1. Presented by: Martha Folchi & Nicole Cosculluela
SUCCESSFUL CLAIM MANAGEMENT
ACI Safety Council: July 16, 2019

2. BEST INJURY IS THE ONE THAT DOESN’T HAPPEN
Zero injuries

3. WHAT IS A LOST TIME CLAIM?
Lost-time claim means the injured worker has missed more than eight days of work.
Weekends and holidays do count even if the injured worker doesn’t usually work them
The eight days don’t have to be consecutive.
Medical-only claim means the injured worker has missed seven or fewer days of work.
The worker can receive treatment and/or benefits for
the injury, yet still report to work.

4. MANAGEMENT OF INJURED WORKER
Communicate with the injured worker. Possibly eliminate attorney involvement.
Don’t use this time to retaliate against the injured worker.
Strictly adhere to the restrictions given by the doctor.
Document and have the injured worker sign light duty job agreement what they are to do within their restrictions.
Make sure the injured worker understands they should stay within the restrictions outside of work also.

5. RETURN TO WORK OPTIONS
Modified work — essential job functions are adapted, altered or removed to accommodate restrictions.
Light duty — job requirements are reduced to the persons physical capabilities. This can be temporary or permanent.
Alternative work —  the injured worker can do this job if they are permanently restricted from their original job, hence using their other abilities.
Transitional work — This gives the injured worker real job duties for a specified length of time (generally not exceeding two or three months) to help them progress back to their original job.
Important: If the doctor (POR) releases the injured worker to return to light duty or full duty work, this does not mean medical treatment will end.

7. transitional work program
Transitional work is a progressive, individualized, time-limited program focused on returning the worker back to work.
BWC pays ¾ of the cost to have this program developed.

8. Ensure your mco/tpa Uses programs provided by the bwc, such as…
Ergonomic evaluation
Modified duty (off site if necessary)
Remain at Work Program
Job Retention Services
Vocational Rehabilitation

9. ERGONOMIC STUDY
Approximately 30 percent of the work-related injuries/illnesses are associated with ergonomic deficiencies, making them one of the most prevalent and costly injuries in many industries.
BWC provides training classes, safety/lifting videos and safety grants. ( – safety and training tab)
All of these services are already included in your premium. SO TAKE ADVANTAGE OF THEM!

10. MODIFIED DUTY – OFF SITE
With this type of work, physical barriers may keep the injured worker from performing their essential job without some part of it being adapted, altered or removed.
MODIFIED DUTY – OFF SITE
If the company can’t accommodate these job requirements, it’s possible to work with your TPA to find a non-profit organization that will work with them.
(There is a cost to the employer for background check and placement.)

11. What are the benefits of a remain-at-work program?
The greatest benefit for Injured Workers is maintaining employment status and regular wages.
For employers, remain-at-work programs can help prevent medical-only claims from becoming lost-time claims.
The average medical-only claim costs $700
The average lost-time claim costs more than $37,000

12. REMAIN-AT-WORK CONTINUED
MEDICAL CLAIM ONLY
Case manager to work with the injured worker to progress
Work hardening
Work conditioning
Job analysis
THESE SERVICES ARE CHARGED AGAINST YOUR RISK

13. Job retention services
Job retention services are for lost time claims when the Injured Worker has returned back to work with restrictions
The employer has concerns about the lack of the Injured Worker’s progression
A Field Case Manager is assigned to the Injured Worker and services are charged to the surplus fund (and not charged against a specific claim or risk policy)

14. Vocational rehabilitation
Ensure your MCO is referring injured workers to participate in Vocational Rehabilitation (“Voc Rehab”) plans once they become stable and eligible
For lost time disability claims, a Field Case Manager is assigned to the Injured Worker with a hierarchy of goals:
Same job, same employer
Different job, same employer
Different job, different employer
Services paid for out of the surplus fund

15. LET’S TALK ABOUT WORKING TO PREVENT
LOST TIME CLAIMS

16. Proactive rather than reactive claim management
Ensure workers are trained to report injuries immediately
Report injury to your MCO immediately
Identify a treatment facility and establish relationship
Post-accident drug testing required? Set up your panel profile with the treatment facility
Injury packets and ID cards
Update procedure manual to reflect your policies and educate employees

17. Train supervisors on the importance of bringing an Injured Workers back to work with restrictions
Document what the injured worker is to do within their restrictions at work and home
Establish where physical & occupational therapy will be performed (on-site or off-site)

18. Don’t automatically dispute a claim
Investigate the accident
Obtain witness statements
Share with your supervisors the cost involved with a lost time claim

19. Communicate regularly with the injured worker
Keep them motivated
Avoid depression
Let them know you care
Now is not the time to have
revenge on an employee
Possibly eliminate attorney involvement

20. What does the mco do?
Objectively medically manages the claims – approves and denies reimbursement (NEUTRAL PARTY)
Keeps the lines of communication open
Collaborates with treating doctor to ensure appropriate treatment is rendered quickly.
Follows up on appointments, testing, surgeries.
Contacts the treating doctor if the Injured Worker is taken off work when you can accommodate restrictions

21. WHAT DOES THE TPA DO? Not a requirement to have a TPA -- but good idea
Disputes the claim & conditions being added to the claim (advocate)
Watches the MCO to ensure they are approving/denying treatment appropriately
Collaborates with the MCO concerning cost saving programs injured worker can get involved in for returning to work
Obtains handicaps
Settles claims
Helps to obtain off-site modified duty positions
Employer pays TPA

22. Case study 1: employer case study
New company as of July 2010
Initial Premium: $551,732
Premium in 2016: $441,646
Increase in payroll
Aggressive claim management
MCO working to make a difference

23. Case study 2: employer case study
New company as of 2010 Initial Premium: $439,545 Premium in 2016: $279,725 MCO & employer working together on returning Injured Workers to Transitional Work Program

24. Case study 3: employee case study
Catastrophic claim 51 year old falls from height of 12 feet Severe head injury, open fracture left scapula and right wrist Injury on 11/25/15 Return to work 2/9/16

25. Case study 4: employee case study
Catastrophic claim 21 year old falls from skylight, 27 feet high Multiple rib fractures, punctured & collapsed lungs, kidney laceration, fracture of sacrum and coccyx Injury on 2/18/14 Return to work 5/27/14

26. thank you!
“It costs less to be safe every day than to make one careless mistake along the way.” –Anonymous