By Donna Motley, Vice President of Claims

I’ve written in the past about Fraud in Workers’ Compensation. Types of Insurance Fraud include: Welfare, Unemployment, Mortgage, Automobile, Healthcare, Medicaid, etc.

This year we had our tri-annual State Audit and one of the questions they asked was how we handle fraud. We would first have to define “fraud”. Webster’s dictionary defines fraud as: “intentional perversion of truth in order to induce another to part with something of value or to surrender a legal right”. Per the Insurance Institute of Michigan website, an example of (insurance) fraud (pertaining to Workers’ Compensation) is: exaggerating the extent of a minor injury to collect (W/C) benefits; billing insurance companies for medical services that were not rendered. I think we can take it further. What about alleging a work injury when the injury really occurred outside of work? Or what about the person who alleges their medication was “stolen” and they need another re-fill when the reality is that either they are addicted to the drug or they are selling the pills on the street? What about the person who claims they need “in home assistance” because they are too incapacitated to even make themselves a sandwich? Or how about the person that won’t let the Nurse Case Manager in the examining room so they can tell the doctor how heavy or repetitive their job is, or their pain level is a 14 on a scale of 1 to 10?

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It is that time of the year when you will be receiving sales calls informing you that there have been important changes on the State and Federal Labor Law posters.

We are aware of those changes and are in the process of compiling these updates ~ please expect your new 2016 updated labor law posters to arrive at the end of December.

By Donna Motley, Vice President of Claims

If you have ever been involved in litigation, you are aware that the legal process moves at a snail’s pace. Workers’ Compensation litigation is no different. The average litigated case takes approximately 2 years to resolve; that’s resolution without trial. If the case goes to trial, it would be even longer than 2 years. The Workers’ Compensation Agency has now put rules in place in hopes of expediting the process to “18 months”. As an employer, it is understandable how frustrating this can be – we feel your pain! Let me explain what happened on a recent case.

The “alleged” injury “allegedly” occurred on March 25, 2013. After a verbal altercation with a co-worker, the 52 year old employee walked off the job. The employee went to an emergency room the next day and returned to work on March 28, 2013 and proceeded to walk off the job again. The employer informed the employee to report to work on April 1, 2013 if they still wanted their job. Instead, the employee returned to the emergency room on March 31, 2013 and called the employer on April 1, 2013 to advise of the alleged work injury (first notice of claim).

The Claims Department was notified of the incident on April 11, 2013 – 17 days after the date of injury. The insured advised they wanted us to “take a hard line on this” claim. The employee alleged a back injury after lifting a box; names of witnesses were provided. Three witnesses were contacted, and no one knew anything about any type of injury the claimant may have sustained. Medical records were requested from the treating physicians.

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By Donna Motley, Vice President of Claims

Workers’ Compensation insurance coverage is mandated in the State of Michigan. Even so, Workers’ Compensation is a “benefit” to the employee (and the employer). Employees are “entitled” to medical care and compensation should they have an injury while in the course of employment. But that does not allow the injured worker to have an “entitlement attitude”. Workers’ Compensation is not a “social program”. Benefits are governed by laws that were enacted over 100 years ago. Those laws have been periodically modified to change with the times. When you talk about laws, you are talking about attorneys – hence the modifications! Our success in the Workers’ Compensation courts is strongly influenced by the current political arena in our State at that time.

Employers know the part they play in the process: safety programs, safety training, drug screening, employment physicals, prompt reporting of injuries, accident investigations (and preventions).

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By Travis Halsted, Loss Control Consultant

Accident investigation and analysis is a means used to prevent accidents. As such, the investigation or analysis must produce information leading to corrective actions to prevent or reduce the number of accidents in the workplace. In 2014 the state of Michigan had 37 workplace fatalities. The investigations from these events are essential as they provide the possible root cause of the accident as well as assist in developing long term remedies. Injuries result in loss of productivity and efficiency, increased workloads on supervisors and co-workers, possible damaged equipment costs, economic hardship to the injured workers’ family, and a cost of the time spent on the accident investigation, return to work programs, and workers’ compensation claims management. By conducting accident investigations a company could possibly implement a remedy that could prevent future occurrences.

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By Donna Motley, Vice President of Claims

We are all aware of how and where potential “serious” injuries can occur in the workplace and hopefully actions are taken to avoid those situations. Things like weight limits on lifting, guarding on machinery, wearing safety glasses and other personal protection equipment. But what about those seemingly innocent actions and movements, that are almost second nature to a person? The following are actual claims handled by our office.

An employee stopped to get the mail and slipped on black ice and snow resulting in an ankle fracture in three places and a shattered heel. Surgery was performed with plates and screws; and the employee remains disabled from work.

An employee jumped off the bed of a truck resulting in a heel and foot fracture. The employee has been referred to a specialist to see if surgery is necessary. The foot fracture was not noticed on the initial diagnostic testing. The employee remains disabled from work.

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By Donna Motley, Vice President of Claims

Studies have indicated that the longer a person is off work due to a work related injury, the less likely they are to return to productive employment. Once (physical) restrictions are imposed by the treating physician, an employer has the decision to make whether or not they will let the injured worker return to work with those limitations. For the office worker that is given the restriction of “sit down work only” or the machine operator that is restricted to “no lifting over 50 pounds” and his regular job does not require any lifting or only lifting up to 10 pounds, the decision to return the employee to work is not that difficult. As indicated, a return to work policy is beneficial for the employee as they remain productive members of society, and the employer, as it does not impede work flow and will aid in limiting their Workers’ Compensation exposure. Bringing an employee back to work with restrictions also sends a message to all employees that being injured at work will not result in a paid vacation!

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By Donna Motley, Director of Claims

Medical expenses always seem to be on the rise. The Workers’ Compensation weekly benefit (the amount paid to the injured worker) usually increases annually even though it is based on the State Average Weekly Wage. Workers’ Compensation coverage is mandatory in the State of Michigan – part of the cost of doing business!

Once a Workers’ Compensation claim is turned in to our office, we take the reins and take control, attempting to minimize all the costs involved, the length of disability, and to assure a successful return of the injured worker to productivity. Everyone benefits. But, as an employer, there are things that you can do to help mitigate the expenses or costs on the claim.

Obviously, one of the most important things an employer can do, is report the claim As Soon As Possible! That way, we are controlling treatment (and costs) from the onset. As an employer, NEVER tell an injured worker to seek treatment with their primary care physician or a physician of their choosing. Any treatment outside the Occupational Clinic results in a delay in obtaining medical records that are required before authorization to treat can be rendered. If an employee is off work during this period – the cost of the claim has just increased significantly. If the injury is questionable and/or you are unsure of the direction that should be taken, PLEASE call our office for advice.

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By Chris Demeter, Senior Loss Control Consultant

OSHA has expanded the list of severe injuries & illnesses that employers must report and updated the list of industries who are partially exempt from routinely keeping OSHA records.

“OSHA will now receive crucial reports of fatalities and severe work-related injuries and illnesses that will significantly enhance the agency’s ability to target our resources to save lives and prevent further injury and illness. This new data will enable the agency to identify the workplaces where workers are at the greatest risk and target our compliance assistance and enforcement resources accordingly.”
— Assistant Secretary of Labor for Occupational Safety and Health, Dr. David Michaels

For workplaces under Federal OSHA jurisdiction

• Final rule becomes effective January 1, 2015 For workplaces in State Plan States (MIOSHA)
• States encouraged to implement new coverage provisions on January 1, 2015, or as soon after as possible.

The rule expands the list of severe work-related injuries and illnesses that all covered employers must report.

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By Donna Motley, Director of Claims

While scanning some publications, I came across an article that itemized “8 CHARACTERISTICS OF A SUCCESSFUL W/C PROGRAM”. The original source of the article was Zurich American Insurance Company. Below we have modified the article to explain these characteristics and include ways MTMIC can help you with your programs. The characteristics were listed as follows:

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By Donna Motley, Director of Claims

Communication in our industry is crucial. We have at our disposal multiple ways to communicate, telephone, computer (e-mail), faxing, even the old fashion form of “written” communication. In the Workers’ Compensation arena, we still need “written” proof of a claim. As you are aware, the Employers Basic Report of Injury (Form 100) must be submitted before we can physically set up a claim file. Obviously, the form needs to be completed properly in order to fill in the fields required by the computer. Claim information is tracked by the State of Michigan – hence the required fields.

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By Donna Motley
Director of Claims

The cost of insurance, any kind of insurance, is not cheap. As premiums escalate, there appears to be a new “buzzword” – FRAUD. While the notion of fraud is not new, more and more people are starting to get angry and show interest in putting a stop to it. Some states (not Michigan) have started movements to prosecute those committing insurance fraud. I read recently that Michigan’s automobile premiums had the largest increase in the U.S. in 2013 because of claims paid outside of property damage. That would mean the bulk of payments were for “alleged” injuries and medical care.

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By Donna Motley, Director of Claims

Late reporting of employee injuries can be costly in multiple ways.

We received a claim on August 16, 2013 for a July 3, 2013 injury date – approximately 6 weeks after the injury allegedly occurred. The employee said they “bumped” their elbow on a part. The diagnosis was “post traumatic olecranon bursitis”. The employee did not lose time from work. The employee treated for the condition on July 3, 2013 (the day of injury), July 8, 11, 22, 29, and October 8, 2013 when they were discharged from care.

Notice there were five visits with the medical provider before we even received the injury report. Per the Workers’ Compensation Act, the W/C provider/insurance carrier exclusively directs all medical treatment for the first 28 days! In this particular case, we lost that opportunity. Could we have shortened the length of this claim and thereby the amount spent – very likely!

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By Cindy Boyce, Senior Claims Adjustor

In the majority of Workers’ Compensation cases employees who are injured at work recover and return to work. In some cases employees do not return to work claiming that they are still disabled from the work injury. A small percentage will end up in court and enter into litigation by filing an Application for Hearing. Shortly after the Application is filed, it is processed by the Workers’ Compensation Agency and the employer will be served with an Acknowledgement and Notice of Hearing. Below are a few recommendations that will assist you in understanding the litigation procedure.

1. Once a claim is disputed, the employee may resort to filing an Application for Hearing.

When you are served with the Acknowledgement and Notice of Hearing, you will note the Magistrate assigned to hear the case, the hearing site and the date of the initial pretrial hearing. In most cases, the adjuster will also be served. However, it is recommended that you contact MTMIC upon receipt of the Application to confirm that we have been served.

Once we receive the Application for Hearing, we will retain an attorney to represent your company’s legal interests.

In most cases you will not be required to attend the pretrial or subsequent hearings unless we have notified you otherwise.

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By Donna Motley, Director of Claims

A New Year – new opportunities, new challenges, a chance for all to improve! 

Please remember to promptly report all injuries. Failure to promptly report injuries results in delayed medical treatment and inconvenience for the injured worker. If an employee does not report an injury in a timely fashion, we suggest disciplinary action be invoked.

Authorization to treat, other than the initial visit, should only be given by our office. That would include authorization for continued treatment, testing or referral to a specialist. We can only extend authorization if we have the claim information in our office.

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