Keeping Claims on Track

What is the smartest way to improve the claims process? At the 2022 WCR Conference, a panel of experts provided 60 practical tips and strategies in 60 minutes that can be used to ensure your workers’ compensation claims stay on the right track. Speakers included:

• Moderator, Stuart D. Colburn, Esq. Downs Standford P.C.

Panelists:

• Edward Canavan, Hudson Claims Consulting
• Hon. Clint Feddersen
• Rafael Gozalez, Esq.
• Jeff Adelson, Esq.
• Heidi Bastien, Jacuzzi
• Sheri Lawrence, SoCalGas

60 Tips to Ensure Your Workers’ Compensation Claims Stay on Track

1. Query the claims file to find out if the injured worker is a current Medicare beneficiary, looking across all four areas of Medicare coverage.
2. A real claims action plan includes actions, execution, timeline, resources, potential barriers and outcomes.
3. Be respectful to the court. This means be on time and treat the judge with respect.
4. The examiner must have a voice-to-voice contact with the injured worker — an actual meaningful conversation, not a voicemail message.
5. As an employer, make the process simple. Send a new injury email with all the critical information in it to the injured worker.
6. File proposed orders ALWAYS. Most judges are very busy and appreciate these.
7. Be accurate and timely on the Centers for Medicare & Medicaid Services (CMS) Ongoing Responsibility for Medicals (ORM) date, ICD-10 codes and Total Payment Obligation to Claimant (TPOC) date and amount. Incorrect information will revert exposure to a $1000/day per file civil fine.
8. Claims examiners should understand subrogation and pursue it vigorously. This is often a missed opportunity.
9. Keep your word no matter what.
10. If you make a mistake, admit it and correct it.
11. You should communicate to the employee what to expect in the claims process, and encourage the employee to be an active participant in their recovery.
12. Ask injured employees to download their claims application that is provided by the TPA or carrier. If your TPA or carrier does not have this, find one that does because it is a tremendous asset to the process.
13. Provide email addresses with your notice of representation. This is required under California law.
14. Don’t just look into traditional Medicare. You need to also look at whether the worker has a Medicare Advantage Plan or a Prescription Drug Plan outside of Medicare, as they also have reimbursement rights.
15. Examiners must hold the treating physician accountable to provide sound reasoning and the details to move the employee through treatment.
16. Be the first attorney to present at a doctor’s office to be respectful of their time. Don’t make them wait.
17. When taking a deposition of an injured worker speak directly to them with respect and understanding.
18. Ask the employee what they expect in the claims process and if if they are losing time from work when they expect to return.
19. The two-point contact should be the injured employee and the healthcare provider. Speaking to the employer is a given.
20. With conference lines and virtual meetings, mute your line when not speaking.
21. Under Federal law the employer/carrier is the primary payer and therefore responsible for reimbursement of conditional payments made by Medicare or state Medicaid agencies.
22. Use nurse case management from the beginning of the claim.
23. Respect your opposition and do not underestimate them.
24. Start with the end in mind. Provide goals to the injured worker backed up by credible data, such as the Office of Data Governance (ODG), detailing when most people return to work from their type of injury.
25. Special handling instructions from the employer to their claims team need to be done correctly and updated as your expectations change.
26. Set alarms for all your calls, so that you don’t miss them.
27. On disputed claims, if traditional Medicare comes back with $0 due, that is usually a sign that either Advantage, Medicaid or Veterans Affairs (VA) may have paid for the medical relating to your claim.
28. Employers, please do not ignore your injured employees. Show empathy and mean it.
29. Do not put anything in an email, document or text that you would not want to see as an exhibit in front of a jury. There are inappropriate comments found much too often.
30. With the end in mind, make sure the employee understands how claims are resolved.
31. Provide workers’ compensation 101 training for all new HR employees describing their role and how to communicate with injured workers.
32. Submission of Medicare Set Asides (MSAs) are still voluntary.
33. Non-submit MSAs are still legal and permissible.
34. Every TPA, carrier and employer should have a medical pre-authorization program for simple procedures to expedite initial treatment.
35. Make your client understand you are an officer of the court, and that ethics will enter into your analysis always.
36. Explain the physicians role, and how they are accountable to make sure the examiner can correctly administer the claim.
37. Utilize shared drives for items like work status reports, investigations, etc. This is much simpler than emailing numerous documents.
38. If using non-submit MSAs, Medicare may ask for details and explanation of the allocation when the funds are exhausted.
39. The Family and Medical Leave Act (FMLA) is not a four letter word. Every claims examiner should have training to understand with workers’ compensation benefits.
40. Do not take anything personally in litigation.
41. Keeping in constant contact with the injured worker avoids surprises.
42. Call the injured worker before they receive notice in the mail of something that impacts their claims.
43. If your employee is having surgery for an injury, send them flowers or some type of gift to let them know you care.
44. Make sure Maximum Medical Improvement (MMI) reports include specific references to the applicable American Medical Association (AMA) guidelines. Also include the how and why, explaining rationale.
45. The US Supreme Court says state Medicaid agencies may collect their full liens from settlement proceeds.
46. Workers’ compensation claims are a key component of an employer’s risk program and collaboration with safety, HR and legal are imperative.
47. Do not promise what you cannot deliver.
48. The claims adjuster is the manager of the claim.
49. Hold all stakeholders accountable.
50. Ask your injured workers if they like their doctor. If they don’t, give them options.
51. Social determinants of health are drivers of injured worker health outcomes and return to work, affecting disability duration and medical treatment.
52. Defense attorneys should be open to litigation claim reviews and present a detailed recommendation for claim resolution on all files.
53. Return phone calls and emails.
54. If claims are open longer than 90 days, conduct an analysis of why and what needs to happen to resolve it.
55. The ultimate goal is to keep people engaged and working, therefore return-to-work programs need to be creative.
56. 80% of employee health is due to their surrounding environment.
57. A successful investigative report includes timely supervisor accident reporting.
58. Make it easy for your clients and opposition to work with you.
59. An examiner should be viewed by the injured worker as their advocate and trusted advisor.
60. Red flag analysis from investigators can provide a high-level understanding if surveillance is worth it.