Transcript Claims Management - Atlantic County Municipal Joint

Claims Management
Presented by:
Patty Davidson – Qual-Lynx
2013 ACM JIF Retreat
MANAGING YOUR CLAIMS
Managing Your Claims
• The cost of a workers’ compensation claim is directly
proportional to the time it takes for injured employees to
reach “maximum medical improvement” (MMI) and
return to work. MMI means that injured workers have
improved medically as far as they are going to improve.
• Workers’ compensation claims can be controlled by
performing up-front investigation; using the most skilled
provider to treat a particular injury; eliminating delays in
treatment; and, reducing the number of lost workdays to
the minimum required to reach MMI.
Managing Your Claims
• Local Government has the highest accident rate of any
employer classification.
• Effective safety programs can reduce your accident rates.
Ninety-five percent of all employee accidents are
preventable.
• Effective accident investigations can help prevent future
accidents. Safety records can be improved by changing
behavior – reducing unsafe acts and quickly correcting
unsafe conditions.
Managing Your Claims
• Job Descriptions – Develop ADA approved job
descriptions and keep them up to date. Share them with
Qual-Lynx.
• Post Offer Testing – You are permitted to have
prospective employees examined to determine if they
are able to perform the essential physical requirements
of the job. Employers may require a physical agility test
representative of the work.
Managing Your Claims
• Pre-Injury Intervention – Educate your employees and
show them you are willing to help if they are injured.
• Communicate Safety – Make certain new workers,
including seasonal and temporary staff, are thoroughly
oriented to workplace conditions and shown how to
perform their jobs safely.
• Health Care Needs – Look for injury patterns and relay
them to your Fund Professionals.
Managing Your Claims
Reporting Procedures
• Every department head and supervisor must know how
to report an accident. The procedure should require
immediate reporting to QualCare by telephone so early
contact can be established with the injured employee
and treating physician.
• The Supervisor Incident Investigation Report should be
completed for every claim and sent to Qual-Lynx. Scene
photos are very helpful and should be taken
immediately.
Managing Your Claims
Doctors
• The treating physician is the single most important factor
in reducing workers’ compensation costs and preventing
fraud. New Jersey is one of the few states that still allow
the employer to contract with a managed care
organization (MCO).
Managing Your Claims
Maintain Contact with the Injured Employee
• It is the employer’s responsibility to periodically contact
the injured worker and express support.
• The major reason injured employees retain lawyers is
because they are uncertain of their benefits or
concerned that they are not receiving adequate medical
treatment.
Managing Your Claims
Develop a Transitional Plan for Each Injured Employee
• Studies have shown that many injured employees are capable
of assuming their full responsibilities at an earlier date if they
start a transitional plan before reaching MMI.
• Depending on the circumstances, a transitional plan includes
both specialized rehabilitation and transitional duty on the
job.
• Work with QualCare, Qual-Lynx and the treating physician to
identify what the injured employee is capable of doing on the
job while recovering. Focus should be on what activities the
employee “can” perform.
THE VALUE OF TRANSITIONAL DUTY
The Value of Transitional Duty
• 12 Benefits of Maintaining a Return-To-Work Program
1) Gain control and increase chances for a positive resolution of
all claims
2)
Retain the services of your valuable, trained employee
3) Maintain a productive employee for the wages you pay
4) Avoid replacement and training costs of hiring a new employee
5) Experience faster recoveries, both psychologically and
physically
6) Reduce the chance of permanent disability
The Value of Transitional Duty
• 12 Benefits of Maintaining a Return-To-Work Program
7)
Discourage fraudulent claims
8)
Increase morale among employees
9)
Increase awareness of safe work practices and injury prevention
10) Comply with the “Americans With Disabilities Act” (ADA) by
accommodating disabilities, and avoid costly lawsuits
11) Identify cross-training opportunities that enhance employees’
abilities in their regular jobs
12) Overall reduction of claim frequency and associated Workers’
Compensation costs
The Value of Transitional Duty
• The most important goal in establishing effective Return-ToWork Programs is to restore the occupational relationship
between the employer and the employee.
• The occupational relationship involves the physical,
psychological, social and environmental aspects of work.
• Ergonomics is the relationship between the worker, the work
tasks and the work environment.
• Ergonomics becomes the critical link in restoring the
occupational relationship between the employee and the
employer.
The Value of Transitional Duty
• It is important that the written physical job descriptions
accurately reflect the actual job requirements.
• These descriptions must be developed with input from
the employees doing the jobs, from the supervisors, and
from actual job observations.
• Once the physical demand job descriptions are
established, bringing the employee into the Return-ToWork Program is finding a “match” that is acceptable to
the medical provider and the claims team.
PERMANENT RESTRICTIONS
Permanent Restrictions
• NJSA 34:15-15 provides that “The employer shall furnish
to the injured worker such medical, surgical and other
treatment, and hospital service as shall be necessary to
cure and relieve the worker of the effects of the injury
and to restore the functions of the injured member or
organ where such restoration is possible.”
Permanent Restrictions
• Permanent restrictions are restrictions in effect for the
duration of a person’s working life or as long as the
employee remains permanently disabled. The medical
provider assesses these restrictions after the employee
has reached maximum medical improvement (MMI).
MMI is the point at which the physician believes the
employee’s condition is not going to improve any further.
Permanent Restrictions
• Some injured employees are not capable of assuming full
duties even after reaching MMI.
• If you cannot reasonably accommodate the injured
employee’s permanent restriction(s), you may be able to
proceed with termination.
• However, before you terminate you should make sure
that you are not taking risks with respect to other laws
like the Americans with Disabilities Act (ADA) or Family
and Medical Leave Act (FMLA).
Permanent Restrictions
• Two most common issues which implicate Workers’
Compensation, ADA and FMLA:
1) Return to work following a work-related injury
2) Termination of employment following a work-related
injury
Permanent Restrictions
• If the employee has been discharged at MMI with permanent
restrictions, the employer must decide if it is willing to
accommodate the restrictions and allow the return to work.
• Refusal to accommodate the restrictions may increase the
eventual award for permanent disability benefits as it will
evidence a greater loss of function; however, it may prevent
future claims or a worsening of the injured employee’s
condition.
• The New Jersey workers’ compensation statute does not
require that an employee’s job be held open indefinitely while
the employee is out because of a work related injury.
Permanent Restrictions
• Termination in the context of a workers’ compensation
claim may result in a wrongful discharge claim pursuant
to the prohibition against retaliatory discharge under
NJSA 34:15-39.1.
• Always, always consult with your labor attorney prior to
proceeding with termination. Make sure all medical
records are reviewed, as well as the job description, to
determine if reasonable accommodations can be met.
Thank You!