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Every North Dakotaemployee deserves a

safe work environmentand every employer

deserves to havehealthy employees.

www. workforcesafety.com

InjuriesRelatedWork

Robin HalvorsonReturn to Work Services

Reyne RichterClaims Management


Understanding & ManagingWork Related Injuries• Introduction to Claims• Introduction to Return to Work

Services• Claims management philosophy• Roles and players• Return to Work Services• Transitional Work• Vocational Rehabilitation• Define Incident Compensable Injury

Claims Management

Important StatisticsReturning to Work• Injured workers begin to lose

confidence after a disability as short as 2-4 weeks

• Almost always by 6 weeks• 12 weeks or more Likelihood of RTW has

dropped 50%• 1 year Chances only 1-2%

Claims Management


To Think AboutSomething

Average cost of a time loss claim

Approx. $87,956

Average cost of a medical only claim

Approx. $1,524

UnderstandingClaims Management/Claims Philosophy• Knowing an injury took place• How minor or the severity

• Medical treatment

• Job restrictions

• Resolving the injury

Claims Management

Claims ManagementSteps for Success• Injury has occurred• Educate employee

• Communication is key

• Prompt medical treatment

• Restrictions and/or limitations

Claims Management

Work RelatedClaims Philosophy• Be proactive• Being prepared

• Know your beliefs

• Establish your ideas

• Work is part of the recovery

• Established transitional workand/or modified work

Claims Management

Claims PhilosophyImportant Benefits• Domino effect• WIN-WIN for both parties

• Job status and paycheck

• Valued worker

• Supports financial need

Reduce workers’ compensationcosts and premiums• Claims management• Transitional work

Claims Management

Team Partnership is Key


EMPLOYER

EMPLOYEE

CLAIMSADJUSTER

RETURNTO WORK

MEDICALPROVIDER

Injured Worker’sResponsibility• Report ALL injuries immediately• Complete the First Report of Injury (FROI)• Maintain Medical Compliance (this

includes following MD recommendations at home and work)

• Keep employer informed of medical status (providing copies of the C3 to the employer)

• Law requires an injured worker to seek, obtain, and retain reasonable and substantial employment to reduce the period of temporary disability to a minimum.

Claims Management

EmployersResponsibility• Establish and implement pre-injury and

post injury policies and guidelines• Train managers and supervisors in

claims management procedures• Educate all employees about claims

management procedures• Take charge of the claims

management process and hold other team members accountable

• Monitor medical management of the claim

• Develop a written transitional work plan (for modified/alternate work)

Claims Management

Claims AdjusterResponsibility• Investigate the claim and

determine compensability• Determine wage replacement

benefits and issue check• Participate in medical treatment

coordination and pay medical bills• Inform the injured worker of his/her

rights and responsibilities• Assist in coordinating transitional

(modified/alternate) work• Manage the claim

Claims Management

DesignatedMedical Provider Role• Provide prompt and appropriate

treatment• Provide reports that are complete• Include the job as part of the

recovery process and define appropriate restrictions focusing on abilities

• Share the employer’s goal of transitional work

• Knowledgeable about the employer’s business

• Maintain responsibility for the direction of medical management of the claim

Claims Management

Return to WorkServices Role

• Onsite Case Management• WSI Medical Case

Management Program• Vocational Rehabilitation Program• Preferred Worker Program

The goal of the return-to-work services is to return the injured worker to substantial gainful as soon as possible after an injury occurs. A strong focus is placed on the coordination and implementation of strategies for the best return to work outcomes.

Claims Management

Medical CaseManager Role• Evaluate the proposed treatment

plan for appropriateness and medical necessity

• Provides recommendation (Do not make compensability decisions)

• Coordinates transitional work• Liaison for team members• Advocate for the injured worker• Medical resource for the adjuster

Claims Management


Any job, task, function or combination that a worker with restrictionsmay perform safely, for remuneration and without the risk of re-injury

Transitional Work

Considerations ForTransitional Work

Alternate Work:A temporary work assignment when the injured worker is unable to perform their pre-injury position.

Modified Work:The injured worker’s pre-injury position that is modified to restrictions imposed by theprimary treating provider.

Return to Work

Goals & ObjectivesTransitional Work• Job descriptions are best

utilized in injury management when they include a list of tasks that are necessary to be completed and the physical requirements associated withperforming each job.

• Develop job descriptions and transitional job offers

Return to Work

• Implementing an effective monitoring process from time of injury until the injured workerattains maximum medicalimprovement (MMI)

Goals & ObjectivesTransitional Work

• Focus on abilities rather than disabilities

• Ensure proactive endorsement by management, labor unions, and co-workers

• Encouraging the injured worker to participate in this process

Return to Work

Goals & ObjectivesTransitional Work

• Transitional work is work that is meaningful and productive. An effective plan does not include“make-work”.

Return to Work

Reflects the estimated overall strength requirement of the job, expressed in terms of the letter corresponding to the particular strength rating. It represents the strength requirements which are considered to be important for average, successful work performance.

Physical DemandsStrength Rating

Return to Work

Determining OverallPhysical DemandsIn order to determine the overall rating, an evaluation is made of the worker’s involvement in the following activities:

Standing Remaining on one’s feet in an upright position at a work station without moving about.

Walking Moving about on foot.

Sitting Remaining in a seated position.

Return to Work

Determining OverallPhysical Activities

Lifting Raising or lowering an object from one level to another (includes upward pulling)

Carrying Transporting an object, usually holding it in the hands or arms, or on the shoulders.Pushing Exerting force upon an object so that the object moves away from the force (includes slapping, striking, kicking, and treadle actions).

Pulling Exerting force upon an object so that the object moves toward the force (includes jerking).

Return to Work

DeterminingWorkability Assessment• A modified version of the

functional capacity evaluation (FCE) utilized to establish capabilities for injured workers using objective measurementsperformed by a physical or occupational therapist.

• The workability is utilized as a tool to more accurately determine the capabilities in cases where the practitioner is unclear of the injured workers capabilities.

Return to Work

AddressingWork ConditioningWork conditioning programs address flexibility, strength, endurance, and work-related function• Single discipline• 2 – 4 hours per day• Focus on strengthening

and endurance• May include work-related services

Return to Work

Functional CapacityEvaluation (FCE)Evaluates an individuals capacity to perform work activities related to his or her participation in employment (Soer et al., 2008). The FCE process compares the individual’s health status, body functions and structures to the demands of the job and work environment. In essence, an FCE’s primary purpose is to evaluate a person’s ability to participate in work.

Return to Work

DeterminingJob Analysis• A detailed description of the

demands of a particular job, based on ergonomic principles.

• Includes frequent and infrequentjob tasks, as well as the essential

functions (in compliance with the Americans wit Disabilities Act). Matheson (2012)

• Analyzes what the employee actually does on the job, the required qualifications needed to perform those duties and the context in which the work isperformed.

Return to Work

DeterminingErgonomic AssessmentA work-station evaluation designed to measure a job’s potential for injury or fatigue. The evaluation is based on the applied science of ergonomics, which maximizes productivity by designing equipment and work flow to reduce operator fatigue and discomfort. Standardized risk assessment tools are used to quantify risk. The evaluation takes place in both industry and office settings. (Matheson 2012)

Return to Work

DeterminingErgonomic AssessmentProvides strategies for risk remediation. Focuses on handful of issues including awkward postures, long-duration repetitive movements and tasks requiring high levels of physical effort. Fit job/task to person NOT the person to job/talk

Return to Work

N.D.C.C. 65-05.1-01Vocational RehabilitationIt is the goal of vocational rehabilitation to return an injured worker to substantial gainful employment.

Substantial gainful employment means bona fide work, for remuneration, which is reasonably attainable in light of the individuals:Vocational rehabilitation utilizes a workers functional capabilities, education, employment history, experience, and transferable skills to develop a return-to-work plan.

Return to Work

Vocational CaseManager’s Responsibility• Assess and evaluate the injured

worker’s function, education, job history, experience transferrable skills

• Coordinate transitional work • Coordinate skill upgrading services• Act as liaison between the injured

worker, employer, medical providers and claims adjuster

• Establish medical assessment teams• Develop a return-to-work plan• Assess functional abilities both

physically and mentally

Return to Work

A “compensable injury” means an injury by

accident arising out of and in the course of hazardous employment which must

be established by medical evidence supported by

objective medical findings.

Work Injury

QUESTIONS


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every north dakota employee deserves a safe work ... conference/b11 understanding a… ·...

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