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EWC Magazine - Spring 2019 :

Healing the Whole
Injured Worker
Create a
Competitive Advantage
Top 3 Traits
Up, Up
& Away!
Around the
World in 80 Days”
A Look Back at EWC Conference 2019
SMS National
(800) 404-0761
DME, Home Health
Investigation Services
Investigation Solutions Inc.
(844) 719-5165
Dictation & Transcription
TASK Transcription Services, Inc.
(866) 288-8808
Complex Rehab & Accessibility
National Seating & Mobility
(800) 509-4886
Investigation Services
Excaliber Investigations, Inc.
(209) 835-6413
Home Care
Continuity Care Home Nurses
(818) 753-5106 Ext. 108
Adjuster Training & CEUs
Insurance Educational Association
(800) 655-4432
Case Management, UR/UM
(866) 808-4742
Brain Injury
Centre for Neuro Skills
(800) 922-4994
Lien/Walk Thru Resolutions
Work Comp Resolutions
(714) 408-4429
(415) 399-9769
Managed Care Services
Rising Medical Solutions
(866) 274-7464
Medicare Compliance
ISO Claims Partners
(866) 630-2772
MSP Compliance Solutions
(866) 858-7161
National Case Management
MKCM, Inc.
(866) 654-6526
National Document Retrieval
Macro-Pro, Inc.
(800) 696-2511
Nonprofit Trust Provider
CPT Institute
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Investigation Services
Specialized Investigations
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Professional Administration
(877) 275-7415
to reserve your space in the next issue
Settlement Consultant
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Urgent Care
Reliant Urgent Care
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Staffing and Recruiting
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Qualifying America’s Workers
Safety Solutions Ergonomic & Workplace Safety
(714) 329-4877
2 EWC Magazine
32 26
3 Providing Service Excellence
Sponsored article by National Seating & Mobility
4 From the Editor
5 Workers’ Compensation
5 Tracking the Most Pressing Issues Impacting
Medicare Secondary Payer Compliance
By Mark Popolizio
7 Create a Competitive Advantage by Fostering
Continuous Learning and Thought Leadership
By Greg Johnson
9 The Case for Treating Injured Workers With Empathy
By David Deitz, MD, PhD
12 Healing the Whole Injured Worker:
The Loma Linda Approach to Workers’ Compensation
By Kimberly Kinney, WCCP, CPDM and Jay Garrard
16 The Nuts and Bolts of Field Case Management
By Mollie Kallen, MS, CRC, CCM
18 Top 3 Traits of Superior Workers’ Comp Claims Teams
By Rachel Fikes and Peter Rousmaniere
21 Peer to Peer
Smart solutions to real challenges
21 Finding the Right Fit
By D. Diann Cohen
22 EWC Conference 2019: A Look Back
26 Management Center
26 Mindfulness Principles at Work
By Brenna Hampton
28 Start Your New Job Right:
Why You Should Strive to be Likable
Contributed by TheBestIRS Blog Team
30 Risk Management
30 The Orchestrator: How Risk Managers
Maintain an Effective Return to Work Program
By Ken Hernandez
32 Will the Real ERM Please Stand Up?
By David B. Dolnick
34 Doctors’ Perspective
34 Keeping Up With Changes in Orthopedic Surgery:
Platelet Rich Plasma and Stem Cells
By Gary Brazina, MD, FACS, FAAOS, DABOS
36 Legal
36 The Independent Bill Review System
By Paul C. Herman and Aidan P. McShane
38 In the Spotlight
One minute with industry leaders
39 Carl’s Corner
Negotiation tips for the claims professional
hen an individual who is active in the workforce sus-
tains a catastrophic injury, that person’s life – and his or
her family’s life – changes immediately and dramatically. Most
everything the injured individual used to do without assistance
will now require intervention by a caretaker and/or medically
necessary equipment. In addition, home modifications will likely
be needed to allow the injured worker to remain comfortable and
mobile inside and outside the home, and to complete most, if not
all, activities of daily living.
National Seating & Mobility (NSM) understands the life-changing
mobility and accessibility needs an individual with a serious work
injury faces. The company has been providing mobility and adap-
tive product solutions for individuals with disabilities and profound
health care challenges since 1992. As the nation’s premier Complex
Rehab Technology Solutions provider, our national network of more
than 400 RESNA-Certified Assistive Technology Providers (ATPs),
operating from 140 U.S. branch locations spanning 46 states and six
locations in Canada, work alongside physicians and therapists to
design customized innovative mobility, rehabilitation and adaptive
product solutions for our clients.
NSM’s Centralized Referral Intake and
Dedicated Account Management Team
Given our 25+ years of experience as a service-focused provid-
er, NSM understands the demand for service excellence in the
workers’ compensation sector. As a result, we have developed a
central intake process and a dedicated account management team
supporting a best-in-class service approach including proactive
communication, real-time updates, and an assigned point of contact
to streamline communications.
A 360-Degree Complete Mobility Solution
NSM’s approach positions the company as a one-stop mobility and
accessibility solutions partner giving workers’ compensation orga-
nizations the convenience of working with one trusted company as
opposed to several.
NSM knows that injured workers and carriers demand service
excellence, and responds to this critical need with A+ service levels
in the workers’ compensation arena. Therefore, you can expect a
quality service experience for your teams and clients. Our number
one goal is to deliver all required services and equipment as quickly
as possible to your injured workers.
Central Referral Intake & Customer Service:
Telephone: 1-800-509-4886
Corporate Contacts:
Kiley Russell, Account Manager
Brendan Swift, VP Account Mgmt.
Providing Service
Home &
Aids for
Daily Living
Power &
Seating &
Every Chair
“Having spent much of my career in
Health Plan Operations, both on the
group health and workers’ compensa-
tion ends of the business, I have seen
firsthand just how important it is for a
service provider to oer a proactive and
dedicated service model. NSM has implemented
a best-in-class one-on-one service solution that
allows our valued payer partners and their teams the
proactive case management and communication
that their clients demand. More importantly, NSM
prioritizes trusted relationships with our partners’
clinical operations teams.
Brendan Swift - VP, Workers’ Compensation
Account Management
Oering Your Injured Worker a 360-Degree Complete Mobility Solution
NSM-WorkersCompArticle.indd 1 5/14/19 6:16 AM
4 EWC Magazine
From the Editor...
pril may be known for showers that bring May
flowers, but at EWC, April means conference
season is in full bloom! The beginning of April
found the EWC staff and board pouring a vast amount
of time, effort and expertise into producing a symposium
that we purposed to be your best conference of the year.
As we closed out the conference at the end of the month,
we collectively caught our breath and looked back at the
fond memories we made of connecting with old friends,
meeting new people, and learning much from each other.
With conference production over, post-event briefing began.
To make sure the conference hit all our marks, we sent out a
short survey to find out what worked – and what didn’t go
quite as planned. When reviewing the attendee responses,
96 percent said the Executives in Workers’ Comp Conference
was superior when compared to similar conferences, that they
planned to return, and they enjoyed the education as well
as the networking.
Overall, the feedback was
tremendous, but the following
statement summed it up best:
“Great speakers, great networking,
excellent venue – it was obvious a
lot of hard work went into this
event. Outstanding job to the
team that made it all happen!
It was a huge success!
Speaking of the team, I would
be remiss if I did not thank
Cindy Mariani with SMS National,
Mandy Farquhar with ISO Partners,
Victoria Maker with Argus West
Investigations, and Lacey Atkinson
with EWC Events for all of their
help in making our vision for this
conference come to life. After four
years of putting on this event,
I know firsthand how much time,
energy and expertise it takes to
produce a conference of this caliber.
From the big-picture planning
sessions down to the final touches on the name badges, our
advisory board willingly devotes countless hours to every last
detail to ensure our event-goers have a top-tier experience.
Thank you to our board who makes EWC Conference such
a success. They are the most delightful board members I’ve
had the pleasure to work with, and I am honored to call them
my friends. Each one of them has her unique style of getting
things done, but they are all fiercely committed to providing
outstanding educational opportunities to benefit the workers’
comp and risk management community.
Just as each spring we see the buds of new growth burst
into bloom, so has EWC Conference grown exponentially,
and every two years we have had to move to a new location to
accommodate the increase. Right on schedule, we are moving
our conference for 2020 to the Hyatt Regency Huntington
Beach Resort & Spa in hopes that this will be our last move
for many more years. Not only will we have a new venue, but
we will be joined once again by the Womens Alliance, making
our conference a 1-1/2 day event. I hope that you will join The
Executives in Workers’ Comp Conference 2020 for a full day
of education on Thursday, March 19th and join The Womens
Alliance on Friday, March 20 for a half day event. It promises
to be a memorable affair brimming with Glamour, Gambling
& Grand Prix!
Together we can do great things!
Debra Hinz
Editor in Chief
And thats a wrap!
Managing Editor
Lacey Atkinson
Art Director
Hannah Peacock
To advertise, contact:
(760) 613-4409
Great speakers, great networking,
excellent venue - it was obvious
a lot of hard work went into this
event. Outstanding job to the team
that made it all happen! It was
a huge success!”
Cindy Mariani
Mandy Farquhar
Victoria Sparhawk
Tracking the most pressing issues impacting
Medicare Secondary
Payer compliance
By Mark Popolizio, VP of MSP Compliance & Policy, and Sid Wong, AVP of Policy, ISO Claims Partners
s a new year settles in, it is even more important
to keep tabs on the evolving issues, trends, and
initiatives that affect claims and settlements.
To help you prepare for what is ahead, the following
explores the primary topics to keep on your radar in 2019.
After several years of silence, Centers for Medicare & Medicaid
Services (CMS) appears ready to revisit establishing formal
Section 111 penalty provisions. In December 2018, the Office
of Information and Regulatory Affairs (OIRA) issued a notice
indicating that CMS is planning to release proposed rules
for public comment regarding Section 111 of the Medicare,
Medicaid, and SCHIP Extension Act of 2007, reporting
civil money penalties (CMP) for Non-Group Health Plans
Based on this notice, CMS is apparently ready to take the
next steps toward implementing formal criteria and practices
to which CMPs would apply relative to Section 111s “$1,000
per day” penalty as required under the Strengthening Medicare
and Repaying Taxpayers Act of 2012 (SMART Act).
The Office of Information and Regulatory Affairs notice does
not provide any information on the specific penalty proposals;
rather, it simply advises the public that CMS will be issuing
proposed rules on Section 111 CMPs at some point in the
future. Thus, the industry needs to be on alert for the release
of CMS’ formal proposals which will, according to the
OMB notice, allow for public comment. It will be interesting
indeed to assess the nature and extent of CMS’ proposals
including proposed criteria for establishing “good faith
safe harbor provisions.
In March 2018, Capitol Bridge, LLC, replaced PRI as
CMS’ Workers Compensation Review Contractor (WCRC).
The WCRC is the contractor that reviews and approves
Workers’ Compensation Medicare Set-Asides (WCMSAs).
Capitol Bridge’s new role has resulted in significant changes
in the handling and pricing of services and prescriptions for
WCMSAs. For example, the WCRC has been including off-
label medications, such as Lyrica, in instances where they were
previously excluded; requiring medical records to be submitted
in conjunction with all zero-dollar WCMSA requests;
including additional urine drug screens involving Schedule II
drugs; and adding treatment if Medicare-covered treatment is
merely referenced in the medical records.
These trends appear to be firmly directed at both increasing
the price of services and including more treatment in
WCMSAs. It will be critical to monitor whether CMS will
continue this trend by implementing other changes to the
WCMSA review process.
To meet these challenges, claims payers need to have a
firm grasp of the new WCRC’s approaches and implement
practices aimed at mitigating their impact to keep WCMSA
allocation amounts reasonable.
This may be the year CMS revisits the issue of future medicals
for liability claims. Of note, in December 2018, the Office of
Information and Regulatory Affairs issued a notice indicating
6 EWC Magazine
that CMS plans on issuing proposed rules regarding options
to address future medicals in relation to liability, workers’
compensation, and no-fault cases. Per the OIRA,
a Notice of Proposed Rulemaking (NPRM) is targeted for
release by September 2019.
In the bigger picture, this announcement will likely generate
interest in liability circles where questions regarding future
medical obligations and LMSAs have been a vexing issue for
years. On this front, CMS issued proposed regulations for
liability cases back in 2012 but then withdrew them in 2014.
OIRAs notice indicates that CMS is prepared, in some
manner yet to be determined, to explore options for parties
to address future medical obligations in relation to liability,
workers’ compensation, and no-fault settlements. The
exact nature and extent of what CMS is contemplating is
unknown at this time but will be unveiled when the
NPRM is ultimately released.
Over the past several years, Medicare Advantage Plans (MAPs)
have been on a judicial quest to establish private cause of
action rights, which would allow them to sue claims payers
(and potentially other parties) for “double damages” to the
extent their recovery claims are not properly addressed. So
far, the United States Third and Eleventh Circuit Courts of
have ruled that MAPs enjoy double damages rights.
In addition, United States District Courts in Louisiana,
Tennessee, Texas, and Virginia have also ruled in favor of
MAPs on this issue.
In 2018, the United States District Court for Connecticut
and a second Texas District Court joined the growing
jurisdictions finding that MAPs enjoy double damages rights,
while a district court in Illinois gave a strong signal that it too
viewed MAPs as possessing these rights.
Entering 2019,
we will need to keep a close eye on pending litigation in other
states to see if additional courts will continue this trend.
In October 2018, CMS amended its Medicare Prescription
Drug Benefit Manual (Part D Manual) to add, in part,
stronger language regarding Medicare Part D sponsors’
secondary payer rights and recovery.
As part of these changes, CMS is directing Part D
sponsors to ensure processes are in place to effectuate proper
secondary payer recovery efforts. Further, the new updates
preclude Part D sponsors from paying for a prescription that
should be paid under the Medicare Secondary Payer (MSP)
provisions or submitting these claims to CMS for payment.
If acted upon, these updates could lead Part D plans to
assert more aggressively their secondary payer status, either
through coverage denial or increased Part D recovery claims
regarding workers’ compensation, liability, and other non-
group health claims. In this regard, it is noted that Part D
recovery efforts have been changing over the past year or so.
Initially, Part D sponsors were simply sending letters to claims
payers asking them to confirm primary payer status, injury
date, claimed injuries, and other claim-related information.
However, an increasing number of sponsors are now sending
letters asserting recovery and providing a breakdown of
alleged payments for reimbursement.
Whether these CMS policy updates will propel more
aggressive practices in collection or denying coverage is
something all claims payers should closely watch going
forward. As the recovery spotlight shifts to Part D recovery,
claims payers should have processes in place to address Part D
recovery notices to assess what responsibility, if any, may be
owed and whether grounds exist to challenge said claims.
Keeping pace with all these changes can seem daunting.
But being aware of the issues and knowing how to respond
to them affect your efficiency, costs, and bottom line. J
In re Avandia, 685 F.3d 353 (3rd Cir. 2012) and Humana v. Western Heritage,
832 F.3d 1229 (11th Cir. 2016).
Collins v. Wellcare Healthcare Plans, Inc., 73 F.Supp.3d 653 (E.D. La. 2014),
Humana Ins. Co. v. Farmers Tex. Cnty. Mut. Ins. Co., 95 F.Supp.3d 983
(W.D. Tex. 2014), Cariten Health Plan, Inc. v. Mid-Century Ins. Co., No.:
2015 WL 5449221(E.D. Tenn. 2015), and Humana Ins. Co. v. Paris Blank
LLP, 187 F.Supp.3d 676 (E.D. Va. 2016).
Aetna v. Guerrera, 300 F.Supp.3d 367 (D. Conn. March 13, 2018), Humana
v. Shrader, 584 B.R. 658 (S.D. Tex. March 16, 2018); and MAO-MSO
Recovery II, LLC v. State Farm, 2018 WL 340021 (C.D. Ill. January 9, 2018).
Medicare Part D was added to the Medicare program in 2003, with benefits
commencing in 2006. Part D is a voluntary outpatient prescription drug
benefit plan available to all Medicare beneficiaries. Beneficiaries enrolled in
traditional Medicare can purchase what is known as a “stand-alone” Part D
plan, while Medicare Advantage Plans (MAP) beneficiaries may purchase a
plan as part of their coverage under their particular MAP program. Similar
to Part C (Medicare Advantage) MAPs, Part D benefits are provided by
private companies (referred to as sponsors), and the scope of coverage varies
from plan to plan. In 2018, more than 43 million Medicare beneficiaries
were enrolled in a Part D plan. Of this total, 58% of traditional Medicare
beneficiaries were enrolled in a stand-alone prescription drug plan, while
roughly 42% were enrolled in a Medicare Advantage Drug plan. “See The
Henry J. Kaiser Foundation, An Overview of the Medicare Part D Prescription
Drug Benefit, October 2018.” Currently, United Health, Humana, and
CVS Health account for 55% of all Part D enrollees. “The Henry J. Kaiser
Foundation, Medicare Part D in 2018: The Latest on Enrollment, Premiums,
and Cost Sharing, Data Brief, May 2018.
Claims payers should have processes
in place to address Part D recovery
notices to assess what responsibility
may be owed and whether grounds
exist to challenge said claims.
Create a
Competitive Advantage
by Fostering Continuous
Learning and Thought Leadership
By Greg Johnson, Director Marketing & Operations/Consultant at Insurance Educational Association
abor is one of the highest costs of any business.
Because of this, there is constant pressure to
find ways to reduce costs. At the same time, any
organization is only as good as the service the employees
provide to the customers. Employees are also the
backbone of every organization. The risk of focusing too
much on reducing employee costs is that it creates an
environment of constant turnover, which actually ends up
increasing costs. The quote above from Richard Branson
demonstrates a perspective of employees as an investment.
It is not labor costs, but human capital.
If turnover increases costs, employee retention reduces costs.
Many people automatically think the best way to increase
retention is to increase salaries. It is not quite that simple.
A high salary doesn’t always translate to employee satisfaction.
We only need to turn to professional sports to see unhappy
athletes getting paid millions of dollars yet demanding trades.
Yes, having competitive salaries is important, but paying more
than the competitors is not the answer to employee retention.
One of the most important ways to improve retention is to
foster an environment that encourages continuous learning.
When you motivate employees to grow and develop, there are
two key results: performance improves, and retention increases.
The key to having your team running at peak efficiencies is
to ensure they are keeping up with the latest trends and best
practices for both function and industry. No matter how long
employees are in specific positions, there is always more they
can and should learn. So how can we empower our employees
to quench their thirst for knowledge?
1. Encourage and provide opportunities for active
participation in professional and industry associations.
2. Encourage and provide opportunities for formal
professional development.
3. Encourage informal learning through continuous reading.
4. Encourage employees to be your Brand Ambassadors
on professional platforms such as LinkedIn.
Professional and Industry Associations
There is no better avenue for continuous learning and staying
abreast of best practices than involvement in a professional
association. Participation in organizations such as EWC
“Some people might see Virgin’s 50,000 employees as a cost to be managed,
but I see 50,000 potential passionate brand ambassadors.
Richard Branson
8 EWC Magazine
allows employees to actively engage with peers in the industry,
offering the opportunity to learn from each other and share
best practices. Attending events enables attendees to hear from
industry experts and take newly acquired skills and tools right
back to their daily jobs. Finally, in attending events, employees
are given the opportunity to be an ambassador for your
organization. When you encourage your employees to attend
events, the subtle message conveyed is that you value them
enough to represent your organization. This support goes a long
way in building morale and dedication.
Formal Professional Development
What does it mean to your organization that your team
pursues professional development? First, when employees achieve
professional designations, it demonstrates that they have the
knowledge and expertise to fulfill the company’s mission and
service the needs of their customers, whether they are internal or
external. Additionally, it is imperative that industry professionals
keep up to date, especially in an area such as workers’
compensation, with the convoluted nature of the laws and
the constant changes. The risks of not doing so are too great.
The most important thing is to have the thirst to get better,
the thirst for knowledge. – Kobe Bryant
Continuous Reading
As Kobe Bryant stated in the quote above, the most important
thing is to have the motivation to get better - the thirst for
knowledge. Often our information is only as current as
what we read today. Reading professional publications and
industry news daily is critical to keeping current. Are we
fostering an environment for our employees to be curious
and forward thinking, or are we cultivating an environment
where employees have to grind every day just to complete
tasks, burning them out and reducing morale? In this scenario,
the employee focuses only on completion of the task without
concentration on optimal results. A better success strategy is
to ensure that employees have opportunities to learn thereby
ensuring they remain fresh, innovative, and most of all
motivated to complete tasks at optimal performance.
Brand Ambassadorship
What does it mean to be a Brand Ambassador? It is essentially
representing your organization. We all know that marketing
and building a brand identity recognized in your industry
is an expensive and never-ending venture. How can you
leverage your employees to be your Brand Ambassadors?
First, ensure that they are on the leading edge with their
subject matter expertise. Next? Train them and encourage
them to use platforms such as LinkedIn to engage with
their peers and your customer base where their subject
matter expertise will be recognized and become an asset to
your organization. Encourage them to share news of your
organization. Sharing your company culture, milestones,
and events the organization is participating in is an excellent
start to building more awareness not only of your company
but of the strength of your employees as trusted thought
leaders in your industry.
Train people well enough so they can leave, treat them
well enough so they don’t want to. – Richard Branson
Is your employee base a cost to be managed and reduced, or
an asset to be invested in? Empowering your team to succeed
motivates them to go the extra mile. Think of our roles as
managers not just as task driven, but as a vital contribution
to the success of a team effort. When everything we do helps
our team to thrive, we are motivated to be better. How are
you helping your employees to succeed in growing your
organization to its full potential? J
Fostering an environment where employees are encouraged
to continuously cultivate their thought leadership and subject
matter expertise results in:
Increased retention and decreased cost of turnover,
Increased productivity and efficiencies,
Improved reputation and brand recognition of your
organization, and
An environment where employees want to go the extra
mile for the organization.
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The case for treating injured workers with
Seeing the world through the eyes of an injured worker
is the fastest and least expensive path to recovery
By David Deitz, MD, PhD, Chief Medical Advisor to ChronWell
mpathy is widely recognized as an attribute that
helps people communicate better, but it’s also
difficult to quantify and is generally considered
a soft skill. However, today’s most profitable companies
are starting to view empathy as a hard skill – something
definable, measurable, and a core value that’s crucial to
their financial success.
A groundbreaking report in Harvard Business Review (HBR)
found that the top 10 companies on HBR’s Global Empathy
Index generated 50 percent more earnings than the bottom
10. HBR also found an 80 percent correlation between higher
empathy and individual performance. And HBR isn’t the
only one noticing; studies featured by every major business
publication, from Forbes to Fast Company, indicate that
10 EWC Magazine
companies incorporating empathy into their culture have
better retention rates and financial results.
Empathy is particularly impactful (but remains uncommon)
in workers’ compensation. While injured worker advocacy
programs have generated great interest over the last few years,
they can be difficult to implement, particularly when adjusters
have high caseloads. New technologies offer an opportunity to
deliver empathy-based advocacy programs on a scalable level.
Anxiety and fear of the unknown are among the primary
factors driving injured workers toward litigation. When
workplace injuries occur, many companies disengage from
injured workers to prevent potential liabilities. Injured workers
are left on their own to navigate initial treatment, medical bills
and insurance claims. This detachment can be frightening
for anyone facing uncertainty about their health and medical
care, their ability to provide for their families, and potentially,
a fractured relationship with the employer.
It’s no surprise, then, that so many people turn to personal
injury lawyers and sue their employers after they’ve suffered
an on-the-job injury. In some states, up to 52 percent of
injured workers retain an attorney for their workers’
compensation claim, according to the Workers Compensation
Research Institute.
When employers disengage, workers who are uncertain
about how to get treatment may turn to the emergency
department (ED) as a quick option. For minor injuries, this
compounds the problem, as such work injuries are better
handled at occupational clinics or through self-care. ED
visits usually drive up claims costs through expensive bills
and poor care coordination.
Focusing on empathy in your workers’ comp program
can change much of that. Published studies confirm that
training supervisors and claims adjusters to respond to
workplace injuries with care, concern and information to
address injuries promptly leads to lower disability durations
and reduced litigation.
When you approach work injuries with empathy and put
yourself in the position of the worker, you expedite the process
of recovery by getting involved in every step of the process
– from the moment of injury, to follow-up care, all the way
through the resolution of the claim. An empathetic approach
dictates that you open lines of communication between
employers, employees and insurers. You stay in constant contact
with the worker, making them feel theyre not alone. While
scheduling appointments or arranging transportation is often
considered managed care basics, making these arrangements
work smoothly can provide an immense return in goodwill
(litigation costs) and productivity (return to work).
How do you inject empathy into an inefficient workers’ comp
system? You build an intelligent platform that connects and
informs everyone, learns about each injured worker, creates
personal, customized engagement plans and monitors progress.
This platform includes advanced technology, Artificial
Intelligence (AI) and skilled employees able to connect with
injured workers on a personal level.
Taking the time to explain the claims process to the injured
worker can have a favorable impact on their anxiety levels and
their perception of the care they receive. When the worker
understands what will happen next, who will work with them,
or why they will have to go through a particular procedure,
they are less likely to engage in litigation.
Applying technological solutions to empathy-based programs
accomplishes three things:
Training supervisors and claims adjusters to respond to workplace
injuries with care, concern and information to address injuries
promptly leads to lower disability durations and reduced litigation.
1. It makes empathy scalable. Considerable advances in AI
and natural language processing have made relationship
management and chatbot technologies more accurate than
ever. By automating mechanical work, employees are freed
up to create human connections and are able to help more
people. Modern technology can understand and respond
to simple questions, monitor worker progress, assess risks
and build intervention plans with minimal effort.
2. It opens lines of communication. In today’s legacy
environment, adjusters are responsible for contacting injured
workers and shepherding the claims process. However,
studies have shown that TPAs tend to overload adjusters
to the point where they become unresponsive to injured
workers. It is essential to open lines of communication
from the first day of an injury and continuously follow
up in order to engage the worker in their recovery.
3. It facilitates training for supervisors. Supervisors are the
first responders for on-site injuries. Technology that helps
them with basic triage, injury reports, and keeping workers
informed and engaged in the process is an integral part of
the solution. Having supervisors who are trained to handle
these tasks is especially important for high-risk industries
like agriculture, construction or retail.
If you treat injured workers with empathy and compassion,
youll see better outcomes. Workers’ comp is one of the
industries least disrupted by technology – but it’s time.
Taking a high-tech approach to treating injured workers with
empathy will allow employers to engage, rather than overlook,
their workers in the recovery process. Ultimately, this will
result in less litigation and lower claims costs. J
A significant amount of companies view their employees
as a strategic asset and creating a personalized experience
for their return to work is paramount.
Today’s most profitable companies consider empathy a key
element for their financial success.
Treating injured workers with empathy can save employers
money in litigation and claims costs by engaging with the
worker in his or her recovery.
Incorporating empathy into your workers’ comp program
efficiently and effectively requires technology.
12 EWC Magazine
Healing the Whole Injured Worker
The Loma Linda Approach
to Workers’ Compensation
By Kimberly Kinney, WCCP, CPDM, Director, Workers Compensation, Abilities
and Accommodations at Loma Linda University Health-Risk Management,
and Jay Garrard, Vice President, Operations at CompAlliance, LLC
oma Linda University Medical Centers
(“Loma Linda”) in the Inland Empire of
Southern California believes in a “whole-person
approach to treating patients in our health systems.
So, in 2015 it was appropriate as we looked to enhance
our workers’ compensation claims management program
that we would apply this whole-person approach to help
our injured employees return to health and work.
Recovery from injury involves more than the simple process
of healing; there are financial concerns for employees
who miss work, they may have co-morbidities that affect
their healing, and their attitudes about injury and their
prospects for recovery may require additional attention.
We knew that we could not simply “adjust claims.
We needed to manage claims, and we needed to take
a team approach, utilizing all the tools at our disposal.
We implemented an Early Intervention Nurse Case
Management program, which included 24-hour Nurse
Triage/Incident Reporting, along with evaluation of all
new claims for nurse case management within 24 hours
of the report of injury. Claims identified to have a potential
for lost-time or complex ongoing treatment would be
opened to nurse case management with embedded
utilization review. At the same time, nurse case management
services became available for claims that occurred prior to
the start of the program. This enabled us to compare an
early intervention approach versus a “delayed referral
approach to case management.
Simultaneously, we undertook an education campaign to
train all the University and Medical Center supervisors and
managers on workers’ compensation, the benefits of the
Return to Work (RTW) program, and why it was important
for those managers to support RTW efforts for the best
outcomes for recovering employees. The workers’ comp team
also put a renewed emphasis on coordinating RTW efforts
with the various departments. The communication bridges
that were built enhanced the collaboration between the
employer and the claims team to facilitate modified duty
and RT W.
Intervening from the first report of injury, Loma Linda
takes a collaborative approach to claims management.
Claims adjusters, nurse case managers, and the RTW team
work as a unit to address the needs of the injured employee.
This approach yields a quicker return to work, faster claim
resolution, and a reduction in the overall cost of claims.
Additionally, when Loma Linda undertook this approach,
the open claim inventory was 743; we were ecstatic that
at the close of 2018 there were only 489 open claims.
Further, our deposit with the State dropped from
$35.1 million to $32.6 million.
As we looked at the impacts of nurse case management,
the benefits of the early intervention strategy became very
apparent as well:
· Nurse Case Management files that were referred within
seven days of the date of injury were closed to Case
Management within 56 days on average, versus over
180 days for files referred more than 30 days from the
date of injury.
· 96 percent of files referred to Nurse Case Management
within seven days of the date of injury achieved their
RTW goals at closure, versus 77 percent for files referred
more than 30 days from the date of injury.
· The 24-hour Nurse Advice line that directed employees
to self-care and first aid as appropriate, thus reducing total
claims exposure, led to a 14 percent reduction of new claims.
Additionally, the advice nurses set an expectation with the
injured employee and their treating physician from the
outset that the employee should not be written off work.
Rather, Loma Linda emphasizes RTW by asking
treaters to provide abilities and restrictions, if necessary,
for modified duty, which allow the employee to return
to work.
To measure the impact of Loma Lindas refocused claims
strategy, we evaluated claims at 2 years’ maturity. Much
like the rest of California, claims costs were on a steady rise
through 2014. Loma Linda University’s costs peaked in 2014
and have trended in a positive direction every year since.
Being involved from the first report of injury allows the
nurse case manager to immediately set the expectation with
the treating provider that Loma Linda is committed to
RTW efforts. The nurses who take the first report-of-injury
calls send the treating provider information on Loma Linda’s
approach to RTW, and make sure that the provider addresses
abilities, as well as restrictions, so the Loma Linda RTW
coordinators can place an injured employee in an alternate
duty position if they cannot be accommodated in their own
department. This early intervention approach also allows the
nurse case manager to collaborate with the treating provider
on a proactive, appropriate treatment plan to maximize the
injured worker’s progress toward recovery and maximum
medical improvement, reducing the expense of utilization
review by eliminating the need to review (and potentially
deny) unnecessary, inappropriate treatment.
Our experience at Loma Linda illustrates how partnering
with your vendor to develop a comprehensive program with
clear goals, guidelines for collaboration, and delineation
of responsibilities and interactions can produce dramatic
improvements in your injured workers’ recovery and return
to work.
Loma Linda University’s proactive and collaborative claims strategy paid off with
a dramatic decrease in Claims Duration
Versus the peak on 2014, Total Incurred Costs (Medical and Indemnity, including reserves
and case management costs) were reduced by 15% in 2015, another 27% in 2016, and are
trending down another 14% for 2017.
The average Indeminity cost per Lost-Time Claim was reduced from a high of $37,700 in
2014, to under $23,800 in 2016. A 37% decrease.
A utilization review program that
is incentivized to show savings
by denying care can ultimately
run counter to the long-term
goals of your organization.
14 EWC Magazine
When evaluating your workers’ compensation program,
bear in mind that no single change led to our program’s
success. Rather, we made many changes that worked in
concert with each other:
The claims team had to be educated and buy into the
concept of nurse case management and the value that
their clinical eyes could bring to helping resolve the claim.
· Clear parameters for the involvement of nurse case
managers needed to be set. Further, clear goals for each
file needed to be delineated and, barring any additional
complications, achievement of those goals should be
triggers for case closure.
· Corporate-wide, supervisors and managers had to be
trained on the benefits of RTW and modified duty, and
to be accepting of accommodating employees from other
departments in support of the organizations goal of
providing injured employees with work opportunities.
· The provider community had to be trained and
consistently communicated with that Loma Linda
wanted to accommodate every injured worker’s abilities
and restrictions. Providers were educated that it was the
doctors’ responsibility to outline the employees’ abilities
and restrictions, and it was the employer’s responsibility
to take the injured worker off work if they could not be
accommodated. This message was continually reinforced
by the 24-hour triage nurses taking the first reports of
injury, as well as by the nurse case managers assigned to
the claims.
· A utilization management program that is tightly
coordinated with the nurse case managers reduced
unnecessary delays in providing appropriate treatment,
thus assuring faster recovery and resolution of claims.
A utilization review program that is incentivized to show
savings by denying care can ultimately run counter to
the long-term goals of your organization. Make sure
your utilization review organization understands that
the emphasis should be on outcomes, and that they are
collaborating with your nurse case managers who see
the big picture.
Treating the whole person at Loma Linda University Medical
Centers requires a team approach. Recognizing that we
needed to treat the whole injured worker also required a
team approach.
Building a team among the claims department, the return-
to-work staff, our nurse case managers and our occupational
medicine providers within the Loma Linda Health System
resulted in better communication, collaboration, and
ultimately better outcomes for Loma Linda employees.
© 2018 ISO Claims Partners, Inc. Verisk Analytics and the Verisk Analytics logo are registered trademarks and Verisk and the Verisk logo are trademarks of Insurance
Services Office, Inc. ISO Claims Partners is a trademark of ISO Claims Partners, Inc. All other product or corporate names are trademarks or registered trademarks of their
respective companies. ca18088 (09/18)
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Medicare Set-Aside (MSA): A legal/medical approach to comply with requirements for future medicals
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ISO Claims Partners will help you fully comply— and protect your bottom line.
Thursday, March 19, 2020
Women’s Alliance
Friday, March 20, 2020
EWC Magazine16
The Nuts and Bolts
of Field Case Management
By Mollie Kallen, MS, CRC, CCM, President and CEO of MKCM, Inc
have been in the workers’ compensation case
management space for almost 30 years, and while
there are always a great deal of changes in our industry,
there are some basics that stay the same. It is always a
good time to examine the fundamentals of being a
successful field case manager. I call this the “nuts and
bolts” of case management—or Case Management 101.
In my career as a case manager, I have seen many other
case managers in my travels, and one can’t help but notice
different case management styles. Some of us come from
a nursing background, and others come from a more
vocational background. I believe that your educational and
practical framework truly shapes your case management style.
Here are my top five pointers for effective case management.
Basic Concept #1: Showing Up
Sounds simple, but many times I see case managers that
dont even bother to attend their appointments with the
injured worker. There is indeed a place for case management
by telephone, but if a file was assigned to you for field
management, then there is a good reason. You cannot
fully understand your client, physician and treatment plan
(especially if there are complicated issues, prior injuries,
noncompliance, etc.) without being there. The amount of
information that you glean from an expression and how
someone walks in and out of the appointment—all of these
things must be seen in person. This is the reason you were
assigned this case. Don’t underestimate the importance of
viewing everything and everyone with your own two eyes.
Basic Concept #2: Do Your Homework
It is crucial to review a file (as much as you have been given)
prior to your initial appointment with the injured worker
and to review the file each time before you go to a follow-
up appointment. We all are so busy that sometimes we let
something slide and this often is it. Knowing a client’s medical,
educational, and vocational history is crucial, as many times
a client forgets surgeries, diagnostics, physicians, etc. on the
initial intake form and when they speak with the doctor.
It is our job to fill in those gaps. Important information is
frequently left out (intentionally or unintentionally), and
this impacts the progress and outcome of the case. For more
complicated cases, I usually do a timeline; this assists the
physician, the adjuster and employer as well. Also, the more
you do your homework, the more prepared you are if a
deposition comes your way.
Basic Concept #3: Document, Document, Document
Every email, every phone call, every letter and every meeting
is documented. I use a dictating option on my phone
immediately after each activity in order to best capture billing
(another concept to come). I always get the name of the
person I am speaking or meeting with (first and last), as many
times things are forgotten or lost and having the name helps
enormously in tracking down issues. To effectively move your
case forward you need to think of yourself as the scribe of the
triage (account, employer, and client). It is our job to effectively
document everything that is happening in a case. There are
times, however, when there is sensitive information, and that
should not be documented. That warrants a phone call.
Basic Concept #4: Communication
and Scanning Applications
This is a key concept. If something occurs in the case,
then documenting it is just the first step and the crucial next
step is to communicate it. It does no good to observe and
document something yet fail to communicate it to all parties.
Email is a wonderful invention, and it has made our lives as
case managers so much easier. It is crucial to have either a
smartphone, iPad or laptop with you on the road. I am not
a fan of using these devices when you are with the client or
physician as that appears a bit intrusive, but accessing them
after or before the appointment is appropriate. Not only does
this give you the capability to effectively update all parties
in a timely manner, but it also decreases your workload by
eliminating the need to document and send information out
at a later time. It should also be mandatory that case managers
use scanning apps on their phones. This enables you to do
real-time updates and better capture your billing. It’s a win-win
for you and the customer. Technology is handy, but with that
being said, it is important to call people personally about a file.
Sometimes emails are misread, etc. and nothing substitutes
for a personal conversation.
Basic Concept #5: Know When To Close a File
This pointer is something that is not really taught to case
managers but is a crucial concept, especially for those of us who
are independent contractors and whose inventory is referral-
based and not contractual. There are times when field case
management is needed on a file, and there are times when your
role is minimal (injured worker is almost at maximum medical
improvement [MMI] and compliant).If the entire team is
working seamlessly and communicating effectively, then it
is your role as case manager to know when to recommend
file closure. So many referrals now are “task assignments,
referrals to field case management to accomplish a specific
task then closed (i.e., clarify major contributing cause, obtain
MMI rating, etc.). But if you have a case that is a full field
assignment, it is imperative that you self-identify when it is
appropriate to recommend file closure. It is cost effective for
the customer and shows your ethics and commitment to
honesty as well as ensures future referrals from a thankful
customer. All the cost savings documentation in the world
cannot outweigh the importance of dealing with your
customers in an honest and ethical manner.
As a case manager I am so proud to be a part of this
marvelous profession that keeps evolving in a positive
direction year by year. Case management is a crucial link
in workers’ compensation and in all other areas (geriatric
care management, hospital case management, etc.).
Do not lose sight of your pivotal role in assisting the lives
of so many others. J
If it’s a field case you’re working, that means you need to
be there – you can’t be effective if you’re handling a field
management case as a telephonic case.
Do your homework – review your medicals.
Document, document, document
(unless it’s sensitive information).
Scanning apps can be your friend, saving you time and money.
Know when it’s time to close a file – when there is no ROI
for your customer.
Last but not least: be ethical with everyone. Do the right
thing always even if it means owning a mistake.
18 EWC Magazine
Top 3 Traits of Superior Workers
Comp Claims Teams
By Rachel Fikes, VP & Work Comp Benchmarking Study Program Director, Rising Medical Solutions
and Peter Rousmaniere, Risk Management Consultant
or every injured worker, there is at least one claims
adjuster who is assigned to that persons claim.
Yet, despite the central role of claims adjusters,
very little is known in a meaningful way about what they
do. Most information collected about adjusting relates
to compliance with procedural rules and does not shed
light on the quality of their work. As a result, reliable
information about claims team performance, generally
or comparatively, has been scarce.
Now we have cumulative data of a five-year, 1,700 participant
survey project to shed light on what makes a claims team
– especially a superior one – tick. The annual Workers’
Compensation Benchmarking Study, founded in 2013 and
published by Rising Medical Solutions, pinpoints the three
key traits that make the top quarter of claims teams – as
measured by claims closure ratios – better than the rest.
Since the Studys onset, claims executives – the majority
of whom work for employers, insurers, and third-party
administrators – have been asked to rank in order of
importance the 10 core competencies most vital to
successful claims outcomes.
Survey participants have consistently ranked medical
management, disability/return-to-work (RTW)
management, and compensability investigations as
the top three capabilities most critical to claim outcomes.
Survey participants also define an “employee’s return to
the same or better pre-injury functional capabilities” as
the number one criterion for a good claims outcome.
This definition reflects a shift away from a more
compliance-based, reactive culture and toward a more
proactive, service-oriented approach. The 1,700-plus
survey respondents clearly say that this is the business
they are in.
However, there are striking stratifications in this
business” with higher performing claims teams outpacing
lower performers by factors of five, six, and 10 respectively
when it comes to measuring their performance within core
competencies, measuring claim outcomes based on evidence-
based treatment guidelines, and measuring claim outcomes
based on evidence-based disability duration guidelines.
For claims executives and system designers, higher
performers send a clear message: focus on and measure
key core competencies more in order to succeed.
Action Item: Strategically apply medical resources by
assessing claim risk factors and prescribing the best
interventions, particularly through the use of both
predictive and prescriptive analytics – something
higher performers use eight and three times more.
Action Item: Measure medical provider outcomes.
Specific examples include gauging provider performance
by average medical spend, average narcotic use, and average
number of temporary total disability (TTD) days, which
higher performers do five, six, and three times more than
lower performers.
Superior claims teams better equip and better capitalize
on their most important asset, their claims talent.
They arm adjusters with decision support tools known
to improve claims outcomes four to five times more
than lower performers.
Survey Question: Please rank in the order of highest priority
the core competencies most critical to claim outcomes, with
1 being the ‘highest priority’ and 10 being the ‘lower priority.
Source: 2017 Workers’ Compensation Benchmarking Study
20 EWC Magazine
Higher performers are also more engaged in developing
their claims staff. In response to the industry’s talent crisis,
higher performers are more likely to raise staff performance
expectations, spend money on training, and nurture mastery
in claims management. For instance, they invest in career-long
learning opportunities seven times more throughout their
adjusters’ employment.
Action Item: Build up the claims staffs soft skills.
The adjuster must listen, describe, assign, explain, and
negotiate. Currently, 42 percent and 32 percent of claims
organizations conduct communication skills and critical
thinking training for adjuster staff respectively. Top performers
are four times more likely to do so for both aptitudes.
Action Item: Adopt an advocacy-based
claims model, which is used by high performers at four
times the rate of lower performers. This employee-centric
approach is in stark contrast with the industrys adversarial
and compliance-focused methods of employee interaction.
Customer service-driven models around injury recovery
are a competitive advantage, both from a claims outcome
and a claims staff recruitment and retention perspective.
The most successful claims organizations are far more
likely to have higher IT budgets and engage in numerous
technology initiatives. Here are a few differentiators that
claims executives can act upon.
Action Item: Use a data warehouse to integrate claims,
medical bills, legal documents, case management files,
and numerous other data sources into a coherent display
of a claim. The day of searching for that bit of information
is gone. About half of all organizations use a data warehouse
today, and usage among high performers is five times the
rate of lower performers.
Action Item: Adjuster teams are more focused when
they use measurable claims outcomes. Do what 41 percent
of claims organizations teams do, and what top performers
do six to 10 times more: leverage various outcome-based
systems/data (e.g., evidence-based guidelines). This
finding confirms many informal impressions that the
average claims organization remains wedded to process
management as its key business endeavor, rather than
outcomes management.
Action Item: Like the leading claims teams, develop
integrated systems across multiple programs to generate
targeted medical interventions. Higher performers integrate
their claims system with their diagnostic testing and fraud/
abuse detection programs at four times the rate of lower
performers, and at five times the rate for their bill review,
evidence-based medicine, nurse case management, pharmacy
benefit management, predictive modeling, and utilization
management programs.
With only 24 percent of claims teams achieving top
performer status, what steps can the remaining 76 percent
take to advance their operations?
The data is clear. The best claims teams use an outcome
strategy, versus a process improvement strategy, for success.
As the industry moves forward, we can count on
employers being predominantly interested in outcomes.
Injured workers are only interested in outcomes – theirs.
For those claims teams that choose to close their
performance gap, the path to success is well-marked.
Rising Medical Solutions. (2018). How to Close the Claims Performance Gap.
Retrieved from
The best claims teams:
Measure outcomes.
Equip their claims talent to better influence outcomes.
Allocate more financial resources to outcome
management tools.
Finding the Right Fit
2018 SHRM/Globoforce Employee Recognition
Survey found that 47percent of the companies
polled see employee retention and turnover as
one of the top challenges they face.
As executives and
managers, it is our job to ensure that the employees we
hire not only stay with us but are successful.
I can recall an instance when I experienced this personally.
I was working for a third party administrator and the president
of the company called me into a meeting to discuss some of
my job duties.
During that meeting, he told me that I wasn’t the right
person for an assignment I was handling. I remember feeling
extremely deflated and wanting to crawl under a rock.
However, he went on to say that he saw many strengths
in me that would be beneficial to the company. Therefore,
they were going to restructure my duties to take advantage
of my skill sets. He explained that doing so would allow both
the company and me to excel. Because of the way he framed
the discussion, I went from feeling like a zero to a hero.
Focusing on an employee’s strengths, career growth, and
leadership development shows the employee that they are
valued and that their contributions matter to the organization.
Providing training and new opportunities for employees
expands his or her role, and encourages creativity, longevity,
loyalty, and pride in what they do.
Less than a year later I was promoted to head up the marketing
department, ran a monthly magazine and had many new
opportunities to take part in. I was given duties that frankly
I was afraid to accept because I didn’t have what I thought was
the right experience, but management saw something in me
and allowed me time to develop those skills. My mantra, when
given a new assignment or task, was “consider it done” even
if I had no clue what to do. Because the company believed
in me, I was confident I could figure out how to accomplish
each new task and made sure the result reflected well not only
on me but also on the company. J
Not every employee is going to be right for the job we
hire them for, but that doesn’t mean they aren’t right
for the company.
When reassigning an employee, don’t focus on the
negatives; instead, emphasize the positive aspects.
Employees who are mentored and trained feel valued,
which creates loyalty. This increases retention, reduces
turnover and the need for recruiting, and ultimately saves
time and money spent on onboarding.
By D. Diann Cohen, Vice President Client Relations, MacroPro, Inc.
SHRM/Globoforce Survey Reveals Human-Centered Approaches in the
Workplace Help Organizations Better Recruit and Retain Employees.(2018).
First-hand accounts of unlocking smart solutions to real-world challenges
EWC aimed high and took
flight with our 2019 conference,
Around the World in 80 Days,
held April 23, 2019, at The
Waterfront Beach Resort & Spa
in Huntington Beach, California.
This year’s conference saw an array of creative booth designs,
impressing attendees and adding to the excitement of our
event. Congratulations to all our sponsors and exhibitors on
their fantastic displays! And the Winner of the Best Booth
Award is…Macro-Pro!
Runner-up: Work Comp Resolutions
Runner-up: Parker & Irwin
24 EWC Magazine
To all who helped make EWC
Conference 2019 a smashing success,
from set-up volunteers to engaged
attendees, dynamic speakers, and
outstanding sponsors and exhibitors,
we say THANK YOU!
“Great conference and very well organized. This conference
has grown over the years and attracts attendees of all
levels. Looking forward to next year!Stacy Andreasen,
“One word… Extraordinary!
“Really had a lot packed into one day. A great value and use
of time spent networking, listening to subject matter experts
and talking to vendors who support the industry! Planning
on coming back!Judy Miller, Director of Risk Management
& Environmental Safety, Perris Union High School District
“Great atmosphere and content!
Very well put
together! You all
did a fantastic job
as always! Happy
that it will be moved
once again to a
larger place.
“It was my first time at the EWC conference and I really
enjoyed it. Got to meet great people and also learned
a lot from the speakers. I would really recommend the
EWC conference to my colleagues.
“The location was perfect and the weather cooperated
with the timing of the event. The speakers were all really
well prepared and informative.
There was
a lot of good
energy there.
was very
A perfect blend of great education, networking and industry information.
Mindfulness Principles
at Work
By Brenna Hampton, San Diego Office Managing Partner, Hanna Brophy LLP,
California State Bar Association Certified Legal Specialist in Workers’ Compensation
irst, an exercise: Are you breathing? I mean really
breathing. Try this: breathe in slowly through your
nose, counting to three. Feel your nostrils, lungs,
and stomach expand. Breathe out through your nose,
counting to five. Let any remaining breath go. Rest your
jaw muscles. Release your tongue from the roof of your
mouth. Unless youre reading this as a passenger in a
convertible, go ahead and open your jaw gently a couple
of times. Feel the strength of the front line of your neck
supporting this movement. Dip your chin to your chest.
Feel the strength of the muscles in the back of your neck.
Breathe in three, out five. When you breathe out longer
than you breathe in, your central nervous system
responds; this is a state of controlled relaxation.
The only thing you need to control right now is your breath:
Three in, five out. Three in, five out. Stretch your arms up to
extend the diaphragm, increase your lung capacity, and let your
whole belly fill. Stretch your legs, flex your toes, and release.
Appreciate the feeling of enhanced circulation throughout your
body. Tighten your abdomen and hold while you clench your
thighs and glutes, and curl your toes. Inhale deeply and let.
It. All. Go.
You are in control, simply by breathing. Nothing more is
required of you at this moment from anyone or anything.
You are your own island of resiliency and self-determination.
Mindfulness is the art of noticing, connecting, observing, and
reflecting on the experience that is your life. Focus on each of
your five senses and notice the little things. You are not your
thoughts. You do not need to engage, plan, or control each of
the thoughts you observe. You can find happiness watching a
child devour an ice cream cone without grabbing the cone from
him, right? The same concept applies here. Thoughts of people,
of work, of kids or family, of deadlines…let each of them float
past you. Identify the thought, observe it as a cloud moving
through the sky, but dont attach to it. There is no need to plan,
no need to fix anything right now.
The above exercise may be the simplest, but most difficult
personal challenge you undertake on a daily basis. This is an
excellent mental and physical exercise to ground yourself at any
time of the day. It’s a great exercise to escape anxiety without
26 EWC Magazine
completely ditching your responsibilities or breaking the
pocketbook. Like a good Kegel, no one will even know youre
doing it. Like a deep yawn, your calm, measured breathing
will be infectious to those around you on a subconscious level.
When you are centered, you radiate la pura vida.
As you go through your day, observe who and what is around
you. Notice your reactions to noises, cranky clients, controlling
bosses, beautiful nature, excited coworkers, the smell of
coffee…and notice when you are feeling overwhelmed. Come
back to your breath: three in, five out and put that song on
repeat. You are in control. You decide whether the experience is
a cloud floating by, or whether you will reach out and bring it
closer to prioritize it.
Physical relaxation is a precursor to mindfulness exercises.
Neurologically, your body and brain are connected. “You can
use your mind to change your brain to benefit your mind –
and everyone else” (Rick Hanson, Buddha’s Brain:
The Practical Neuroscience of Happiness, Love, and Wisdom).
So often we start the day off by checking social media,
sleepily responding to emails, and gulping down a caffeinated
beverage of choice before running off to a hectic day.
Put down the phone and start your day with a brief meditation.
The world will wait. Notice if staying more connected to
yourself leads to greater resiliency and self-control throughout
the day. Rinse. Repeat.
If you’re preoccupied with personal matters, it will be more
difficult for you to fully engage all of your senses within
the workplace. Engaging is vital because it allows you to be
mindfully proactive (acting deliberately and strategically) rather
than reactive (rushing when you dont anticipate a situation
brewing). When your attention is divided, you can only give so
much of yourself to each responsibility, and nothing gets your
best self. Everyone feels stretched thin at times. The world goes
on. Controlling your breath clears your head and put you in the
mindset to prioritize your responsibilities. There is always time
for what you want to do.
It is often true of good workers, and especially in the risk
management and insurance industry, that the reward for
doing good work is…more work! We are conditioned to have
a dopamine rush/reward response to new projects, claims or
puzzles to tackle. The external pressures placed on you by
management and your clients are met with internal pressure to
perform at a high level. As an esteemed colleague noted: every
day is a new fire drill.
Think of mindfulness training as an internal spreadsheet for
your brain full of if/then scenarios and pivot tables providing
myriad solutions to continually new challenges. Being mindful
and staying focused and alert to the little moments in life
and at work will train your brain so that when the situation
becomes chaotic and fraught with stress, your brain reverts to
this state of self-controlled focus. If you make it part of your
daily experience, you will notice a difference.
Being mindful will enable essential leadership skills, including
increased situational awareness. A strong leader pays attention
to the efforts and activities of their team in addition to their
own projects. To help your team meet their goals, you should
identify their challenges. You can only do this if you yourself
are calm and present enough to SEE your team and FEEL
the environmental pressures around them, to HEAR the
watercooler gossip and pay attention (not react), to TOUCH
the work and take in the quality that is being produced,
or missing.
Linguistic experts will tell you a second language can only
be learned to the extent you know a first language. It’s a skill
of acquisition, rather than creation (unless youre J.R.R. Tolkien).
By comparison between the two languages, we learn to express
similar concepts in different ways. Similarly, your insight and
ability to direct another persons work will match your ability
to understand and manage yourself. Managing others well
requires you to know yourself first. While it is easier to avoid
your own issues by focusing on those of your team, you are
doing a disservice to both of you if you fail to “put your mask
on first.”
“Stress-related health problems are responsible for up to
80 percent of visits to the doctor and account for the third
highest health care expenditures, behind only heart disease
and cancer. Mind-body practices like yoga and meditation
reduce your bodys stress response by strengthening your
relaxation response and lowering stress hormones like cortisol.
(“Now and Zen,” Longwood Seminars, 3/08/16).
Neurologically, the same area of your brain that focuses
during an emergency is activated when meditating, meaning
an anxiety trigger can be mitigated with mindful meditation
practices. “[Mindfulness] training for emergencies or for
military service is all about teaching the basal ganglia and other
brain structures to learn the automatic reactions needed to
survive” (Arnstern, Mazure, Sinha; Sci Am. 2012 Apr; 306(4):
48–53). When you meditate regularly, something akin to
muscle memory takes over. The same brain under pressure
has less activity in the frontal lobe and reduced stress hormones
like cortisol, enabling rational thought rather than panic –
greater peace of mind, just by breathing. No yoga pants or
man-bun required. J
Mindfulness is the practical art of noticing, connecting,
observing, and reflecting on the experience of your life.
In order to ensure your team meets its goals, you need to be
aware of their efforts and activities in addition to your own.
Being mindful and staying focused and alert to the little
moments in life and at work will train your brain so that
when the situation becomes chaotic and fraught with stress,
your brain reverts to this state of self-controlled focus.
28 EWC Magazine
Start your new job right:
Why you should strive to be likable
Contributed by TheBestIRS Blog Team
laims adjusters, do you want to make a good
impression at your new insurance job? Starting
a new position is both nerve-racking as well as
exciting, so it makes sense you want to make a solid first
impression. Besides knowing your insurance job like the
back of your hand, how else can you stand out for all the
right reasons? By being likable. Showing colleagues how
friendly of a peer you are is vital to your job, but why
does it matter?
You don’t get to redo your first impression
This is excellent advice for a claims adjuster or any new
employee because it’s the absolute truth. You only get one
chance at making a first impression at your job, so you need to
make it count. Be sure to offer a firm handshake, plenty of eye
contact, a friendly smile, and a clear introduction of your name.
It can also be helpful to ask questions in an effort to get to
know others. Maybe your new co-worker binge watches the
same show on Netflix or enjoys the same Thai restaurant you
love. Finding commonalities helps break the ice and build
an instant connection.
Being likable improves morale
Have you ever been in an office where co-workers cannot or
will not get along? It makes for a very awkward, tense and
unproductive day for everyone. By being likable right away,
you wont have to wonder whether you’ll be a nuisance or
an asset to the team. Having a positive, friendly attitude can
improve team morale, and it will make going to your job
every day that much more enjoyable.
You catch more flies with honey than vinegar
Reciprocity can work in your favor; if you are able to provide
a helping hand, others will be more likely to do the same for
you. If you’re known for being a likable claims adjuster, more
people will want to help you succeed. People want to help the
friendly co-worker complete his or her tasks. By being that
likable claims adjuster, you’ll get people behind you who can
assist, support and mentor you.
A manager will look upon a likable claims
adjuster more favorably than the adjuster’s peers
According to a blog from CareerBuilder, “Managers often view
workers who get along well with their colleagues in a positive
light.” Many of you might be wondering why that matters.
Work shouldnt be a popularity contest, right? While that may
be true, managers want a claims adjuster who can get along
well with others. They want a cohesive team that can get the
job done in a pleasant and positive way.
Don’t confuse likability with friendship
The biggest misconception with being likable at your
insurance job is that you need to make everyone your new
best friend, which isn’t true. If youre likable, it’s because youre
hardworking, respectful, and an all-around team player at
the office. However, that doesnt necessarily mean you’ll be
attending happy hour with everyone or inviting them to your
kids birthday party. Although, by being likable, you make for a
better work environment for every claims adjuster around you.
A positive attitude goes a long way
No one likes a “Negative Nelly.” Coming into work with a
smile and an encouraging attitude has a positive impact. Others
will notice and see you as a positive influence around the office,
and your positivity may even rub off on others. There are going
to be ups and downs in every job, but remaining upbeat and
composed makes you more pleasant to be around and reaffirms
that your manager can trust you not to complain or moan
when times get tough.
There are plenty of insurance jobs waiting for a likable claims
adjuster like you. So, adjusters, what are you waiting for?
Making a conscious effort to be likable isn’t always easy,
but it can truly impact your professional journey.
It will help you to build connections with peers and
mentors for years to come.
People will be more likely to help you.
It will impress your manager.
30 EWC Magazine
The Orchestrator:
How risk managers maintain an
effective return to work program
By Ken Hernandez, Managing Director at The Law Offices of Stacey L. Tokunaga
isk managers wear several hats while carrying
out their daily assignment to mitigate risk
for their agencies. In addressing workers
compensation claims, many risk managers perceive
their role as administering the provisions and
monitoring and enforcing compliance with the
state-mandated program.
To fully achieve the goals of workers’ compensation
claims management, risk managers must fully understand
and promote the goal of an injured worker’s expeditious
return to his usual and customary work as it serves the
best interests of injured workers, employers, and society.
Risk managers have a significant influence on the
outcomes and costs of workers’ compensation claims.
One of the greatest challenges faced by the risk manager
is the development of an effective Return to Work (RTW)
program and holding all parties involved accountable.
While risk managers may not control specific medical
interventions or benefit levels in their state or jurisdiction,
they must be familiar with multiple approaches to preventing
chronic or long-term disability, reducing the lengthy duration
of a small population of claims that represent the highest
costs in any workers’ compensation system.
Understanding the key roles and responsibilities of each
stakeholder in the workers’ compensation program and the
critical role each stakeholder plays is crucial to the development
of an effective RTW program. Therefore, it is incumbent upon
the risk manager to ensure that all stakeholders are adequately
trained and fully cognizant of the goal of the RTW program.
Continuous training and constant communication are
imperative to overcome the impediments to full reintegration
of injured workers.
There are many negative attitudes in society regarding
stakeholders and participants involved in the management
of an injury. Some are based strictly on perception and some
on reality. Risk managers must confront and resolve negative
perceptions to develop a system that prevents impairments from
becoming lifelong disabilities. Most injuries, however, do not
lead to lost time following medical treatment, and the worker
returns to his job prior to lost time. It is commonly known
that 15 to 20 percent of workers’ compensation claims
account for 80 to 90 percent of claims costs.
Injured workers are sometimes perceived as malingering,
not interested in returning to work or function, or even as
seeking fraudulent opportunities. The reality is the worker
often returns to function and work before the insurance carrier
is even aware of the injury. Workers in most cases receive
reduced compensation from the compensation or social systems
compared to their pre-injury wages and would rather return to
work at full pay. Risk managers, in collaboration with human
resources teams, must ensure that injured workers are actively
involved in the progression of their return to function and
proactively pursue early return to work to maintain or increase
earning capacity and ultimately improve their quality of life.
Unions are often seen as defending an injured worker’s
entitlement to compensation and resisting an early return to
work at the expense of the worker’s functional recovery. Many
times, lack of understanding of the workers’ compensation
system and lack of trust in the administrators leads union
leadership to inform members to seek legal representation.
These perceptions cause employers, insurance companies,
and co-workers to question the legitimacy of the impairment
and absence from work. This perception likewise extends to
modified duties that are legitimately associated with an RTW
plan. The reality is that when unions understand the inherent
benefits of Return to Work and Function, they can influence
and send a positive message to the injured worker
and co-workers they represent. Risk managers can foster trust
in the system by working with human resources departments
and union leadership to fully understand the workers’
compensation process.
Employers are sometimes perceived as uncaring and only
being interested in reducing insurance costs. Many employers
are reluctant to accept workers back to work until they are
100 percent recovered from their injuries. The reality is
that when employers understand the importance of and the
financial and non-financial benefits of keeping a trained,
valuable worker employed and re-integrating them into the
workplace, higher productivity, financial savings, and a
healthier work atmosphere can be achieved.
Caregivers can be perceived as unwilling participants in an
RTW program. Physicians, in particular, are bound by oath
to act in the interest of the injured worker and prevent further
harm to the individual. Caregivers often do not associate an
effective RTW program as being an integral part of the healing
process and restoration of the individual to maximum function.
In reality, most caregivers want the injured worker to return to
function, and with a better understanding of the benefits of a
successful RTW program, caregivers are in a pivotal position
to begin that process with the injured worker.
Insurance companies are often perceived as being interested
in profitability at the expense of the well-being of the injured
worker. Closure of claims in the interest of capping insurance
costs as opposed to an effective return to function is seen as the
primary objective of the carrier. In reality, the expedient return
of an injured worker through a robust claims management
process where communication with all parties is critical can
keep caseloads down and improve intrinsic relationships with
employers, workers, providers, and others in the system.
Attorneys pledge to represent the best interests of their
clients which could be injured workers, insurance companies,
or employers. Attorneys who represent injured workers are
perceived as being more concerned with the highest dollar value
of a claim settlement than supporting RTW for their client.
They can also be perceived as drivers of government disability
insurance claims such as Social Security Disability (SSDI) in
the United States. Those who represent insurance companies or
employers can be perceived as striving to avoid claim costs by
denying the claim or medical interventions. In reality, attorneys
play a significant role in supporting and advocating RTW
since they counsel injured workers, insurance companies, and
employers when there is a dispute. Collectively, attorneys from
both sides of the aisle should embrace the RTW mantra to the
benefit of all stakeholders.
Regulators and legislators are often seen as being disinterested
in return to function and as responsible for a compensation
system that focuses on cost reduction over balancing the
needs of the injured worker and policyholder. Partisanship
and re-election are viewed as taking precedence over the well-
being of society as a whole. The reality is that regulators should
care about creating fair systems that meet the needs of all
stakeholders but most importantly, those of the injured worker
and employer. The regulatory and legislative frameworks,
however, do not often support this effort.
Whether perception or reality, the resolution of these issues
is critical to adopting a collaborative approach to a Return to
Work and Return to Function program. Full integration of
the injured person can only be possible when the participants
commit to the restoration of the health and function of the
injured person. Risk managers must orchestrate the integration
of the respective roles and responsibilities of all stakeholders
to ensure an effective Return to Work and Function program.
Continuous progress in learning, training, and communication
between all stakeholders are the keys to overcoming the barriers
to an effective integration process. J
A good RTW program benefits the injured worker,
employer, and society.
Risk managers are the orchestrators in the RTW program.
Stakeholders must be thoroughly educated on their roles
in and the goals of the program.
Risk managers must decipher perception versus reality
to facilitate change.
Full integration of the injured
person can only be possible when
the participants commit to the
restoration of the health and
function of the injured person.
32 EWC Magazine
Will the real ERM
please stand up?
By David B. Dolnick, President, Dolnick Risk Advisors
ne of the questions I often ask new
practitioners in the workers’ compensation
field is, “What do you think this industry is
all about?” I get the occasional blank stare, but the vast
majority of people entering workers’ compensation
give me one of two answers. The first is some version
of, “It‘s part of the insurance industry.” True enough
for some of us in this business, but not for all.
The second is along the lines of, “We are how workers
who get hurt on the job get medical care and disability
payments.” This is also accurate, but still not entirely
complete. As most of us with years of experience in the
industry will attest, workers’ compensation is a very
complex and sometimes profoundly intricate field.
In the broader picture, though, workers’ compensation
and all of its different activities and specialties is the
primary mechanism by which employers manage the risk
of employment-related injuries or illnesses. That, in turn,
is part of the broader effort that businesses engage in, that
of managing their risks. Many of you have, no doubt, heard
the term “Enterprise Risk Management” (ERM), which
describes a broad-based approach to managing business
risk. The concept has been around for a long time; the basic
terms and tenets of ERM were first formalized in 2004,
but it recently received some heightened attention when
the International Standards Organization (ISO) issued an
extensive update to their documents describing the process.
Over the years, it has proven to be a highly scalable and
flexible management process which helps a business recognize
and deal with the core risks of conducting its operations.
Another international organization, the Risk and Insurance
Management Society, has also devoted much effort to helping
businesses work with ERM, publishing a Risk Maturity
Model which helps assess how far along an organization
is in implementing ERM. Despite all this international
attention, however, a different meaning has begun to grow and
gather momentum in response to some of ERM’s perceived
shortcomings. Primary among those, the erection of a process
alone is not sufficient to ensure success in the effort. Success
also depends on how that process is implemented, and that’s
where we all have an interest in how this impacts our industry.
For most medium-to-large scale businesses, workers’
compensation is a major expense. The risks of employee
injury are significant for almost all companies, and for some,
especially those in heavier industries like construction or
agriculture, workers’ compensation is among their largest
expenses behind labor and materials costs. That is undoubtedly
true of many public sector employers as well. No organization
can function long without controlling the occurrence and
the costs of employee injury. Many studies have documented
that unsafe employers have higher levels of turnover and lower
levels of productivity than do similar ventures who are better
at controlling those risks. ERM provides a robust method
of integrating a business’s efforts at accident prevention and
injury/illness management with all the other risks that need to
be addressed; that’s what makes ERM so important to all of
us. The companies that are implementing ERM are our clients,
our vendors, our insurers, or our brokers. Their businesses
range from agriculture to health care, and if you haven’t run
into a business that’s implementing some form of ERM, you
likely soon will.
There are, however, some in the risk management community
who feel that ERM itself does not go far enough, and that
merely establishing a series of internal steps and procedures will
not in and of itself be about the kinds of activities and behaviors
that help an organization fully embrace and manage its risks.
Traditional ERM involves a structured set of internal controls
and a formal process of identifying, assessing, and treating
business risks, and a formal mechanism for tracking those
steps (usually called a risk register). While those are all well
recognized and sound management practices, a growing body
of risk managers are coming to believe that, by itself, ERM
is not enough. While there isn’t a consensus on terminology,
a newer meaning for ERM is taking root, and to many,
the phrase now refers to “Embedding Risk Management.
The key position these risk professionals advocate is that an
organization must fully embed the processes and principles
of risk management to fully realize the potential of ERM,
and that the application of risk management practices must
become second nature to all decision-makers at all levels of a
company. This, they point out, is far more than a structural
activity, and requires a broader range of tools and training. It
also will typically require distribution of authority and decision
making, something that not all organizations are comfortable
So, what does all this have to do with us, the workers comp
professionals trying to make sense of all that is happening
around us? Let me approach answering that by asking a
question in turn: Would you like to reduce the frictions in our
industry, along with reducing the sheer number of employees
who need to use the workers’ compensation system every year?
I have not met many people who do not want to reduce the
number or severity of workers’ comp injuries. Most of us would
be delighted to see fewer employees enter the system every year,
or to see those who file claims travel a smoother path toward
resolution and a return to employment if possible. Despite our
best efforts, however, occupational injuries continue to occur,
and while our friends and colleagues in the safety profession
have made great strides in preventing accidents, we all have
much work still before us, and we dont appear to be in any
danger of closing our industry down for lack of work anytime
soon. We have made great strides in protecting workers in
the last century, but the pace of change in industry makes
further improvement mandatory if we are to keep up. Thus,
a new push toward the recent take on ERM, embedding risk
management, may provide us with some of the answers we
need to help keep people safe and uninjured, and to help them
recover more rapidly and effectively if an occupational illness
or injury occurs. Improving an organizations ability to prevent
suffering is never a bad activity, nor is helping it develop more
effective methods of dealing with the problems of recovering
employees and bringing them back into the workforce, and
that is the potential that embedding risk management, “the
other ERM,” offers.
If you would like to know more about the two different
meanings of ERM, a pair of expert and experienced risk
managers, Alexey Sidorenko (Алексей Сидоренко) and
Chris Mandel, released a YouTube video of their discussion,
viewable at Mr. Sidorenko
is a recognized expert in risk management, with experience
in private equity and sovereign wealth fund risk management
in Australia, Poland, Kazakhstan, and Russia, and specializes
in integrating risk management into strategic and investment
planning. He is a widely published author and public speaker
and created Risk-Academy in 2012 to provide training in the
field. Mr. Mandel is a internationally known US-based risk
management expert and thought leader in the field of enterprise
risk management. He was selected as Risk Manager of the Year
in 2004 and has served as president of the Risk and Insurance
Management Society, and many years on that organizations
Board of Directors. J
Simply performing the tasks associated with risk management
isn’t enough in today’s nimble and competitive business
Risk management needs to become embedded as part of an
organization’s culture and should be core component of all
business decisions.
Embedding risk management into an organization’s culture is
time consuming and difficult, but ultimately more effective in
overcoming the challenges a business will face.
34 EWC Magazine
Keeping up with changes in orthopedic surgery
Platelet Rich Plasma
and Stem Cells
By Gary Brazina, MD, FACS, FAAOS, Diplomate, American Board of Orthopedic Surgery
he science of orthopedic surgery and the treatment
of early osteoarthritis as well as soft tissue injuries
is rapidly changing. The goals and trend today
remain how to preserve and rejuvenate articular cartilage
to prevent or delay the need for total joint replacement.
Articular cartilage is the smooth, glistening, white surface
at the ends of bones that allows motion in joints. Articular
cartilage has no blood supply and therefore relies on joint
fluid for its nutrients. Arthritis is the roughening or wear
of this cartilage surface which is caused by trauma, overuse,
joint instability, and some metabolic conditions.
Orthobiologics in Use
The use of platelet rich plasma (PRP) and mesenchymal stem
cells (MSCs) is now more widely accepted as an alternative to
early surgery and has grown in popularity for the treatment of
early osteoarthritis, especially in the knee and hip joint and in
certain difficult soft tissue overuse syndromes such as tennis
elbow, Achilles tendonitis, and hamstring tears.
While acceptance in the orthopedic community has
proliferated, insurance carriers and especially workers’
compensation carriers have been reluctant to accept and
authorize the use of these new “biologic” modalities.
Research has exploded over the past several years looking
into the role of these agents and the makeup, usage,
actions, and advantages and disadvantages of each.
Platelet Rich Plasma
Platelets are a part of the white blood cells and are most often
thought of as helping in clotting and found in the serum
of blood. Platelets contain several protein growth factors in
high concentrations that can turn these platelet cells into
polymorphic cells that can form muscle, cartilage or bone.
We have yet to discover the exact molecule responsible for
this growth factor and ability to morph into different tissue.
The platelets are easily harvested in an office setting.
The physician draws blood from the patient and then spins
the blood in a centrifuge to separate the red cells from the
white cells. For intra-articular injections, the white cells are
then filtered to separate the white cells from the platelets.
The platelets are then easily injected in the knee, shoulder
or hip.
Following the injection, the patient may leave the office.
The use of anti-inflammatory agents such as aspirin,
Motrin or Naprosyn is prohibited in the first two weeks; and
we recommend no vigorous exercise or stress on the joint for
two weeks. The patient can get a flair reaction with swelling
and pain for several days, which is managed by ice and Tylenol,
but this is not common. Usually, the patient can return to work
within 48 hours, and heavy work within one to two weeks.
Most patients begin to feel improvement at about six weeks
and continued improvement over the next six to 12 months.
The cost of this treatment in office is approximately $1,500.
Mesenchymal Stem Cells
Mesenchymal stem cells are another type of cell that has the
potential to transform into a variety of cell types including
bone, muscle and cartilage. The two most common sources
for the cells are adipose tissue (fat) and bone marrow.
In our center, we have found adipose harvesting easiest and
is an abundant source of MSCs. We use a plastic surgeon to
harvest a patient’s adipose (fat) cells in an operating room
setting, much like doing a mini liposuction procedure.
The patient’s own harvested fat cells are then centrifuged to
obtain the “buffy layer” of stem cells, filtered and then injected
into the affected joint by the orthopedic specialist.
Stem cells from bone marrow are harvested much like a bone
marrow transplant. In a sterile operating room environment
using a small incision and a special needle-like tool, the bone
marrow is harvested from the patient. Again, it is centrifuged,
filtered and injected into the patient’s joint. The same post-
operative precautions are used.
Because of the more invasive nature of these two methods,
there are possible risks of complications including infection at
the donor sites. However, using the patient’s own cells creates
a safe acceptance rate and no rejection of the cells because the
procedures are using the patient’s own cells.
Viscoelastic Supplementation
Hyaluronic acid (HA) is considered the “building block” to
nourish the cartilage surface. Natural and synthetic HA (such
as Synvisc, Supartz, Hylgan et al.) is given to patients as an
injection into the joints to try rejuvenating and repairing the
articular surface.
Recently most insurance companies, including Medicare
and worker’s compensation, have stopped authorizing this
procedure which typically costs $750-$1,000 for the substrate
and the physician office fee for between one and five injections.
Chorionic Stem Cells
Many companies are marketing commercially harvested
chorionic stem cells taken from placental tissue. There is very
little research to support the use of this modality and is not
approved as yet by the FDA. Since the source of the cells and
the process used to harvest and preserve these cells are not well
defined, I have been reticent to utilize this method until more
research is available.
The Research
The number of research and peer-reviewed articles has gone
from one in 2001 to 1,500 studies in 2018. The research
is trying to uncover the exact protein that promotes the
polymorphic potential of these cells. Many studies are now
underway to compare and contrast different methods and even
the use of a combination of both MSCs and HA.
The Journal of Arthroscopy in 2017 published an article
comparing HA to PRP and found no difference at six months
but significant improvement at one year post-injection in the
PRP group.
The findings of the research have led to the conclusions
that the use of orthobiologics are:
· Safe (there have been no serious complications in
all the subjects studied), and
· Most effective in patients with normal BMI, under
50 years old, and with early stage osteoarthritis.
The management of the patient’s expectations
remains essential.
Orthobiologics in the WC Setting
Approval through UR is spotty at best. There is no mention
of orthobiologics, PRP or stem cells in MTUS and ACOEM
guidelines. The Official Disability Guidelines does cite articles
and recommends the use of PRP in patients with symptomatic
early to moderate osteoarthritis who have failed a conservative
course of treatment including NSAIDs, physical therapy, and
other modalities. J
The uses of PRP and stem cell preparations are extremely
promising, cost-effective and safe.
More research is needed to refine techniques and help
isolate the active growth factors in the platelets and stem
cells which can increase the ability of these cells to morph
into bone, cartilage, muscle and hopefully nerves. Research
is needed to explore the use of systemic stem cells in the
treatment of autoimmune-type diseases and even complex
regional pain syndrome.
We as an industry must increase monitoring of the supposed
“stem cell centers” who want to ride the wave of popularity
to use them only as a profit center, at inflated prices. As a
specialty, we must instead incorporate fact-based science to
provide quality and expert treatment protocols to achieve
success in returning function to injured workers.
The Independent
Bill Review System
Part 1 of a 2-part series
By Paul C. Herman and Aidan P. McShane, Law Offices Paul C. Herman
ere it is, the most dreaded topic: bills, invoices
and liens. In this article, we provide information
and timeframes mandated by Senate Bill (SB)
863 to combat and control the cost services provided
post January 1, 2013.
With SB 863, the Legislature removed much of the decision-
making process on med-legal invoice dispute issues from judges
and put it in the hands of independent experts. That legislation
is Independent Bill Review (IBR), a process by which a bill
review expert examines fee disputes.
The IBR structure controls the submission and response
to all medical and med-legal billing. However, IBR is only
applicable where 1) services were provided on or after
January 1, 2013, and 2) the only issue left to be determined
is the value of services. IBR does not apply to services where
there is no fee schedule. IBR does not address any threshold
issues related to lien resolution. These threshold issues include
but are not limited to whether services were preauthorized,
liens were properly filed, or if there are defenses like
Statute of Limitations. Once the WCAB decides upon
threshold issues, the disputed balance is processed
through IBR.
Two types of services are submitted to IBR: Med-Legal
Costs and Treatment Expenses. Each service is processed
differently. In this article, we will be focusing on Med-
Legal Costs.
Per Labor Code §4620(a): “a medical-legal expense…may
include X-rays, laboratory fees, other diagnostic tests, medical
reports, medical records, medical testimony, and…interpreter’s
fees …for the purpose of proving or disproving a contested claim.
All other charges (medical, surgical, chiropractic, durable
medical equipment, interpreter, home health care,
etc.) are Medical Treatment Expenses.
If a dispute is only to the proper amount payable per the fee
schedule, then the dispute must go through IBR. (LC 9794)
The process begins with a service provider serving a
completed bill/invoice to an adjuster, with supporting evidence,
such as a medical report, photocopy orders, or proof of
attendance by an interpreter with the certification number.
Thereafter, Defendants must object or pay within 60 days.
Objections must be on the Defendant’s Explanation of
Review (EOR). Any services that are not objected to must
be paid in full.
Within 90 days from the Defendant’s service of the EOR,
the service provider may contest the EOR and request a
second review.
The Defendant then has 14 days from the request for a
second review to respond with a final written determination.
Any services not objected to in the final written
determination are payable within 21 days.
At this point, the second review is completed.
After the Defendant has submitted its final written
determinations from the second review of the submitted bill/
invoice, the service provider has 30 days to object or respond.
If the service provider’s only issue is the amount paid per the
applicable fee schedule, the service provider may request IBR.
The service provider must pay the IBR fees up front.
At this time, the disputed bill/invoice is reviewed and
analyzed by an independent bill review expert. Upon the
completion of the review, the bill review expert issues his
or her findings. The following are the options:
1. If it is found that the Defendant owes more money, then
the Defendant shall pay the additional amounts and
reimburse the IBR fees advanced by the service provider.
2. If the report determines the employer prevails, then the
employer owes nothing further.
IMPORTANT! If any of the foregoing deadlines are missed,
then the consequences are as follows:
1. If the service provider fails to timely comply with its
obligations, the bills submitted are deemed paid and neither
Applicant nor Defendant are liable for anything further.
2. If the employer fails to timely comply with a deadline,
then the full amount is payable, along with interest and fees.
If the med-legal dispute is about anything other than the
application of the fee schedule, then that issue must be
determined through the Non-IBR system. (LC 9794 and
CCR 10451.1(c).)
The Non-IBR system is processed as follows:
1. Service provider submits billing with information
validating the invoice.
2. Defendant has 60 days from receipt to pay any uncontested
services and to object by way of EOR, with supporting
evidence of those services which are disputed.
36 EWC Magazine
3. Service provider now has 90 days to
object to the EOR.
4. If the provider’s objection is timely
and not based on just the amount
per fee schedule, then the Defendant
must file a Petition for Determination
of Non-IBR Medical-Legal Dispute
and a DOR, with Proof of Service,
within 60 days.
5. Defendant’s failure to timely respond
is a waiver of all objections to that
provider’s billing, except as to the issue
of the amount.
6. If the employer does not proceed
with Step 5 above, then the service
provider may file the Petition for
Determination of Non-IBR
Medical-Legal Dispute.
The service provider does
not need to file a DOR.
At this point, the matter will be
submitted to the WCAB for
determination of the noncost-related
threshold issues. The WCJ has the option
to defer until the case-in-chief is ready to
be heard in the interest of judicial economy.
Once those are decided and only disputes
regarding amounts remain, then the
parties return to and begin the IBR
process as initially described.
Timely compliance with the IBR deadlines is mandatory
for the submission of all bills and failure is accompanied
by severe consequences.
This is an adjuster-driven system and will require adjusters
to carefully and timely consider all bills and invoices
submitted. They can no longer be relegated to the end
of the case-in-chief.
38 EWC Magazine
Name a person who has had a
tremendous impact on you as a
leader or mentor. Why and how
did this person impact you?
One person who stands out is
Ilse Spivack, retired Risk Manager
of the L’Ermitage Hotel Group.
Ilse introduced me to the world of
workers’ compensation and liability
claims. She taught me to think “out of the box” when managing
workers’ compensation, and encouraged my continuous
education to further my success in this field. I learned from
her that, in any profession, the keys to success are: to be
truthful, to take responsibility, to show compassion, and
to help others. She inspired me to have courage and
determination, especially during challenging times.
What are 3 words to describe Technicolor?
Innovative: At Technicolor, there is a passion for innovation;
some of the most vibrant and talented people work very hard
uniting artistry with technology to create the most amazing
entertainment experiences for audiences.
Creative: Technicolor’s award-winning creative talent
empowers storytellers to bring their artistic visions to life
throughout the entertainment industry, spanning motion
pictures, episodic television, animation, games, and
commercial advertising.
Dedicated: Technicolor’s dedication has built a legacy of
historic contributions to film and television for more than
100 years – making it only the second company to be
honored by the Hollywood Chamber of Commerce with
a “Star of Recognition.
What is your proudest moment at your company?
My proudest moment is becoming a U.S. Workers’
Compensation Manager at Technicolor because it gave
me an opportunity to grow personally and professionally.
It has allowed me to serve as Environmental, Health &
Safety Co-auditor when visiting manufacturing plants and
other subsidiaries of Technicolor throughout the U.S.,
Mexico, and Brazil. This experience gave me the opportunity
to learn Portuguese and facilitate communication and
understanding of other cultures while co-auditing in
São Paulo and Manaus, Brazil.
What do you do for fun?
In my free time, I enjoy going to the theater, reading –
and I also make custom jewelry!
Maritza can be reached at
and at (818) 260-2623.
Visit Technicolor at:
U.S. Workers’ Compensation Manager
Technicolor U.S.A, Inc.
In the
Industry leaders answer our most searching questions.
Manager, Workers’ Compensation
The Cheesecake Factory
Name a person who has had a
tremendous impact on you as
a leader or mentor.
Kurt Leisure, VP of Risk for
The Cheesecake Factory, is someone
I would like to emulate. Not only does
he serve as my boss but he has become
a loyal friend who has extended an
amazing mentorship program to me.
One of the most valuable lessons I have learned from him as a
mentor is to avoid complacency, as it only promotes mediocracy.
I believe the reason we have come so far with our program is due
to Kurt’s resilience and commitment to always being ahead of
the game. His teachings are strategically inclined and promote
progressive thinking. Kurt is always pushing for the next great
thing. We have implemented successful programs together,
and we intend to change the world of risk one day at a time.
What is one characteristic that you believe every
leader should possess?
Integrity. A leader who takes the fall when things go awry is
honored more than a leader who is quick to take credit for
someone else’s successes.
What is one mistake you witness leaders making
more frequently than others?
Entitlement. Professionals who take on a leadership role feel
entitled to demand respect but I have learned that respect
has to be earned.
What is your most significant achievement to date
professionally or personally?
To have been able to run a successful nationwide workers’
compensation program and being afforded the proper tools to
do so. Our litigation rate is at an all-time low of 1.8 percent. I
would not have been able to accomplish this if it wasn’t for the
fantastic teams and partnerships I have cultivated during my
career. The year 2019 will be about how we can we exceed past
accomplishments and create new ones.
Luis can be reached at
and at (818) 871-8372.
Carls Corner By Carl Van, ITP
As a workers’ compensation claims professional, you often
have to deliver bad news. You have to say “no” for
many different reasons: “There is no pain and suffering
consideration;” “There is no reimbursement for finance charges
on medical bills;” and more. Dont shy away from delivering
bad news. You are in the customer service business and even
relaying disappointing news is an opportunity to have an
impact on the customer. It’s all in how you control and deliver
the information. As a professional, this is when you strategize
and prepare your message.
Delivering bad news is the perfect time to express empathy
with a short and clear empathic statement. This gesture
demonstrates you are a human being and you understand
the injured worker is, too. Who knows – show a little
empathy and you might even get a “Thank You” at the end
of the conversation.
When explaining the reasons for rejection or denial to the
injured worker, never say “but” and debate the reason. Remove
the “but.” When delivering bad news, take extra care to say
and,” not “but,” in the sentence. Saying “but” removes the
positive impact from the front of the sentence and shifts the
focus to the negative. “Leading with the positive” still delivers
the necessary bad news to the injured worker and helps the
injured worker see you are working for their benefit.
Just like when you are on the receiving end of bad news,
the injured worker also has a right to how they feel. During
the negotiation process, the injured worker may respond
when you deliver the news. Don’t consider this an attack on
you or a reason to argue. Listen carefully to the injured worker
and take this as a gift. For example, you tell the injured
worker you can’t pay for their claim whether in part or in full,
and they respond, “Oh, that’s lousy” or “That really stinks.
There’s your gift. That response tells you that, even though
they dont like the news, they believe you and understand what
you just said. Here is your opportunity to express empathy,
which will help mend the wound.
Great negotiators use their skill in delivering bad news to their
customers and keep the negotiation moving along to closure.
We’ve all heard the phrase, “never bid against yourself.” For
the most part, that’s accurate. There is, however, an exception.
Great claims negotiators know you can bid against yourself as
long as you stay in your conversation (see “Negotiation Tips,
EWC Magazine Winter 2019). “Staying in your conversation
means you negotiate by starting at your offer of $5,000,
increasing it to $5,500, then increasing it to $5,750, rather than
wasting your time trying to bring an injured worker down from
their demand of $50,000.
You can bid against yourself all day, as long as you and the
injured worker stay in your conversation. Your conversation is
your value of the claim, and that’s where you want to be.
Just like with humor, timing is everything. During
negotiation, many workers’ compensation claims professionals
will increase their offer when the other side has made a valid
argument. We hear this all the time while monitoring claims
phone calls. An injured worker or other party makes a good
point, and the next thing the claims adjuster says is, “Okay,
let me increase the offer,” or the dreaded, “Let me throw in a
little bit of money.” This is the wrong time to increase the offer.
This practice conditions an injured worker to believe that
every time they make a good point, you are going to reward
them with more money. Think about a pet you trained by
giving them a treat to reinforce the behavior you wanted
them to continue. If you “reward” an injured worker with
an increased offer when they make a point, what are you
training them to do? Make more points.
The best time to increase your offer is once you’ve
demonstrated to an injured worker that you shouldnt have
to raise your offer. The powerful concept here is to show an
injured worker that your offer is already fair – then you can
increase it. Consider this example:
Delivering Bad News When Negotiating
In part two of a three-part series, Carl talks
about saying the right things at the right time.
Great negotiators use their skill
in delivering bad news to their
customers and keep the
negotiation moving along to closure.
“Mr. Smith, if you believe your case is worth more than the
$32,000 I mentioned because you lost some potential job
opportunities and you might have to have an additional
surgery later, I understand that. In fact, those were both
heavily considered in this evaluation along with your disability
rating. So, based on what you just said, I am even more convinced
that the $32,000 figure is fair. However, to be exceptionally fair to
you, I am going to increase the figure to $34,000.
Skilled claims negotiators know this timing is vital because it
makes an injured worker feel you have made a concession and
are being extraordinarily fair. When making the increased
offer, it is essential you make it sound like a concession for you,
instead of a “win” for an injured worker. A “win” for an injured
worker would tempt some injured workers to continue pushing
for increases. Remember: timing is everything.
Many times in workers’ compensation claims, you are
negotiating merely for a response from a customer. Here
are four examples of things we often hear while monitoring
phone calls, which can have the opposite effect from what is
intended. We will look at the pitfalls with certain words
and propose options with the best wording so you can
excel with your customers.
To encourage an injured worker to be patient:
What the adjuster says: Sir, youre going to have to be patient.
What the customer hears: Sir, since I’m not taking your
situation seriously, and I’m overworked and don’t have the
time necessary to do a good job for you, youre going to have
to be patient.
What the adjuster should say: Sir, I understand the need
to get this claim resolved promptly and efficiently for you.
I will do everything I can to keep it moving.
To encourage an injured worker to trust you:
What the adjuster says: “Ma’am, youre going to have to trust
me on this.
What the customer hears: “Ma’am, I have no reason for the
things I do or say. If I did, I would explain them to you in a
way you could understand. So, question everything I tell you.
And for heaven’s sake, DON’T TRUST ME.
What the adjuster should say: “Ma’am, you have every right
to question the process. You, like me, want to make sure you get
everything you are entitled to receive. I’ll do my best to make
things clear.
To encourage an injured worker to calm down:
What the adjuster says: Sir, I don’t know if there is any
reason to get excited over this.
What the customer hears: Sir, you have no reason for your
actions, and your feelings have no value. What a hysterical
moron you are.
What the adjuster should say: Sir, I can understand why
youre frustrated. Let me see if I can help.
To encourage an injured worker to be reasonable:
What the adjuster says: “Ma’am, youre going to have to be
reasonable about this.
What the customer hears: “Ma’am, you are an unreasonable
person. I’m going to make you change your mind. And when you
do, youll be proving that I was right for calling you unreasonable.
What the adjuster should say: “Ma’am, I understand your
points. You are obviously a reasonable person. You are entitled
to an explanation, and I’d like to provide that to you now.
You control your own behavior and how you speak to your
customers. On the flip side, your customers have a right to
how they feel. So, whether its asking an injured worker to be
reasonable, to be patient, to trust you more, or to calm down,
say it in a manner that shows respect and moves the claims
process forward. J
40 EWC Magazine
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