The Source For Workers Comp

The

Source

For Workers’ Comp

The

4

things you should understand about Workers’

Comp….

and WE bet you don’t !

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

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

How To Get

Free

Information

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

The

Source

For How It Works

BWC

MCO

TPA

IW

INJURED WORKER

YOUR COMPANY

INDUSTRAL

COMMISSON

You pay TPA Directly

Your Advocate in all things WC and IC

FFA- Friends, Family, Attorneys Medical Case

Manager and

Bill Processing

Who is your TPA?

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

(Total Expected Losses)

Budget

4 Years of Medical,

Wages, Reserves,

Settlements Etc.

TML

(Total Modified Losses)

Spent

4 Years of Medical,

Wages, Reserves,

Settlements Etc.

TEL vs. TML

GTML

(Group Total Modified

Losses)

Spent

4 Years of Medical,

Wages, Reserves,

Settlements Etc.

INCLUDING 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 you out of group for a period of four years!

Lost time claims trigger a reserve on claim.

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 8th_{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

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

The

Source

For Drug Testing

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

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

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

“Having the option to pay my Ohio

Workers’ Comp bill monthly will

really help my cash flow.”

• Snap Shot

- Will be taken on 9/30

• Group Rating

Deadline – 11/24/2014

• Group Retro

Deadline- Last Business

Day in January

• Destination:

Excellence

Enrollment

Deadline

Last Business Day in May

• 8 Month Credit

July 2015 –Credit will

cover January 2015- August 2015

Premiums

enrollment year vs. calendar year last

6 months of 2010 will not fall off in

2015/2016

• Handicap Submission

–CHP-4A must

be submitted 6/30

• Settlement Submission

-

C240’s must

be submitted by 7/15 for the new

snapshot

• Payment Frequency

- monthly,

bi-monthly, quarterly, bi-annual, or

annual options, companies will default

to bi-annual if they do not pick by July

1

_.

ICD 10 Codes

International Classification Disease

1. October 1st_{2015 start date Mandated for}

all HIPPA covered entities

2. Ohio BWC always used ICD9 codes 1. Many reasons BWC Changing

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

Make sure you include

this in your budget

planning for 2015!

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)

OSHA

Major

Changes

The

Source

For Updates

As of January 1, 2015 all establishments must

report to OSHA within 8 hours any

work-related fatality.

Within 24 hours of learning of the incident

must be reported to OSHA Work-related

amputations

• In-patient hospitalizations

• Loss of an eye.

Industries like restaurants, banks, insurance,

and medical offices will no longer be exempt.

To find out if you are required to prepare and maintain records under the updated rule:

• Go To http://compsourcetpa.com/exempt-2015-osha-recording-changes/ to

find out.

• Exceptions are based on:

• Small employer exemption – 10 or fewer employees at all temporary,

and seasonal workers.

The

Source

For Workers’ Comp

We have you covered!

Additional Programs FMLA and OSHA Recording Enrollment Deadlines December 1

_!

888-294-9578

[email protected] 732 Middleton Way Suite 204

Loveland, OH 45140