4-10-2018; Can You/Should You Stay in Touch with an Injured Worker? What If They Have Counsel?; Understanding UR or Utilization Review in Workers’ Comp and more

Synopsis: Can You/Should You Stay in Touch with an Injured Worker? What If They Have Counsel?

Editor’s comment: We were asked this question by a valued reader and wanted to expand our thoughts and recommendations.

Please note when you have any workers’ comp claim, a natural tendency is to avoid your employee—we feel all employers should actually do the opposite.

Never, ever trust the workers’ compensation system to work in your best interests in a work comp claim.

Other than for accrued vacation time, we feel you need to have a strong HR policy to tell all workers and their supervisors to stay in close contact on at least a weekly basis. Other than vacations, we feel this applies to any and all PTO, WC or other lost time.

Don’t let anyone “disappear” from sight. Someone out on work comp or sick leave may want to get away from you and do their best to vanish while still getting paid and accruing other benefits. Whenever we see a worker off work for months or years, it almost always seems like they have vanished from sight of the employer—don’t fall into that trap.

We are asked all the time—what if the worker has counsel? Isn’t there an “ethical” restriction on staying in touch and talking to such a worker? Well, there is an ethical restriction on me and anyone who is a licensed lawyer, when the worker has their own counsel. Before I can talk to a represented worker, I have to have prior approval from their attorney and/or have the attorney on the call/conversation.

That doesn’t apply to most managers or co-workers who aren’t lawyers. You can and should tell your workers you are going to call them or they are going to accept the call or call you back in a timely fashion. If you don’t hear from them at all, you then need to decide what is best for you and your company. In our view, you can and should consider cutting off TTD and other benefits to insure you are receiving regular communication.

What Can and Should You Discuss With an Injured Worker Who is Out on Benefits?

When you talk with the injured employee, never, ever encourage them to terminate their counsel or drop their claim. We are certain if you make this claims mistake you may be fired or at least receive a challenging call from Claimant’s counsel. We also feel you should stay away from any discussions of settlement.

When you or your team talk to a represented claimant, we feel you can and should check to insure

*        Reasonable, necessary and related medical bills are being paid

*        The worker is receiving TTD/TPD or disability checks

*        The worker is happy with medical care

*        The worker is progressing along expected medical recovery path

*        Where appropriate, let them know their job is waiting

If you need help with drafting/implementing a personnel policy to maintain regular contact with all workers out on work comp and other leave, send a reply.

We appreciate your thoughts and comments. Please post them on our award-winning blog.

Synopsis: Understanding UR or Utilization Review in Workers’ Comp.

Editor’s comment: Utilization review (UR) can and should regularly be engaged by employers, insurance carriers and TPA’s to dispute reasonableness and necessity of medical treatment and lost time. (Sec. 8.7 of the IL WC Act). This concept was previously unknown to the Illinois workers compensation system and continues to be developed in the years to come. Claims adjusters should assume Illinois WC attorneys on both sides are learning this process from square one. We hope claims adjusters who know UR from other states can quickly adapt their UR protocols to Illinois.

One of the best aspects of UR in this State is a UR denial has presumptive effect—Claimant has to overcome a presumption the final UR determination is accurate. For that reason, we feel it can be more valuable and less expensive than some IME’s in corralling medical care.

The 2005 amendments to the Illinois Workers’ Compensation Act codified a political trade-off between business and labor. Business, concerned over rapidly rising medical costs, which comprised approximately 50 percent of total workers’ compensation spend, agreed to a 7.5 percent increase in the schedule of benefits (excluding person as a whole claims), increased minimums, and increased death benefits in exchange for a medical fee schedule, utilization review, and WC fraud provisions.

Utilization review addresses the reasonableness, necessity, and frequency of treatment.

What Is Utilization Review?

Section 8.7 of the Illinois Workers’ Compensation Act defines utilization review as: [T]he evaluation of proposed or provided health care services to determine the appropriateness of both the level of health care services medically necessary and the quality of health care services provided to a patient, including evaluation of their efficiency, efficacy, and appropriateness of treatment, hospitalization, or office visits based on medically accepted standards. The evaluation must be accomplished by means of a system that identifies the utilization of health care services based on standards of care or nationally recognized peer review guidelines as well as nationally recognized evidence based upon standards as provided in the IL WC Act. Utilization techniques may include prospective review, second opinions, concurrent review, discharge planning, peer review, independent medical examinations, and retrospective review (for purposes of this sentence, retrospective review shall be applicable to services rendered on or after July 20, 2005). Nothing in this Section applies to prospective review of necessary first aid or emergency treatment.

820 ILCS 305/8.7(a) (2005)

Section 8.7(b) requires the utilization review provider must register every two years with the Department of Financial and Professional Regulation.

Section 8.7(e): A utilization review program shall have written procedures to ensure that patient-specific information obtained during the process of utilization

Utilization review programs monitor quality and efficiency of health care delivery by achieving common understanding of excellence among employers/insurance carriers/TPAs, medical providers, and patients through the establishment of standards, education and communication and accreditation. You can find out more about utilization review at: http://www.urac.org/.

In addition to optimizing medical treatment, we assume UR is used to demonstrate a claimant should be back at modified or full work and is over-treating. We confirm for the insurance carriers/TPA’s that your defense counsels and Petitioners’ counsels are “flying by the seat of their pants” during the implementation of UR and how it should work.

Your defense counsel will need your expert help in presenting disputes relating to denial of treatment or TTD due based upon UR protocols before the Arbitrators and IWCC.

We appreciate your thoughts and comments. Please post them on our award-winning blog.