Table of Contents* *As an information tool, the Table of Contents includes Pre-Loss Planning and Post-Loss Implementation Chapters.

Transcription

1 Table of Contents* *As an information tool, the Table of Contents includes Pre-Loss Planning and Post-Loss Implementation Chapters. Mastering Workers Comp Costs Volume I: Pre-Loss Planning Chapter 1: Workers Compensation Insurance Basics Purpose of Workers Compensation... 1 Who Pays for Workers Compensation Parties Involved in Workers Compensation Benefits for the Employer Independent Contractors Benefits for the Employee Injuries Covered Determining Compensability Aggravation vs Exacerbation Standard Defenses Types of Workers Compensation Insurance How Losses Are Categorized How Losses Are Reported Reducing Your Premium. 14 Calculating Your Premium.. 14 How Mod Affects Your Premium Good/Bad Mod Examples Ways to Reduce Your Mod. 15 Unit Statistical Date Types of Insurance Structures Voluntary Markets Alternatives to Voluntary Markets Collateral Requirements Chapter 2: Fundamentals of Cost Containment. 19 Reasons Workers Compensation Costs Are High Who Is in Charge Work Ability Form Properties Who Is Responsible for Managing Workers Compensation Claims Who Is Responsible for Managing Workers Compensation Process Hidden (Indirect) Costs of Workers Compensation Additional Costs Calculating Workers Compensation Costs. 22 External Obstacles to Cost Control Internal Obstacles to Cost Control 23

2 Chapter 3: Training and Building Commitment Implementing a Workers Compensation Program. 25 Key Training Responsibilities Management Awareness Presenting to Supervisors Conflicting Roles of Supervisors Supervisors Must Be Involved Develop Supervisor Guide Building on Success Consider Use of Tools Bringing Employees on Board Your Company Message Workers Compensation Implementation Timetable.. 29 Facilitator s Training Agenda.. 30 Chapter 4: Injury Management Best Practices Roles and Responsibilities Injury Coordinator Best Practices Supervisor Best Practices Employee Best Practices Middle Manager Best Practices. 41 Risk Manager Best Practices. 42 Medical Department and Medical Director Best Practices Senior Management Best Practices.. 44 Special Investigation Unit Director Best Practices.. 45 Legal Department Best Practices.. 46 Chapter 5: Reporting the Claim Immediately Report All Losses Critical Issues Reporting Procedure Intake Procedures Essential Intake Considerations Injury Triage Employer s First Report of Injury What Is Included on the FROI Completing the FROI.. 51 Penalties Chapter 6: Post-Injury Response Procedure.. 53 Post-Injury Response Procedure Guidelines.. 53 Benefits of a Consistent Post-Injury Response Post-Injury Response Worksheet Implementing Post-Injury Response on the Road Sample Post-Injury Response Procedure Summary Steps and Format

3 Chapter 7: Communication with Employees Proactive Communication Reactive Communication 59 Keep Complete Record Two Types of Communication Employee Brochure. 60 Meeting with Your Employee. 60 First Day Phone Call Weekly Contact 61 Weekly Meeting Guidelines 61 Scheduling Weekly Meetings. 61 Reducing Attorney Involvement. 61 Chapter 8: Working with Your Insurance Adjusters or TPA Claims Adjusters.. 63 What Is a TPA Adjuster File Assignments Dedicated vs Designated Claims Units. 64 Bundled and Unbundled Services Deductible vs Control.. 64 How to Select a TPA Learning About Your Claim Partners Preparing for the TPA Visit. 66 Meeting with Your Claims Handler Chairside Visits. 67 Doing a National Rollout Vendor Day Account Handling Instructions Reviewing Open Claims with the TPA.. 68 Reserving Practices. 69 Information Needed to Establish Reserves. 69 Reserve Calculation Worksheets.. 69 Reasons Reserves Are Higher Than Expected.. 70 Verifying Reserves Accuracy. 70 Plan of Action (POA).. 70 How to Evaluate a TPA Medical Management Quality Review.. 73 Quality Control File Audit 74 File Reviews and File Audits.. 74 Audit Timing.. 74 File Review Procedures.. 74 File Audit Procedures.. 75 File Audit Participants.. 75 MD Participation How to Control Leakage.. 77 What Is Leakage Types of Leakage. 77 Causes of Leakage.. 77 Leakage Claim Audits. 78 Leakage Identification Checklist 78

4 Chapter 9: Safety and Loss Control How to Develop an Effective Safety Program Initial Assessment Assignment of Roles and Responsibilities Record Keeping What OSHA Requires Select Safety Committee, Chairman, and Recording Secretary Safety Committee Responsibilities Safety Committee Meetings Communication Methods Conduct a Thorough Workplace Assessment Hazard Correction/Safety Work Order Tracking System Develop Written Policies, Procedures, and Programs Accident Investigation Program Education and Training: Employees, Supervisors, and Managers Who Receives Training Safety Equipment Required Signs Communicate Safety Often Safety Awareness Posters Safe Days Posters Safety Recognition and Incentive Programs Employee Screening Hiring Safe Employees Job Analysis.. 85 Screening Tools Chapter 10: Wellness Programs Wellness in the Workplace Benefits of Wellness Programs. 87 Incentives for Wellness.. 87 Negative Effects of NOT Having a Wellness Program.. 87 Types of Wellness Programs Weight Control Smoking Cessation Programs Depression/Anxiety Awareness Treatment Migraine Headache Management. 88 Substance Abuse Treatment Drug, Alcohol, and Substance Abuse Policy Drug, Alcohol, and Substance Abuse Testing Putting Wellness Programs into Practice Appendix A: Glossary of Abbreviations.. 91 Appendix B: Documents Referenced in Book INDEX - Volume I... 93

5 Table of Contents* As an information tool, the Table of Contents includes Pre-Loss Planning and Post-Loss Implementation Chapters. Mastering Workers Comp Costs Volume II: Post-Loss Implementation Chapter 11: Return to Work and Transitional Duty Cost Savings. 1 Measuring Effectiveness of Return-to-Work Programs. 1 Transitional Duty Policy Overview. 2 Benefits.. 2 Program Goals Drafting a Transitional Duty Policy... 2 What to Include in a Transitional Duty Policy Characteristics of Transitional Duty Assignments Transitional Duty Program Pay Rate... 4 Estimating the Duration of an Injury Medical Treatment Guidelines... 5 Medical Treatment and Comorbid Conditions Using Medical Treatment Guidelines 5 Using Injury Treatment Guidelines to Estimate Cost Savings.. 6 Types of Transitional Duty.. 7 Modified Duty 7 Alternate Work.. 7 Alternative Off-Site Jobs. 7 Non-Profit, Volunteer, or Charitable Positions 7 Transitional Duty Tips. 8 Putting Return-to-Work into Action... 9 How to Identify Transitional Duty Jobs Employees Who Never Return to Work 9 Overlapping Benefits Americans with Disabilities Act (ADA) Key Points.. 11 Coordinating Workers Compensation with Federal and State Leave Statutes. 12 Workers Compensation, ADA, and FMLA Interactions Case Study Working with Unions Chapter 12: Other Indemnity Cost Containment Methods Work Hardening Independent Medical Evaluations (IME) Before the IME Customize Medical Inquiries Timeframes for Scheduling and Obtaining IME Functional Capacity Evaluations (FCE) Retraining Programs Telephonic Disability Intervention.. 22 Translation Services Transportation Services Layoff Planning

6 Chapter 13: Directing Medical Care. 27 Gain Cooperation from Medical Providers Types of Doctors Remote Health Services Methods of Doctor Selection.. 29 If the Employer Can Direct Care If the Employer Cannot Direct Care Ten Considerations for Your Company Doctor.. 29 Eleven Reasons NOT to Select a Doctor 30 The PRIMARY Treating Physician (PTP) Understand the PTP s Perspective.. 30 Information You Need from the Doctor Understanding KEY Medical Injury Terms California Medical Provider Network (MPN).. 32 Chapter 14: Medical Cost Containment Medical Cost Containment Services Utilization Review Accreditation Commission Certification.. 35 Preferred Provider Organizations Injury Triage Telephonic Nurse Case Management (NCM) Field Case Management (FCM) Mental Health Registered Nurses Chronic Pain Programs An Aging Workforce. 40 Medical Review 41 Medical Advisors and Medical Directors Independent Medical Evaluation (IME). 43 Durable Medical Equipment (DME) At-Home Recovery Services Medical Bill Review Medical Fee Schedules Usual and Customary.. 45 Hospital Bill Reviews 46 Using a Diagnosis Related Groups (DRG) Review Company. 46 Cost Savings Using DRG 46 Medical and Hospital Bill Review Considerations.. 46 Chiropractic Care. 47 Chapter 15: Fighting Fraud and Abuse.. 49 When to Investigate a Claim.. 49 Types of Investigation Red Flags of Fraud Medical Terminology Used to Identify Malingering Important Times to Use Surveillance How to Use the Results When Not to Use Investigation Reviewing Investigation Reports and Videos Avoid Good Day/Bad Day Syndrome Additional Fraud Controls... 55

7 Chapter 16: Rehabilitating the Injured Employee What Is Physical Therapy What Is Physical Rehabilitation What is Occupational Therapy What is Vocational Rehabilitation.. 57 Provider Differences 58 Physical Therapy. 58 Physical Therapy Management Determining Rehabilitation Needs 58 Reasons for Physical Therapy.. 58 Measuring Outcomes.. 58 Doctor s Reevaluation. 59 Determining Therapy Outcomes Physical Therapy Settings.. 59 Physical Therapy Office Characteristics.. 59 Physical Therapy Cost. 59 Physical Rehabilitation. 60 Physical Rehabilitation Networks and Specialties.. 60 Medical Assessments. 60 Cost of Physical Rehabilitation.. 60 Physical Rehabilitation Facilities Measuring Physical Rehabilitation Outcomes. 61 Occupational Therapy. 61 Occupational Therapy Management. 61 Role of the Occupational Therapist.. 61 Use Occupational Therapy When. 62 Vocational Rehabilitation 63 Use Vocational Rehabilitation When 63 Managing the Vocational Rehabilitation Process.. 63 Chapter 17: Managing Prescription Drug Use and Abuse. 65 Pharmacy Benefits Managers.. 65 Reasons to Use Pharmacy Benefits Management.. 65 Prospective and Retrospective Components Proactive Drug Management Techniques. 66 Authorized Drug Formulary.. 66 Narcotics for Pain Control Cognitive Behavior Therapy (Pain Management) 67 Pharmacogenetics Testing.. 67 Addiction Networks 67 Reviewing Your Program Key Selection Criteria for a PBM Prescription Drug Monitoring Programs. 70 Toxicology Screening Implementing the Program.. 71

8 Chapter 18: Claims Resolution and Settlements When and How to Settle a Workers Compensation Claim Action Plan Disability Rated Losses Disability Scheduled Losses Jurisdictional Issues Local Influences Include Future Medical in the Settlement Selecting Physicians to Obtain a Fair Disability/Permanency Rating Challenging Impairment Ratings Medical Issues Disputed Issues Offsets Against Other Payments Social Security Disability Benefit Offsets Social Security Reverse Offsets States with Reverse Offset Prior Injury Offsets Subrogation Pre-existing Conditions and Second Injury Funds Availability of Future Employment in the Marketplace Voluntary Resignations Strengths and Weaknesses of Both Sides Negotiations Waivers and Releases Include Medicare in Release Medicare Set-Asides Conditional Payment and Final Demand Pharmacy Component of Medicare Set-Asides Structured Settlements and Annuities Structured Settlement Benefits Structured Settlement Vendor Selection Criteria.. 82 California Settlement Process... 83

9 Chapter 19: Federal Employees Compensation Act.. 85 Federal Employees and Workers Compensation.. 85 Paying for FECA Costs.. 85 Administering FECA Claims Selection of Medical Providers Medical Benefits Lost Wages Federal Employees Receive 85 Permanent Disability or Death.. 86 Registering as a Federal Medical Provider Challenges in Controlling Costs Traditional Cost Control Techniques Independent Medical Examinations Cost Containment Vendors and Services Gaining Management Commitment Return-to-Work Programs.. 87 Federal Employees Return-to-Work: Transitional Work (before Maximum Medical Improvement) Defining and Determining Maximum Medical Improvement Transitional Duty Work and Assignment Transitional Duty Barriers Checklist. 89 Role of the DOL in Transitional Work Federal Employees Return-to-Work: Alternative Work (after Maximum Medical Improvement) Alternative Employment Vocational Rehabilitation and Retraining Difference between an Impairment and a Disability.. 89 Appendix A: Glossary of Abbreviations.. 91 Appendix B: Documents Referenced in Book INDEX - Volume II... 93