims earlier. The model looks at medical bills, comorbidities, pharmaceuticals, and treatments, and by combing through that data constantly, it can send an alert to the claims adjuster to review it before the costs potentially soar.
“We have seen significant reductions that we associate with putting that model in place, and the ability to get nurses on those files sooner, engage with doctors, talk about treatment plans … it’s an area that is always important because (these types of claims) can look innocuous at the beginning.”
Warning signs that a claim may require more scrutiny may also be evident. “You can see the writing on the wall when a worker goes in and asks for an opioid by name — you know you’re in trouble,” said Ms. Bilton. “And intuition is super important. If you feel like the claim could go bad, treat it as if it’s going to.”
Another key is maintaining a “settlement mindset” from the day the claim is filed, according to Mr. Anders, and ensure that you’re clearly communicating with the worker and getting medical case management early on in the claim.
“You should be thinking about what should be addressed in that claim to ensure, of course, that the injured worker gets the treatment that they need, that the treatment doesn’t go beyond what’s reasonable, and that you’re not paying for treatment that’s unrelated to that injury,” said Mr. Anders.
Workplace injuries can happen in any industry, and they can be costly, inconvenient and debilitating to both employees and the company as a whole.
Travelers, which provides workers’ compensation insurance, analyzed its claims data to find the most common on-the-job accidents and injuries. Here are the most frequent workplace injuries, according to the company’s recent Injury Impact Report:
- Strains and sprains
- Cuts or punctures
- Contusions (bumps and bruises)
- Inflammation (e.g., tendinitis)
The leading causes of these injuries include material handling (32 percent); slips, trips and falls (16 percent); being struck by or colliding with an object (10 percent); accidents involving tools (7 percent); and traumas occurring over time (4 percent).
According to Travelers, it’s important to focus on protection and recovery techniques in the workplace to prevent injuries and minimize their effects if they do occur.
“The most common injuries we see can often be prevented if the proper safety measures are in place, if safety issues are promptly addressed and if leaders continuously emphasize a culture of safety with employees,” Woody Dwyer, second vice president of workers’ compensation and risk control at Travelers, said in a statement.
To help prevent workplace injuries, Travelers recommends that employers hire only the candidates who are truly qualified for the job and understand the safety hazards involved. From there, workers should participate in safety programs and training sessions. Leaders should also provide support to employees, ensuring appropriate communication regarding safety measures, Travelers representatives said.
If an accident or injury does happen, it’s important to put your employees on the path to recovery as quickly as possible, Dwyer noted.
“Even seemingly minor injuries, such as strains or sprains, can substantially impact an employee and slow a business’s operations and productivity,” Dwyer said.
By supplying the proper equipment and support to your employees, you can help them to recover more quickly.
The report was based on the analysis of more than 1.5 million workers’ compensation claims filed between 2010 and 2014 by various businesses and industries.
Author: Sammi Caramela
Source: Business News Daily
Employers are on the front lines of nipping one particular sort of workers compensation fraud in the bud: the incident that never happened or one that is being exaggerated, according to panelists on a session on fraud at the 38th annual International Risk Management Institute Construction Risk Conference.
Weighing in on what employers can do to prevent fraud at the onset of a claim, especially on a construction site where the landscape alters daily and the workers — witnesses — on the site can change from day to day, the first step is to gather facts with an effective reporting system and immediate documentation, the presenters said Monday at the conference in Houston.
“It’s important when these claims occur to collect information, because it might not be there when you go back to get it,” said Melissa Schultz, co-founder of Chicago-based SitePatterns LLC, which markets incident-reporting software for the commercial construction industry.
Simplified and immediate incident reporting is a must, said Ms. Schultz, who spent several years on construction sites in risk management and workers compensation.
“You want to make sure (your system) is asking the right questions … You don’t want (the form) to be 15 pages long. You want something they can complete, easily fill out and is easy to understand,” she said. “It’s important that you get those reports early and review them.”
Witness statements are just as important, as subcontractors who witnessed the incident might not be working on-site later on when an employer needs more facts on a claim that is likely being inflated, according to presenters.
“Pay attention to the witness statements,” said Patrick Duggan, Chicago-based vice president of risk for Power Construction Co. LLC. Mr. Duggan said employers sometimes go back to investigate when a simple claim becomes more complex — with a surgery looming or a plaintiff’s attorney asked for a large lump sum — and it’s sometimes too late to gather facts.
Ms. Schultz said to make sure witnesses are separated and provide accounts individually — as stories start to sound “more similar” the closer the witnesses are before reporting.
Making it routine for site safety coordinators and other supervisors to take photographs of scenes is another step, she said. “Job sites changes quickly … if you go back days later to take photos, chances are it will not look the same,” she said.
She recalled one claim where a subcontractor reported that he fell down a staircase. A supervisor was able to take video of the stairwell with his phone immediately after the incident. Weeks later the injured worker’s attorney called with a claim that the stairwell was full of “gushing” water, she said.
“I gladly shared that video with that attorney,” Ms. Schultz added.
Incident-reporting culture on-site is another factor in preventing fraudulent claims, she said. “You want to make sure you communicate the process regularly,” she said. “You want to make sure that you remind the field how to fill out that report.”
Supervisors can become more used to the incident-reporting process and can think of it as “more than just checking the boxes,” she said. “They start anticipating the things you will need,” she added. The supervisor who took video of the stairwell, for example, did so immediately without having been asked to do so, she said.
Brian Koch, Chicago-based partner/shareholder with Wiedner & McAuliffe Ltd., said early documentation, including photographs, can also work in reverse: helping to prove a legitimate claim that an employer deemed possibly fraudulent, thus cutting down on legal costs.
He told the story of a subcontractor who was injured within his first few hours on a job site — sometimes a telltale sign of fraud, but not in this case, he said. A photograph of a tear in some anti-slip skids on the floor helped show how the worker did, in fact, trip. Attorneys saved the company “a lot of energy and expense” in seeing what happened immediately with photos taken of the site as evidence — part of a claim that the worker would have likely fought if the employer had denied it, according to Mr. Koch.
Author: Louise Esola
Source: Business Insurance