The Source For Making the Complicated Simple Ohio BWC: 4 states - - PowerPoint PPT Presentation

The Source For Workers’ Comp

The 4 things you should understand about Workers’ Comp…. and WE bet you don’t !

Workers' Comp Beating You Up

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

Don’t walk away until you understand!

The Source For How It Works

BWC

MCO

TPA

IW INJURED WORKER YOUR COMPANY INDUSTRAL COMMISSON

• DHO -District
• SHO - Staff
• Commission Hearing

 New Evidence

• Common Pleas

Neutral Neutral

You pay premium to BWC 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? Who is your MCO?

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 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

• f 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 Surveillance

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

Employees entitled to a 1 time lump sum payment

The Source For Drug Testing

Warning!

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

What Is A Claims Fire Drill & Why Have One?

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
• Voc-Rehab in house and with non-profit

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 1st.

Prospective Payment Impact Private Employers?

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

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.

• Low-hazard industry exemption

The Source For Workers’ Comp

We have you covered!

Additional Programs FMLA and OSHA Recording Enrollment Deadlines December 1st!

888-294-9578 compsource@compsourcetpa.com 732 Middleton Way Suite 204 Loveland, OH 45140

www.compsourcetpa.com