claims management 101 - aiha-rms...claims management 101 for the safety professional jolene donahue,...
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Claims Management 101 for the Safety Professional
Jolene Donahue, CSHS, OT, AIC, AIS The OSHA Connection, LLC
303-908-5506 or 1-877-646-4974 9035 Wadsworth Parkway Ste. 3440 Westminster, CO 80021
WELCOME What to Expect
Techniques *Save money *Lower Injury Rates
Case Law and Case Studies
!IMPORTANT!
It is never acceptable to discriminate against or
terminate someone for reporting an injury or filing a workers’
compensation claim.
Lag Time Number of days between
oEmployee: An injury and when employer notified
oEmployer: When notified and reported to insurance
Lag Time Colorado – employer 10 days ; employee 4 days up to 2 years
Lag Time Praxiom – 33% more costly after 24 hours. AMAXX – 35% more costly after 24 hours vs 45% more costly at 4-5 weeks. 22% litigated within 10 days vs 47% after 31 days. NCCI (Nat’l Council Comp Insurance) – 44 states 35% increase after 14 days vs 47% after 28 days.
Medical Treatment “Right to Direct” choice from employer selected panel
Medical Treatment Employee may not be paid Date of injury To/from appointments During appointments
Employee Responsibilities
• Complete tasks assigned
• Bring in physician note after each appointment
• Attend every appt (both Dr & PT)
• Adhere to work restrictions 24 hr/day
• Cannot decide what tasks to do while restrictions assigned
• Maintain confidentiality
Employee Responsibilities
• Follow policies & procedures: o Cannot call-in “in pain”
(send to the treating provider)
o Can call-in “sick” (follow company policy)
o Can take “vacation” (follow company policy)
o Cannot decide when to terminate treatment
o Advise of any concerns or questions
Claim Coordinator Responsibilities
• Document
• Be consistent and fair
• Enforce policies
• Stay in contact with injured worker
• Notify the adjuster of any concerns, change in
status, all attorney correspondence
Claim Coordinator Responsibilities
• Actively manage all open
claims
• Gather/maintain all paperwork and treating provider notes
• Maintain the OSHA 300, 300A and 301
• Neutral party
Safety Professional
• Document! Document! Document!
• Fact finding
• Thorough
• Root causes
• Identify, eliminate and prevent
• Retrain
HIPAA Health Insurance Portability and Accountability Act • Federal Privacy Rule
• Does not apply
o Work Comp insurers o Work Comp administrative
agencies o Employers
• Safety Violations
• Positive post-accident drug or alcohol screens
Drug/Alcohol & Safety Policies
Drugs / Alcohol
Drug and Alcohol testing Company policy vs. law
• Even if late report • Even if seeks treatment later • Even if treatment sought, before
next appointment • Results may affect benefits • Results may affect employment
BE CONSISTENT!
Not everything that happens “at work” or “on the job” is considered Workers’ Compensation
(But sometimes it does)
Contact your adjuster for any of the following
Statutes and Compensability
Spiders/snakes/bees/etc
Anytime/Anywhere
Aggravations / Pre-Existing
Stress and Mental Health
Voluntary Participation
Food/Drink (prep and consumption)
Personal Tasks (medication or deviation)
Cold, Flu, Contagious Disease
Travel
Intentionally self-inflicted
Clumsy or Less then Brilliant
Work from Home
QUESTIONS
The OSHA Connection, LLC is a privately owned company and is not affiliated with OSHA nor any regulatory agency. Participants are always encouraged to review the standard(s) and interpretations from OSHA directly or at www.osha.gov Copyright 2016