Return To Work programs really can work!

At the CLM & Business Insurance Workers Compensation Conference in Chicago recently, a panel illustrated the financially positive effects of the implementation of a Return to Work program with a large employer, Sodexo, Inc..  Sodexo has facilities in all 50 states and employs 150,000 people at 3100 sites.  They average about 6,000 workers comp claims every year!  Focusing on Return to Work has allowed Sodexo to shave between $8 million to $12 million in temporary total disability costs!  This type of program is a perfect example of how hard work, collaboration and advocacy can create a program that centers around the goal of transitioning the injured worker back to work!  You can read the article here:


“We still can’t get our work comp under control!”

There’s a simple answer for this.  The insurance model is a game of chance and designed to ensure you lose.  Employers are sold on illusion, but the reality of a reactive risk and claims model is just one injury away.  The only path to change is your decision to do so and the gradual adoption of a culture of advocacy.

The term “workers compensation advocacy” has been tossed lightly around recently, but to most employers it’s a meaningless term.  Brokers offer their clients a complimentary off-target version, but anything more extensive involves a greater commitment that the broker likely cannot afford.  Work comp advocacy is important.  Advocacy can prevent claims, reduce claims, reduce litigation, speed a return to work and purge a heavy claims inventory.  It can also help an employer get a better handle on their workers comp claims program.  Below are two more tips toward advocacy.

Tip #1 – When we meet with employers, as a matter of practice, we ask a very key question – “Did you  notify your new TPA of your company’s goals and objectives for your WC claims program?”  When there are no expectations for the TPA, outcomes for the employer are usually less than hoped for.  Without accountability, responsibility for shortcomings and errors can be easily set aside.

Tip #2 – Use nurse case management to bridge the communication gap while the claimant is off work.  Don’t use nurses to pressure the doctor to release the claimant to work before he/she is ready.  Rather use the doctor to approve alternative work; communicate in easy-to-understand terms that will not confuse the injured worker; the doctor’s diagnosis, estimated time off work; the employers desire to keep them working.  Nurse case management can help to keep litigious  urges at bay.

These tips are part of our Workers Comp Transformation advocacy practice which we make available to employers throughout southern California.  Feel free to contact us in order to discuss your workers comp challenges.

Chipotle settles wrongful termination claim for $9 million!

Sometimes human resources personnel or workers comp claim representatives take subsequent wrongful termination, serious & willful misconduct claims or negligence claims too lightly.  They become accustomed to these claims being washed away in settlement negotiations and fail to prepare their files for eventual pursuit by the injured  or terminated employee.  Sometimes, they may even fib about the evidence maintained in their file.  Last week the Fresno Bee reported on such a case stemming from a workers comp claim to  poor employment practice.  You can read this very interesting story by following the link:…ews/local/article211101999


Do we really owe our police & firefighters lifetime WC benefits?

Do we really owe retired firefighters and police personnel lifetime workers comp benefits?  Do we really owe lifetime workers comp benefits to other city and county retirees?  That may have been the policy in the past, but for public entities today, the cost of maintaining a growing inventory of complex future medical claims is a heavy burden and creates greater long term risk.

What if we could figure a win-win solution to this conundrum?  What if you could give the claimant full control over his medical treatment? What if you could reduce your overall risk exposure and free up hundreds of thousands in reserves?   What if we could do it in 60 to 90 days?

There are alternatives to growing the future medical inventory.  As for your retired police & fire personnel that have given so much to our counties and cities, maybe we owe them control over their futures as well.

Our 6 Step Future Medical Claim Resolution service can help you reduce your legacy claim inventory.  Call or write to schedule a time to meet!


Understanding Medicare Set Aside Arrangements

What is it?

In a nutshell, the Medicare Secondary payer statute asserts Medicare’s position as a secondary payer, whenever a primary payer is responsible for the payment of health services.  What that means to us as claims adjusters is that Medicare does not want to pay for your injured claimant’s injury and you will have to “set aside” funds in a separate account so that the injured worker can pay his own medical treatment after you settle the claim.

As adjusters, we’re accustomed to viewing claims from a technical perspective. We see these claims in terms of disability rating and reserve figures up until it’s time to settle. Once the key issues have been hashed over with the defense attorney, reality begins to sink in. The claim may not settle all that inexpensively. The injured worker is currently on Medicare and you will likely need to do a Medicare Set Aside Arrangement.

Sometimes we figure a claim may need a Medicare Set Aside Arrangement because we have a claim that rates out at a very high percentage of disability.  The Centers for Medicare & Medicaid Services (CMS) has a different perspective about injury disability. CMS is interested in the monetary value of a claim. Your best indicator of potential Medicare compliance issues is clearly indicated by your claims benefits paid to date, primarily for the medical care but CMS also factors in temporary disability, permanent disability, attorney fees, lost wages paid, and previous stipulated settlement amounts.

Identifying the need for a MSA is the easy part. Figuring how to use the MSA report is a bit more of a challenge. Here are some thoughts:

  • Use the report to accurately set reserves.
  • Provide reality check to the claimant attorney if the settlement demand is not realistic.
  • Identify the true need for specific medical treatment.
  • Use the report to finalize a structured settlement deal.
  • Most important, use the report to finalize a settlement.

So now you have a completed Medicare Set Aside Arrangement report in front of you, but before you can actually put it to work, it’s best you figure out some key aspects of the report and their implications.

Medicare Recovery Claim Identification – One of the more unpleasant surprises that can come along with the MSA process is the discovery that the injured worker has been receiving treatment for his work-related injury and Medicare has been footing the bill.  The result is a potential Medicare lien which needs to be resolved outside the settlement agreement.  Failure to resolve Medicare’s recovery claim may lead to litigation by the US Department of Treasury for double damages plus penalties.

Rated Age – When it comes time to settle a claim, it rarely feels like you are actually saving money.  It seems that after all the negotiations; all you’ve done is spend.  This is one of the few opportunities you have to save a little money. Once we receive your medical records, we immediately send a few select reports to your structured settlement broker who in turn sends them to a life insurance underwriter in order to calculate the injured workers medically rated age. Usually this means that the underwriter has shaved numerous years off of the claimant’s life due to his or her medical condition, including the non work injury.  What that means to you as an adjuster, is that the period of future medical care has been diminished, resulting in reduced future medical costs.

Coaching you to effectively utilize and understand Medicare Set Aside allocations is our primary purpose.  Supporting you in using the MSA to move you closer to settlement is equally important.  We are committed to your success.

What are the best WC claims for settlement?

The big question from most of our clients is, “How do I know which claims to pursue for settlement?”  I usually follow the question with a question of my own.  “What are you trying to accomplish overall?”    In most cases employers simply want to reduce reserves and long term expenditures.

There are a number of criteria we discuss:

  • Do the claims involve former employees?
  • Are they catastrophic injury claims?
  • Are they old forgotten claims?
  • Do the claims have long term unresolved legal issues?
  • Can you settle the claims for the estimated reserve exposure?
  • Do you have an accurate projection of future medical exposure?

In most cases our clients use these simple questions to develop proactive criteria for identifying prospective claims for settlement.  By developing a proactive approach to settling claims an examiner can eventually realize better control over their claim inventory and the employer a significant reduction in legal & medical costs as well as a reduction in reserves.   I hope this is helpful.

Please let us know if we can help you move a case toward settlement using our Medical Cost Projection service or Medicare Set Aside arrangement.

7 Things Injured Workers Should Know About Administering Their MSA

7 things claimants should know about administering their own MSA funds

  • Medicare can begin paying for the work-related injury only after the MSA monies have been properly spent on Medicare-covered items.
  • The MSA account may be used to pay for :
    • Banking fees related to the MSA account
    • Postage
    • Document copy fees
    • Income taxes on interest income earned from the set-aside account
  • Claimant is responsible for keeping accurate records of expenditures.
  • Claimant must sign an attestation letter every year attesting that all expenditures were for Medicare covered items. Attestation must continue until the account is depleted.
  • Claimant must ensure that all services and expenditures are Medicare-covered.
  • Claimant must keep receipts for all expenditures.

Feel free to call or write with questions!