Denver Worker's Compensation Info: adjusters workers compensation adjusters

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Thursday, July 2, 2015

The Texas Lawbook

Workers at thousands of Texas businesses who are seriously injured on the job may find it harder to sue their employers for damages after an accident.

The Supreme Court of Texas, in a potentially precedent-setting decision issued last week, slammed the courthouse door on damages for many employees hurt while working in hazardous situations. The case affects employees of companies that have opted out of the state’s workers’ compensation system.

The justices unanimously ruled that millions of workers at the approximately 144,000 noninsured Texas businesses are no longer able to seek compensation in such cases.

But the ruling — which is a huge loss for workers under the “premises liability” law — is a bit of a two-edged sword.

In that same opinion, the high court stunned lawyers by stating that employees should be able to recover damages under a separate “negligence” law if the employer failed to provided proper equipment, training or supervision that could have prevented the injury.

Such negligence claims with potentially major damage awards have not been previously available to workers in Texas.

Texas is the only state that does not require companies to be part of their state workers’ comp system. About a third of Texas employers don’t buy workers’ comp insurance. Kroger, Wal-Mart, Albertson’s, Taco Bell and Whole Foods are some of the biggest.

Legal experts say the ruling was intended to provide clearer guidance for litigation between workers and those employers.

Mopping accident

The case in question began in July 2009 when Randy Austin, a longtime maintenance employee for Kroger in Mesquite, fell while mopping oil that had leaked onto a restroom floor.

The Kroger handbook recommended cleaning such spills with the powdery absorbent product Spill Magic, which was estimated to reduce the likelihood of a slip-and-fall by 25 percent, according to court records.

Spill Magic was unavailable, however, so Austin cleaned the restrooms with a regular mop. As he cleaned the women’s restroom, Austin slipped and fell, fracturing his femur and dislocating his hip.

Austin spent nine months in the hospital and underwent six surgeries, which left his left leg 2 inches shorter than his right.

When Kroger refused to compensate him the amount he believed he deserved, Austin sued in federal court in Dallas. U.S. District Judge Jane Boyle rejected both Austin’s negligence and premises liability claims.

The federal court of appeals asked the Texas Supreme Court to clarify state law on the matter.

Future litigation

Lawyers for Kroger contend the ruling significantly strengthens the legal position of all businesses in all future premises liability litigation involving injured workers.

“Most importantly, it dispels the misconception among the plaintiff’s bar that Texas ‘punishes’ Texas employers who opt out of the workers’ compensation system,” said Dallas appellate attorney Donna Peavler, who argued the case for Kroger.

While lawyers who represent workers admit the premises liability part of the decision is terrible for their clients, they eagerly point to the justices’ view that Judge Boyle should reconsider Austin’s negligence claim.

“We have never addressed the interaction between premises-liability and an employer’s other general negligence duties. We do so now,” wrote Justice Jeffrey S. Boyd, who delivered the 34-page opinion. “As Austin’s employer, Kroger owed Austin duties in addition to its premises-liability duty and its duty not to engage in negligent activities, including the duty to provide Austin with necessary instrumentalities.”

For a longer version of this article, please visit TexasLawbook.net

Contact the Law Office of O'Toole & Sbarbaro, P.C. today if you have a workers' compensation or a Social Security disability case.

http://www.otoole-sbarbaro.com

Phone: 303-595-4777

We are located in the Denver Metro area.

226 West 12th Avenue Denver, Colorado 80204

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Friday, June 27, 2014

Wisconsin DWD To Innovative Programs Training Workers With Disabilities

Madison, WI (WorkersCompensation.com) – Department of Workforce Development (DWD) Secretary Reggie Newson today announced that DWD is accepting grant applications from businesses to train workers with disabilities under Governor Walker's $35.4 expansion of the Wisconsin Fast Forward worker training program. The expansion is part of the Governor's Blueprint for Prosperity initiative.

Up to $1 million in Wisconsin Fast Forward – Blueprint for Prosperity funds will be available for innovative workforce solutions to train workers with disabilities.

"Persons with disabilities have diverse strengths and skills that help improve a company's bottom line to the benefit of the employer and worker," Secretary Newson said. "Governor Walker is committed to developing Wisconsin's workforce in part through initiatives that encourage employers to hire persons with disabilities, and his Blueprint for Prosperity initiative invests additional Wisconsin Fast Forward funds in this key area."

DWD's Office of Skills Development is overseeing the grant implementation in partnership with the Division of Vocational Rehabilitation (DVR) and the Office of Veterans Employment Services (OVS). The deadline for applications is September 16, 2014.

Highlights of the grant announcement include:
•Applications are being sought from Wisconsin businesses to train persons with disabilities.
•Potential grants can range from $5,000 to $100,000.
•Potential trainees must be currently receiving Supplemental Security Income or Social Security Disability Insurance and/or veterans with a service-connected disability, and/or eligible DVR consumers.
•OSD will review and evaluate applications and monitor employment and wage outcomes.

Additional considerations will be given to applications that include the following:
•Working with a DVR Business Service Consultant or OVS Local Veterans Employment Representative in the recruitment of trainees
•Recruiting and training persons with significant disabilities.
•Offering community-based employment at a competitive wage.
•Committing to inclusive recruitment and hiring practices that include workers with disabilities after the end of the grant period.

Earlier this year, Governor Walker signed legislation under Blueprint for Prosperity that added $35.4 million to the Wisconsin Fast Forward worker training program. The expansion targeted three areas, including grants to reduce wait lists at Wisconsin technical colleges, grants for collaborative projects among high schools, technical colleges, and employers to train high school students in industry-recognized certifications, and grants that enhance employment opportunities for workers with disabilities.

Under Governor Walker’s Blueprint for Prosperity, the state also is expanding Project SEARCH, a program helping young people with disabilities transition from high school to the workplace. The expansion increases the number of participating businesses by 20, up from seven, over three years.

Governor Walker proclaimed 2014 as the Year of A Better Bottom Line to encourage and promote employment opportunities for people with disabilities. A Better Bottom Line is tailored after Delaware Governor Jack Markell’s initiative with the National Governor’s Association, which details the vast benefits for employers, employees, and communities.

Original Source

Contact Neil O'Toole and John Sbarbaro

at the Law Office of O'Toole & Sbarbaro, P.C.

Phone: 303-595-4777

Located in the Denver Metro area.

226 West 12th Avenue Denver, Colorado 80204

Disclaimer

Monday, September 23, 2013

Automated Adjudication = Automatic Waste

By ReduceYourWorkersComp 09/19/2013 09:30:00

I look at all of my bills. Not just during work for business matters, but my personal bills as well. I do not catch many errors. In fact I think I have only caught maybe a handful of issues my entire life. These weren’t big issues, sometimes they were just duplicate charges, service fees that were supposed to be waived, or deposits on hotels that were supposed to be waived because I rescheduled within the allotted time frame without penalty.

Of course I know of people that just pay their bills online automatically every month. They don’t review the itemized statements, nor do they even read the automated email notifications saying their bills were due and automatically paid per their own permission. For obvious reasons this drives me crazy. Humans sometimes fail. Systems sometimes fail. Mistakes happen. No matter how insignificant the duty may be, these risks of errors are always out there every day. Not just in billing matters, but in everything. My coffee order gets prepared incorrectly. My salad came with the dressing on the salad instead of on the side. Don’t even get me started about other issues involving flights being “on-time,” The point is to err is human, and last time I checked we were all human at least to some degree, especially in this industry.

Claims Industry Working To Become More Efficient

The latest craze is the argument over automated adjudication of minor claims and of lifetime claims that have steadied out as far as invasive treatment goes. Adjusters are busy, and insurers/TPAs are trying to do more with less. They want to become more efficient. They want to spend less and less time on what they deem to be “trivial” claims and spend more time on the more important claims that carry a higher exposure.

This makes sense. Adjusters should be spending more and more time focusing on the matters that are more important than Jim Worker who cut his finger and had to go to the doctor for a few stitches. Minor medical-only claims constitute a lot of the pending file counts on certain levels of adjusters, and those adjusters are also the ones that are just starting out in the claims world. This is where they should be learning the process, and how important it is to review every bill for relatedness.

But to introduce automatic claim handling by a computer worries me. I worry about leakage all the time, because wasting money is one of my many pet-peeves. The marketers of automated claim technology say that they protect against error, because of the data that has to be input into the system for a person. Date timeframes need to be in place. Body injury codes are input so the injury body part can be correctly identified. CPT codes and billing coding is also entered into the system to prevent certain treatments from being automatically paid. Maximum bill amount parameters can be placed so any big bill they may come in would be flagged and not paid so the adjuster can review and authorize the payment.

These are all well and good. In fact, it looks great! If this system works according to plan, then how could anything ever be paid in error? On paper, these automated systems appear to be the next greatest thing since the computer so adjusters can do more and become more proactive at their desks. So what could the problem possibly be with implementing an automated adjudication process?

I can tell you one problem right now—it would only be as good as the person inputting the information. Like I said above—to err is human.

Automated Adjudication on Lifetime Claims = Large Medical Leakage

Let’s say automated adjudication is used for lifetime claims. After all, you have accepted the left knee as being compensable for life. You owe it, and you owe treatment on it, depending on your jurisdiction. But for ease of an example, we will just say you owe it no matter what. So it makes sense to just automate the medical bill payment on it, right?

No it does not. And I will tell you why: What if the doctor this person treats with just has their left knee as the primary diagnosis? This injured worker treats with their primary care doc. In the doctor’s system, they have the injured worker down as the left knee being most important and primary diagnosis. But if he comes in for a non-work related back strain, I doubt the primary diagnosis will change. The CPT code would probably just be for an office visit, so the system has no idea that the person treated for their back because it just sees the diagnosis code, and the CPT code. Nobody is there to view the medical report, so this bill gets paid. Along with bills for the flu, arm pain, lab results, medication of various types for various elements, and so on. Now you have paid the medical bills for who knows what, for who knows how many years. That is a leakage emergency!!

When will this be corrected? Who is in charge of making sure the treatment is for the compensable knee? The answer is probably nobody. Plus this can happen on a number of claims. Add all of that up, and now you have a substantial number of medical leakage. One that should have never occurred in the first place if you had a real person reviewing medical notes that go with the bill before they paid it.

I saw a fantastic statistic from Acrometis in an article on their website entitled “How much is your auto-adjudication costing you?” (http://www.acrometis.com/strength/0123.htm) In this article, Acrometis states that “…auto-approving all submissions under $250 results in overpaying $8,000,000 if you only look at submissions that were returned but not resubmitted. Applying the same approach to all the submissions analyzed results in overpayment of more than $133,000,000.”

Now I could stand a bill here and there being paid in error. But you have to look at the total from a macroeconomic view. Look at the entire scope of a carrier/TPA, not just on the one claim itself.

Auto Accepting Bills May Accept Large and Unrelated Medical Services

Lastly and yet another great point in that article shows that auto-accepting some bills may loop you into also accepting much larger and potentially unrelated medical services. This could include costly prescriptions, DME bills, unwarranted exploratory surgical procedures, and so on. This would depend on your jurisdiction, but the end result is the nightmare that every adjuster has, which is being forced to accept treatment on an unrelated non-compensable body part due to adjuster error. This is going to land the adjuster in some hot water, and probable disciplinary action I would hope. This type of error is inexcusable!

All of these errors do not need to happen, and should not happen at all. They should not happen because adjusting claims should be done by a real person, not some automated service. Before we jump on the ship of automatic adjudicating, we had better take a step back and look at the consequences of error, both from a human standpoint and from a systems standpoint.

Original Source

The Law Office of O'Toole & Sbarbaro, P.C. can help you with your workers' compensation or Social Security disability case.

http://www.otoole-sbarbaro.com

Phone: 303-595-4777

We are located in the Denver Metro area.

226 West 12th Avenue Denver, Colorado 80204

Disclaimer