Claims ManagementPresented by:Patty Davidson – Qual-Lynx2013 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-To-

Work 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-To-Work 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!