1. Workers’ Compensation Basics Presented by: Stacey Markel, CHSP, HEM, CHCM

2. What is Workers Compensation?
Workers Compensation is a type of insurance that provides wage replacement and medical benefits to employees that are injured in the course and scope of their employment.
*In most cases the employee relinquishes their right to sue their employer by filing a WC claim

3. The Claim Process SC
Let’s take a look at how the claim process works.

4. Claim Process Employee Injury Employee Reports Injury to Employer
Employer Reports Injury to Carrier/TPA
Carrier/TPA Files First Report of Injury with MD WCC
Investigation by Claim Adjuster
Root Cause Analysis and Corrective Action by Employer
Compensability Decision
Indemnity and Medical Payments
Return to Work
Maximum Medical Improvement
Permanency or Settlement
File Closure

5. Employer Actions for a New Injury
The first 24 hours are crucial!
Communicate with the injured employee
Respond with compassion but be proactive
Do not judge validity of the claim
Get the employee medical care
You cannot direct care in Maryland but you can offer to arrange an appointment with a physician if the employee is receptive
Report the injury to carrier/TPA as soon as possible
Analyze the accident (Video, root cause, corrective action)
Support transitional duty

6. Claim Investigation Things to Consider
The claim adjuster will make a 3 point contact with the employer, employee and physician within 24 hours of receiving a lost time claim. Many factors will be considered while investigating the claim and it may be necessary to obtain a recorded statement from the injured employee and witnesses.
Things to Consider
Any prior injuries or health conditions?
New Hire?
In the Course and Scope of Employment?
Performance Issues?
Witnessed? Video of the incident?
Out of PTO or upcoming holiday or weekend?
Medical Report consist with injury description?
Immediate
Representation?
Not Compensable
Going and Coming Rule
Recreational Activities
Lunch Breaks
Company Cars
Deviation
Horseplay
Idiopathic Condition

7.  In the course of Employment  Benefit to the Employer
Compensability
A Claim must be –
 A specific incident
 Arising out of, and
 In the course of Employment
 Benefit to the Employer
Adjusters generally make a decision within 14 days of receipt of a claim.
Once an Employee Claim Form is filed with the MD WCC an Adjuster has 14 days to formally accept the claim or to raise “Issues” contesting the claim.

8. Red Flags Injured employee:
Disgruntled? Verge of being disciplined, fired or laid off?
New to company?
Career hopper?
Never home/screening calls?
Financial difficulties?
Missing appointments?
Accident:
Late reporting?
No witness or video?
Vague account/mechanism doesn’t match injury?

9. Reserves
Reserves are the amount of money that is set aside to pay the cost of a workers’ compensation claim.
Indemnity
Wage loss
Permanency
Settlement
Medical
Prescription
Nurse Case Management
Bill Review
Legal
Defense
Litigation
Filing fees
Transcription
Expense
Surveillance
ISO Search
Transportation
Translation
Reserve
Paid
Collections
Total Incurred

10. Vocational Rehabilitation
Benefit Types
Injured workers are entitled to Workers Compensation benefits if an Employee Claim Form is filed with the Workers Compensation Commission within 2 years of the date of injury.
Indemnity
TTD – Temporary Total Disability
TPD – Temporary Partial Disability
PPD – Permanent Partial Disability
PTD – Permanent Total Disability
Death
Medical
*Lifetime benefits for reasonable, necessary and causally related treatment unless the claim is settled
*Medical Benefits are paid per MD WCC Fee Schedule
Vocational Rehabilitation
If restrictions become permanent it may be necessary to find the employee another position within the company or perform job search outside of the company
Mileage/
Transportation

11. Most Common Indemnity Benefit Types
TTD or Temporary Total Disability
Totally disabled for a limited period of time
3 day waiting period before benefits begin
If 14 days are missed then the waiting period is paid
Maximum compensation of $1,094 per week (2018)
Tax free
Paid every 14 days
TPD or Temporary Partial Disability
Partially disabled for a limited period of time
Employee is paid ½ of the difference between pre-injury AWW and the current wages earned
Ends when employee returns to pre-injury job or reaches MMI
Paid upon submission of pay stub
PPD or Permanent Partial Disability
Partially disabled for a permanent period
Tiered award system. Paid a minimum of $183 a week for minor injuries or $789 per week for major injuries (2018)
Ends after a scheduled number of weeks awarded by the WCC
A claim can be re-opened for additional indemnity benefits within 5 years of
the date of the last indemnity payment

12. Transitional Duty How it Works
Transitional duty allows an employee to return to work in a modified capacity which accommodates their temporary physical restrictions.
Get specific restrictions
Compare restrictions to job duties
Assign temporary job tasks
Tasks, NOT jobs!
Build a task assignment bank
Document the assignment
Monitor the employee
Track employee’s progress
NEVER send employee home without management approval

13. Transitional Duty Should Be….
Short-term, ideally lasting less than 30 days but no more than 90 days. Employees should know that your goal is to return them to their regular job. You don’t want employees on Transitional duty to “root in”, in other words, assume that transitional duty is now their regular job. We recommend that the assignment is reviewed following each medical appointment.
Progressive, restrictions should be re-evaluated at every follow-up medical appointment. The transitional duty assignment should be updated to reflect changes in these restrictions. If Transitional duty tasks last more than 30 days, there should be a full review of the case to verify that progressive restrictions have been specified by the medical provider and that transitional duty has been adjusted to meet those changes in restrictions. The point is to continuously match physical ability to the tasks performed. If employees aren’t progressing, that needs to be evaluated and the next course of action decided upon.
Positive, not punitive, you are not punishing the employee, you are accommodating their restrictions and providing them with meaningful employment.
Consistent, every injured employee should have the chance to recover by working transitional duty.
Monitored. Supervisors need to make sure that employees follow restrictions while at work, even if employees say they’re feeling better. All concerns should be documented in writing and shared with your adjuster.

14. Transitional Duty Benefits
Benefits everyone!
Speeds employee’s recovery.
Keeps employee connected and in the work routine
Sends a message to the workforce that the company cares
Encourages employee-management cooperation
Lowers unnecessary costs to the employer
Lessens adverse financial impact to the employee
Minimizes employees’ inclination to hire attorney
Helps prevent WC abuse

15. Transitional Duty Obstacles
“That’s not my job!”
*Explain that employers have the right to assign job tasks within their restrictions and employees are obligated to perform transitional work
*Communicate the importance of RTW
*Explain that they could lose their indemnity benefits
“I can’t do it!”
*Send employee back to the doctor to be re-evaluated
*Reassign (or not) based on medical providers updated restrictions
*Communicate with the employee
Employee that is not working within their restrictions
*Determine why
*Do NOT allow the employee to work above their restrictions
No Call/No Show
*Attendance policy?
*Possible termination
*Loss of indemnity benefits
Bad Attitude
*Define performance expectations
*Assess performance
*Address deficiencies
*Put a positive spin on the task
All concerns should be documented in writing and shared with your adjuster.
Supervisors should never send an employee home without management approval.

16. Maximum Medical Improvement
Maximum Medical Improvement or MMI is when a physician (either treating or independent medical examiner) has stated that an injured worker has improved to their maximum medical benefit. In layman's terms, they aren’t going to get any better then they are at that moment despite any future treatment that they may have.
Once an employee is placed at MMI they can be rated for permanency.
Usually when an employee is placed at MMI they are no longer eligible for TTD benefits. In some circumstances a referral will be made for vocational rehabilitation services.
An MMI finding does not necessarily mean that the employee does not require any further treatment.
MMI is the goal on every claim as it a critical finding to place a claim in a posture for closure.
What is MMI and how do we get here? (IME or release by treating)

17. Litigation Process Issues Discussion Hearing Award
If there is a dispute or request that cannot be agreed upon by both parties then “Issues” are filed with the Workers Compensation Commission.
Discussion
When the Notice of Issues is received the parties have the opportunity to try to resolve the issue before proceeding to a hearing. If the employee has an attorney then carrier/TPA can no longer speak to the employee directly and must communicate with their attorney.
Hearing
If the parties cannot reach an agreement then a hearing is held in front of 1 of the 9 Commissioner's at 1 of the 7 Workers Compensation Commission sites. Much like a civil or criminal hearing, we will be able to introduce evidence such as surveillance and medical reports and provide testimony to support our case.
Award
Following a hearing, the presiding Commissioner will issue his or her decision on the issue. An award must be paid within 14 days of issuance. Either party has the right to file an appeal within 30 days.
Maybe do a slide to compare cost with and without an attorney

18. IME: Independent Medical Exam
An IME is an independent medical examination performed by a qualified medical professional to answer questions such as:
What is the current diagnosis?
Is the current treatment plan reasonable, appropriate and causally related to the injury?
Is the claimant able to return to work? With restrictions or full duty?
Are the restrictions permanent?
Has the employee reached maximum medical improvement?
Does the employee have a permanent impairment? Can a
portion of that impairment be apportioned to a prior injury
or medical condition?

19. Surveillance
It is sometimes necessary to hire a private investigator to follow an employee to evaluate the validity of the claim. This may be necessary when:
Treatment has become excessive or is not consistent with the injury
The employee has been out of work for a prolonged period of time
Employee rejected a transitional duty position
Information has been received from the employer, co-workers, friends or family
Information has been found on social media
Employee has not been returning calls
Employee has missed scheduled appointments
There is an upcoming medical appointment or
hearing
Employee has a prior claim history
Employee has history of criminal activity

20. Vocational Rehabilitation
An employee may be eligible for vocational rehabilitation benefits if their injury was severe enough to keep them from returning to their pre-injury occupation. Meaning they can no longer meet the physical demands as outlined in their job description.
Usually permanent restrictions have been provided by a treating physician and confirmed by independent medical exam physician or functional capacity exam (FCE) before vocational rehabilitation is considered.
The employer may be responsible for the costs of vocational rehabilitation including: vocational testing, resume and interview services, job placement, job training, and continuing payment of wages during the agreed upon period of vocational rehabilitation.
The primary goal of vocational rehabilitation is to return the employee to “suitable gainful employment.”

21. Permanency
Workers Compensation Statute provides benefit payments for permanent partial disability for a period of weeks. The period varies according to the body part injured and the severity of the injury. Each party will obtain a “rating” from a physician to assign a percentage of disability per the AMA Guidelines. The parties can then stipulate or agree to settle a case for a certain percentage of disability or proceed to a hearing to have a Commissioner award disability.

22. Stipulation vs. Settlement
We agree to pay a specific percentage of disability
No need for a hearing (usually)
Typically a current employee
May re-open the claim for indemnity benefits within 5 years
Continues to be entitled to reasonable, necessary and causally related medical treatment
Settlement
We agree to pay a lump sum of money
Only recommended when they no longer work for employer
May not re-open their claim for additional indemnity in the future
Unless otherwise agreed, the claimant will not be entitled to future medical treatment
Sometimes requires a Medicare Set-Aside (MSA)

23. MSA: Medicare Set Aside
CMS defines a Workers’ Compensation Medicare Set-Aside as “a financial agreement that allocates a portion of a workers’ compensation settlement to pay for future medical services related to the workers’ compensation injury, illness, or disease.” It is necessary to obtain an MSA when:
The claimant is a Medicare beneficiary and the total settlement amount is greater than $25,000.00; or
The claimant has a reasonable expectation of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.00

24. File Closure Maximum Medical Improvement No Attorney
Attorney Representation
If there are permanent restrictions then we may have to do vocational rehabilitation
Permanency Ratings
Issues
Stipulation, Settlement or Hearing
Award
File Closure

25. Common Terminology IME Independent Medical Exam
TTD Temporary Total Disability
TPD Temporary Partial Disability
PPD Permanent Partial Disability
PTD Permanent Total Disability
MMI Maximum Medical Improvement
RTW Return To Work
AWW Average Weekly Wage
PT Physical Therapy
NOV Next Office Visit
FU Follow up
WCC Workers Compensation Commission

26. Performance Measurement
Regularly review loss runs
Identify metrics that matter to you
Incident Only vs. Medical Only vs. Lost Time
Lag time
Time of injury to time reported to employer and to carrier/TPA
Workers’ Compensation Cost per $100 of payroll
Review OSHA logs
Number of lost time days vs. days of restricted duty
Success of transitional duty

27. An Ounce of Prevention JM

28. Orient employees to your safety expectations.
Key Strategies
Hire the right people!
Orient employees to your safety expectations.
Develop and reinforce specific safe work practices.
Frequently communicate safety information.
Identify and correct unsafe behavior.
Identify and correct unsafe conditions.
Effectively manage post-injury response.
As we said before, our goal, then, is to minimize the cost of unplanned events, in this case, employee injuries. So how do we do that? Let’s look at some key strategies. We won’t have time today to cover them all, but it’s important to emphasize the importance of diligent hiring practices and the need to hire the right people. Once you have them, you need to train them and reinforce safe work practices. Of course, these practices need to be developed, written, and communicated frequently. Behavior needs to be reinforced. Unsafe conditions need to be corrected. And injuries need to be managed after they occur.

29. Focus on your loss drivers!
Prevention & Training
Focus on your loss drivers!
Prevent slips/trips/falls?
Prevent strains and sprains?
Prevent needlesticks/punctures/cuts?
Reinforce good practices
Identify hazardous behaviors and correct them
Identify hazardous conditions and correct them
The majority of healthcare injuries result from patient handling (strains/sprains) & slips, trips and falls. Reinforce the safe practices you have in place to prevent these injuries, such as cleaning up spills immediately, dry mopping floors after wet mopping, mopping during times of low traffic, etc.
Support and encourage the work of your safety committees to identify and correct hazardous conditions. And don’t forget, most injuries occur as a result of behaviors. As managers, you need to correct unsafe behaviors as you observe them.
Let’s go back to Anne for how to minimize the damage when an injury does occur.

30. Safety Culture
“The atmosphere or way of working within the company that influences safe behavior.”
Safety culture consists of shared belief, practices, and attitudes. Culture is the invisible force which shapes our behavior. Q

31. Management and employee attitude Policies and procedures
Culture is the Result of….
Management and employee attitude
Policies and procedures
Supervisor responsibility and accountability
Safety planning and goals
Actions in response to unsafe behavior
Employee training and motivation
Employee involvement or “buy-in”

32. WHAT GETS MEASURED IS WHAT GETS DONE Three Methods
Measurement
WHAT GETS MEASURED IS WHAT GETS DONE
Three Methods
Charge Backs – to Department
Safety Goals – for Management & Supervision
Safety Activities – to achieve goals
What types of things do you do here?
Charge back – could be a percentage assigned to each department based on their accident history and then that department is responsible for that portion of the injury.
Safety Goals – accident investigation, accountability programs
Safety Activities – Safety Committee, reduction in lost work days, reduction in lag time.

33. Accident Investigation & Root Cause
Accident Investigation is Fact Finding Not Fault Finding. It is conducted to determine the Root Cause so that we can prevent future similar events.
Root Cause:
Unsafe Conditions ~ 10%
Unsafe Acts ~ 90%

34. Knowledge - the understanding of how to operate it properly.
Basic Elements of Safety Behavior
Knowledge - the understanding of how to operate it properly.
Skill - the ability to operate it properly
Attitude - the desire to operate it properly
If any one of these elements is in short supply, safety behavior will be unbalanced.
Knowledge - Everyone has a knowledge of how to drive – but do we all know the safest way to drive? How many people here know how to make a left hand turn when driving? Did you know that the safest way to make a left hand turn when stopped at a stop light is to keep your wheels pointed straight? EXPLAIN WHY…..
Skill – I have seen a shot given in the arm about a million times, but it does not mean I am skilled enough to give you a shot – and I am sure you don’t want me to give you a shot.
Attitude – Cell phone use. We all know it is not safe to use a cell phone when driving – but some of us have the attitude that “ IT WON”T HAPPEN TO ME!” but it only takes a second for an accident to happen.

35. Minimize Damage AJ
OK, so despite your best efforts, an injury occurs. What do you do?

36. Incident Reporting Form
Forms
Report
Incident Reporting Form
Treat
Intro to Physician Letter
Return-to-Work Form
Investigate
Incident Investigation Form SC
Let’s take a look at the forms you should use in conjunction with employee injuries.
We mailed you copies of these in advance of this call. Make sure you check that these are the forms in use at your property.

37. Contain Costs with Effective Medical Treatment
Who are you sending your employees to?
Do you have a good relationship with this medical provider?
Have you provided your reports to them? SC
We discussed timeliness and appropriateness of the initial response to employees. Let’s take a look at another means to contain costs – using network providers.
Key Risk has a network of preferred providers who have been qualified by our folks to provide timely and effective medical treatment at discounted rates.
You can see how individual sites are faring.

38. Communicate and Coordinate ResponsibilitiesSC
From the insurance company perspective, I like to have a main contact at your locations who serves as the communication and coordination “hub”.

39. WCC Workers’ Comp Coordinator Sr. Management Supervisor
Safety Committee
Medical Providers
SISCO
Employee SC
Someone at your facility should fill the role of the workers’ comp coordinator. This person plays a key role in assisting the employer and the insurance company in their efforts to control WC costs. They are the hub in the wheel, as pictured above., managing the folks at the end of the spokes. They keep the wheel going, making sure it runs smoothly.
First, they act as an employee advocate. They are the contact between all involved parties in an effort to support the injured employee at the time of injury and through the return-to-work process. The Coordinator tracks the progress of the injured employee through the entire process, from time of injury and immediate medical attention through the offer of transitional duty, the follow-up visits, and finally the return to regular duty.
Senior management – the coordinator keeps them informed
Supervisor – the coordinator acts as a resource to the supervisor, coaching them through the process,
Safety Committee– WCC interacts with safety committee and becomes aware of trending issues.
Medical providers – manages the partnerships with medical providers in order to meet expectations.
Insurance co claims department – serves as a lifeline to the insurance company. Lets them know what’s working or not working.

40. Claim reporting – 24 hours Case management
Responsibilities
WC Coordinator
Claim reporting – 24 hours
Case management
Communicate with employee and supervisor
Assist with transitional duty placement
Work with insurance claim department
Thorough documentation and organization SC
Let’s take a look at some specific duties of the Workers Comp coordinator..
First, they should report the claim within 24 hours, which entails gathering the required information.
They are charged with managing the case from the employer’s perspective, by communicating regularly with the injured employee and his or her supervisor to let him or her know how the employee is progressing. The coordinator should encourage the supervisor to maintain regular contact with the employee.
The coordinator should work with supervisors to find transitional duty work for employees with medical restrictions, and should work closely with the insurance company claim handlers to manage claims to closure. This would involve periodic discussions and on-going communication. This relationship needs to be developed in order to be effective.
An important note, the coordinator should never get into specific claim details with employees…employees should be referred to the insurance company claims handler for this.

41. Follow-up with doctor and employee after appointments
Medical Management
Follow-up with doctor and employee after appointments
Forward appropriate documentation to insurance company
Establish new providers when necessary SC
The coordinator establishes case files. WC information should be kept in files separate and apart from personnel files, as we’ll discuss a bit later. The coordinator should track employee medical appointments, making sure that medical providers complete return-to-work forms after each employee visit.
They should update the claims department, discussing the employee’s progress regularly with the employee, the doctor, and the insurance company. They should inform the insurance company of any missed doctor or therapy appointments and requests by the employee to change treating physicians. Don’t assume that they know…

42. Stay in contact with injured employee:
Case Management
Stay in contact with injured employee:
Monitor medical progress and appointments
Assess employee’s emotional state SC
Finally, workers’ comp coordinators should communicate regularly with employees who are out of work., at least once a week. Calls should be made by both the coordinator and the employee’s supervisor. The purpose of the call is to let employees know that they are missed, and that the organization wants to do all it can to help the employee get back to full health. Get well cards are also appreciated.
Verify that indemnity payments are being received on time and that medical bills are being paid. If not, reassure the employee that you will work with the insurance company to correct the problem.
Through these communication efforts, the coordinator is well positioned to assess the employee’s emotional state. Is the employee satisfied with the medical treatment he or she is receiving? Have there been any changes in attitude? Any problems to be resolved? Share news about the workplace, as it helps the employee feel connected. Encourage the employee to visit the workplace and invite the employee to attend meetings and social events. If your company has an EAP, an employee assistance program, encourage the employee and his/her family to use it for counseling and support.

43. Work closely with insurance claim department Document everything
Case Management
Work closely with insurance claim department
Document everything
Ensure employees know how company benefits will be handled
Communicate with the supervisor
Update claim consultant regularly
Team effort in resolving claims
Keep lines of communication open SC
The coordinator needs to work hand-in-hand with the insurance company’s claim department in order to help control WC costs. Make sure your insurance company knows who your coordinator is so that correspondence can be directed to one person; the insurance company should know who your medical providers are, as well as their contact information. You should share your company’s transitional duty policy and examples of transitional duty tasks. This information is helpful when the claims handler speaks to treating physicians. The insurance company should also know if there are any company policies that might impact employee’s ability to return to work. An example of this might be a policy that terminates employees after a certain time out of work.
The coordinator should document information about the claim in a separate workers’ comp file. This information should NOT be in the HR or personnel file. If there is litigation, the entire file may be subject to a subpoena.
If employees remain out of work, make sure the injured employee understands how company benefits will be handled during this period of disability. For example, clarify how the employee’s portion of health benefits will be paid during his or her absence.
Update the supervisor on the employee’s progress. Communicate regularly to let him or her know how the employee is progressing.

44. Communicate employee responsibilities Employees should:
Employee’s Responsibility
Communicate employee responsibilities
Employees should:
Report injuries immediately
Assist with accident analysis
Follow any and all restrictions at work and at home
Keep all medical appointments
Follow doctors’ instructions JM
Employees have a role to play as well.
First and foremost, the employee should know the importance of immediately reporting an injury and to whom to report the injury. Do not assume your employees will know what to do if injured on the job. If an employee reports an injury late, it doesn’t necessarily mean the injury is not work-related.
The employee has first-hand knowledge of what occurred and is a valuable part of the accident analysis team.
Employees must follow all restrictions, both at home and at work.
And employees must keep their appointments, even if they feel better.
The key is to communicate your expectations to employees and give them the opportunity to ask questions. Make sure you cover this information with each new employee during his or her orientation and throughout the life of the claim.

45. WC Is Not OSHA
Remember, compensability does not equal “OSHA Recordable”…
Recordability is a Federal Standard
Compensability is determined at the state level
One does not always equal the other! WC

46. RCM&D Disclaimer
Your continuing effort is essential to accident prevention, regulatory compliance and control of risks in your workplace. Our assistance may be used as adjunct in certain areas of that effort, but we assume and have no responsibility to you or others for the control or correction of conditions or practices existing at your premises, whether reviewed or not in this presentation. Further we do not warrant that the completion of this presentation will assure your operations are safe and healthful, or are in compliance with any laws, regulation, code or standard. 

47. Thank you!
Thank you for your time! Questions: Stacey Markel