The Source For Workers’ Comp The 4 things you should understand about Workers’ Comp…. and WE bet you don’t ! Workers' Comp Beating You Up
The Source For Making the Complicated Simple • Ohio BWC: – 4 states have State Managed Workers’ Comp • Ohio, North Dakota, Washington State, & Wyoming • All the others have privatized insurance – State of the BWC » 7.7 - 8.4 Billion in Investments » Fund to be Solvent 3-5 Billion » If stock Market does well next year?.. » Billion back 2x, Lawsuit, 8 mths credit….
The Source For Making the Complicated Simple How To Get Free Information One pagers & Safety Meetings at the BWC website: bwc.ohio.gov ① Choose Tab>BWC Library ② Drop Down>Publications ③ Bullet Point>Ohio Employer Publications
The Source For Making the Complicated Simple Create a network of Workers’ Comp trusted experts 1. A group of HR/Safety/Controllers etc. 2. TPA- not just your ‘day to day’ Rep 3. Attorneys – workers’ comp and employment specialists: go to other attorney’s classes 4. Safety Councils -suggest topics 5. CompSource Don’t walk away until you understand!
The Source For How It Works BWC INDUSTRAL COMMISSON Neutral • DHO -District • SHO - Staff You pay premium to BWC • Commission Hearing New Evidence • Common Pleas TPA You pay TPA Directly MCO YOUR COMPANY Neutral Your Advocate in all things WC and IC Medical Case Manager and Who is your TPA? Bill Processing Who is your MCO? IW INJURED WORKER FFA- Friends, Family, Attorneys
The Source For MCO Info Deloitte Findings Info Extract From 2009 Deloitte Report: In many instances concerning managed care organizations, their services such as bill and utilization review, voc rehab are viewed as just an afterthought. However, the amount of money that runs through these programs can be far greater than the amount of any claims contract with a TPA, and clients should take the time to understand the relationship between an MCO and a TPA. A lack of understanding of how all of these programs work and how they are integrated in a claims program can create a multitude of misconceptions. Clients should know that if claim fees from a TPA appear to be artificially low in a bundled program, chances are the TPA is more than making up the difference with the managed care fees (MCO). Understanding these services and their relationship to the overall claims program will drastically reduce the chances of conflicts within the claims program.
The Source For The Numbers TEL vs. TML GTML TML TEL (Group Total Modified (Total Modified Losses) (Total Expected Losses) Losses) Spent Spent Budget 4 Years of Medical, 4 Years of Medical, 4 Years of Medical, Wages, Reserves, Wages, Reserves, Wages, Reserves, Settlements Etc. Settlements Etc. Settlements Etc. INCLUDING Max Claim Max Claim
The Source For Budgets This number must be at least 20% less than your expected losses to qualify for a traditional group program. One max value claim will kick Lost time claims trigger you out of group for a period a reserve on claim. of four years!
The Source For Beyond Just Claims Management BEFORE : Create a Safe Environment Safety Minded Culture and Meetings Industry Specific Safety Program Safety Council Transitional Work Program Grant Money Consistency In Reporting Process Drug Free Policy and Program Include Prescription Drug Clause Fire Drill Investigate First Report of Injury VIDEO FROI Witnesses Non Witnesses Supervisors
The Source For Beyond Just Claims Management DURING : Claim Allowance or Denial Industrial Commission Salary Continuation Must decide and submit C-55 by 8 th day off work IME Independent Medical Exams C-101 With Past Medical History Refusal to sign results in suspended claim C-72 Run a Claims History Review Helps determine fraud/abuse or pre-existing Quarterly Prescription Drug Reviews Return to Work Make an offer if they refuse =no more TT Offsite Work at Non-Profit Voc-Rehab Surveillance
The Source For Beyond Just Claims Management AFTER : Return To Work Full Duty - Release Light Duty – Transitional Work RTW Date Handicap Reimbursements Timing Is Everything and Research by TPA Settlements With Resignation/Confidentiality Agreement Additional Allowances Permanent Partial Employees entitled to a 1 time lump sum payment
The Source For Drug Testing Warning!
The Source For Fraud Management Three Types of Workers’ In This Scenario Abusers- • not injured at work but were injured elsewhere or previously and claim the injury occurred at work • file multiple fraudulent workers’ compensation claims • will also file fraudulent automobile or general liability claims. Opportunists- • actually injured on the job but then take advantage of the system to gain more benefits • work to extend their benefits beyond a reasonable period • exaggerate their symptoms • are uncooperative with treatment plans; • use stalling techniques when TPAs, medical providers, or employers take positive actions for the claims management process. Forgotten, frustrated, and forlorn employees- • If barriers arise that adversely affect the employee’s treatment or recovery, a once cooperative employee may become demotivated, sad, stressed and depressed
The Source For Fraud Management Red Flags: 1. Has there been recent adverse employment action? 2. Is the timing of the claim suspect? 3. Does the employee have a prior claim history? 4. Do the circumstances of the claim raise red flags? No witnesses 5. What are the employee’s outside activities? Pre-existing Injury?
The Source For The Fire Drill What Is A Claims Fire Drill & Why Have One?
The Source For The Fire Drill GET PREPARED Create file of forms • FROI, witness statement, directions to medical facilities, injury packet from MCO etc. • C-101 & a list of doctors in last five years signed by IW • Witness Statements, NON -witness statements & supervisors statements/investigation • Do use a process evaluation form when accidents occur to determine areas to be improved to prevent further injuries. • File of emergency contact and who has access Form a relationship with a preferred Occupational Medical Provider. • Ohio cannot direct care for injured workers but can have a preferred panel of providers • Have maps printed and place them in your injury packets. • Set up all protocols for Transitional Work Drug Testing and $15K with provider. Formalize AND KNOW Your Policies • Transitional work - job descriptions • Drug free safety programs • $15K Program • Salary Continuation • Voc-Rehab in house and with non-profit
The Source For The Fire Drill THE PROCESS 1. Come up with Scenarios Design one On/OFF Company Property Design one during and after hours Vehicle accident Severe Injury or Death Minor Near/Miss Injuries 2. Determine Who Does What When creating a team have names for the positions because team members change Who will ensure the FROI is 100% complete? Use 5 senses! Change up the roles -One scenario with you …One scenario you are not there 3. TPA conversation of overall situation & STRATEGY (Make ‘em work! ) 4. Put It In Writing 5. Literally Perform Scheduled Drills 6. Revise After Drills
The Source For Updates Be Sure to read any email from CompSource Titled “Green Alerts!” These emails are designed to be simple and informative with upcoming dates and deadlines that DO concern you.
The Source For Updates Prospective Payment Impact Private Employers? enrollment year vs. calendar year last 6 months of 2010 will not fall off in • Snap Shot- Will be taken on 9/30 2015/2016 • Group Rating Deadline – 11/24/2014 • Handicap Submission – CHP-4A must • Group Retro Deadline- Last Business be submitted 6/30 Day in January “Having the option to pay • Settlement Submission - C240’s must • Destination: Excellence Enrollment my Ohio be submitted by 7/15 for the new Workers’ Comp bill Deadline Last Business Day in May snapshot monthly will • 8 Month Credit July 2015 – Credit will • really help my cash flow.” Payment Frequency- monthly, bi- cover January 2015- August 2015 monthly, quarterly, bi-annual, or Premiums annual options, companies will default to bi-annual if they do not pick by July 1 st .
The Source For Updates ICD 10 Codes International Classification Disease October 1 st 2015 start date Mandated for 1. all HIPPA covered entities 2. Ohio BWC always used ICD9 codes Make sure you include this in your budget 1. Many reasons BWC Changing planning for 2015! 1. New Diseases & Technology 2. Uniform with the rest of the Medical Industry 3. Easier for Apple to Apple National Comparison 4. More specific i.e.) Right wrist fracture
The Source For Updates ICD-9 ICD-10 Three to five characters in length Three to seven characters in length Approximately 13,000 codes Approximately 68,000 codes First digit numeric First digit is alpha, digits two and three are numeric; digits four-seven are alpha or numeric Limited space for adding new codes Flexible for adding new codes Lacks detail Very specific Lacks laterality (left vs. right) Has laterality (i.e. codes identifying right vs. left)
The Source For Updates OSHA Major Changes
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