Source: https://premiumreduction.blog/2018/03/
Timestamp: 2019-04-24 20:29:12+00:00

Document:
Wellness programs and insurance coverage that includes bariatric surgery can help manage worker obesity and alleviate its economic costs to employers, according to a released guidance statement from the American College of Occupational and Environmental Medicine (ACOEM).
The first edition of NCCI’s Court Case Update provides a look at some of the cases and decisions being monitored by NCCI’s Legal Division, that may impact and shape the future of workers’ compensation.
The University of Pittsburgh Medical Center and the National Association of State EMS Officials have partnered on a set of guidelines aimed at reducing work-related fatigue among emergency medical services workers.
Cal/OSHA adopted a new rule to help reduce injuries for hotel housekeepers. The rule will require employers to establish, implement, and maintain an effective written musculoskeletal injury prevention program that addresses hazards specific to housekeeping.
The Division of Occupational Safety and Health is moving to create a new safety standard to prevent and handle workplace violence for general industries.
The state is drafting workplace safety rules for the burgeoning marijuana industry.
State Workers’ Compensation Board is inviting public comment on a proposed Pharmacy Formulary. The comment period expires on February 26, 2018.
Industrial Commission recently announced an update in the rules for the workers’ compensation system addressing the opioid crisis. Published January 16, 2018, in Volume 32 Issue 14 of the North Carolina Register, the rules are for the utilization of opioids, related prescriptions, and pain management treatment. A public hearing is scheduled for March 2, 2018 at 2:30 p.m., and the Commission will accept written comments until March 19, 2018.
The Governor signed a statewide disaster declaration related to the opioid crisis to enhance state response, increase access to treatment, and save lives. It will utilize a command center at the Pennsylvania Emergency Management Agency to track progress and enhance coordination of health and public safety agencies.
In Billups v. Emerald Coast Utilities Authority, an Utility Service Technician II suffered a shoulder injury and received physical therapy, but after two months it was determined he required surgery. The surgery was delayed because of his reaction to anesthesia. His company had a policy of 26 weeks of leave for work injuries. Following surgery, the doctor said it would likely take six months for his shoulder to recover to the degree that he could perform the essential functions of the job.
The company sent a notice indicating he would be terminated if he could not return to full duty by June 18, 2014, which was the end of his six-month period of leave. At the time, they were short staffed and dealing with severe flooding damage to the water and sewer infrastructure. At a predetermination hearing, he was given one day to obtain a doctor’s statement regarding his full-duty return to work date. He was able to obtain a note from PT about his release date, but not from his doctor and was fired on June 23, 2014. He was not cleared by his doctor to return to work full duty until October 23, 2014 and it was with limitations.
After losing in district court for not identifying a reasonable accommodation, the employee appealed arguing that a short period of leave would have been a reasonable accommodation under the ADA. The court noted he had not demonstrated that his requested accommodation would have allowed him to return to work “in the present or in the immediate future” and therefore, the request for additional leave could be interpreted as a request for indefinite leave, which is unreasonable.
In Marsh-Godreau v. State University of New York College at Potsdam, the U.S. District Court for the Northern District of New York ruled reassignment of minor job duties did not violate the FMLA. While the employee was on leave, the university reassigned some entry responsibilities for the annual report and did not return the responsibilities when she returned.
Her suit alleged that the university reduced her responsibilities, her supervisor exerted unwarranted and excessive scrutiny, and the university no longer allowed her to perform essential functions of her role. The court found in favor of the employer, noting the employee continued to be employed and that she received raises annually until her retirement.
The 1st District Court of Appeal has ordered publication of its ruling in Zuniga v. WCAB (Interactive Trucking) that found injured workers do not have a due process right to know the identities of medical professionals performing independent medical reviews. Only published opinions are binding precedent in California.
In Florida, witnessing tragic events on the job are classified as within the scope of employment for first responders and, therefore, PTSD must accompany a physical injury in order for first responders to be eligible for benefits. The responder argued that he had been hospitalized for hypertension and this should be considered a physical injury. The judge ruled that since the responder had not reported a physical injury, nor had his blood pressure taken on the night of the shooting, hypertension could not be claimed as a physical injury.
In Ascension Benefits & Insurance Solutions of Florida v. Robinson, the 1st District Court of Appeal ruled that a worker was not entitled to the surgeries that an expert medical adviser had counseled against, even though the adviser acknowledged that the procedures would be reasonable treatment for the worker’s injuries. Based on the report of the Expert Medical Adviser (EMA) and IME, a judge determined surgery on the injured employee’s elbow and index fingers was reasonable.
Upon appeal, the court said reasonableness is not the only standard to apply when awarding medical treatment, treatment must also be medically necessary. The EMA never said the surgeries were medically necessary and, in fact, recommended against them. Under Florida law, the opinion of an EMA is presumed to be correct, unless there is clear and convincing evidence that it is wrong.
In McBee v. Team Industries, the Court of Appeals ruled that an employer was not required to engage in an interactive process to determine whether an injured worker could be accommodated, and that the employer had defeated the worker’s claims of discrimination and retaliation under the state Human Rights Act and Workers’ Compensation acts.
A machine operator worked for a foundry and aluminum die-casting facility and was required to do heavy lifting and operate, repair, and maintain heavy machinery. She sought medical attention for severe pain in her hands, back and neck and her doctor found she had disc narrowing, a bulged disc and bone spurs in her vertebrae and he imposed lifting restrictions. A month later, she was fired from the job and sued under the MHRA.
The law requires that employers make a “reasonable accommodation to the known disability of a qualified person.” However, the court found that a “qualified person” must be able to perform the essential functions of the position and there was no reasonable accommodation for her to perform the heavy lifting, which was an essential function of the job.
Since the federal Americans with Disabilities Act pre-dates the MHRA, the court said it had to assume that the Minnesota Legislature consciously refrained from including the ADA’s interactive-process language in the act. This position differs from an earlier decision by the 8th U.S. Circuit Court of Appeals.
A judge has ruled in favor of the widower of a former state employee, awarding him his wife’s death benefits after she committed suicide. His wife had worked for the state Department of Marine Resources and had grown increasingly distraught over land purchases by the director that benefited family members and felt she was going to be blamed for the corruption.
After her first attempt at suicide failed, she was admitted to the hospital and began undergoing psychiatric treatment, but hanged herself months later. Psychiatrists testified that her employee’s participation in the corrupt land deal – and her concern that she would also be implicated – were clearly the reason for her distress. The judge ruled that the inappropriate actions of the department’s employees caused her to suffer a mental disorder that prompted her suicide and awarded close to $200,000 in death benefits.
In Wright v. Turan-Foley Motors, the appeals court cautioned attorneys against being overzealous in their attempts to prove an employer-chosen medical examiner is biased against their client. It found the Workers’ Compensation Commission was right to dismiss an attorney’s “overly burdensome and unduly broad” subpoena against an employer’s medical examiner, but should not have imposed a $5,000 penalty against the attorney or made him pay the medical examiner’s attorney’s fees.
In Morris v. Captain D’s, an employee suffered injuries in a car accident and additional injuries in a workplace fall. He quit his job several months later and filed for comp benefits. An administrative law judge found that he was permanently and totally disabled from the combined effects of his injuries and pre-existing conditions, which included knee, back, and neck injuries and high blood pressure and heart disease. The judge found, and the court of appeals agreed, that he that was entitled to future medical treatment on each claim.
In Colamaio-Kohl v. Task Essential Corp, the employee worked as a skin care specialist and spokesmodel at a Bloomingdale’s store and fell and suffered injuries while heading to the restroom. He later filed a comp claim and the appellate court upheld an award of benefits, noting that the Skin Care Company had control over his schedule, training, and dress code. Therefore, he was not an independent contractor nor employee of Bloomingdales, but an employee of the Skin Care Company.
In Bain v. New Caps, an employee had earned just $2,950 in 16 days of employment when he was in a car accident. The company submitted a wage earnings statement indicating it had paid $2,950 during the 52-week period preceding the accident and that the employee had earnings of $2,121.81 from other employers during the same period. The law says a worker’s annual earnings shall consist of not less than 200 times the average daily wage or salary earned during the days when he was employed, as divided by 52. Thus, the appellate court found that Board’s determination of the AWW of $709.15 was correct.
In County of Allegheny v. Workers’ Compensation Appeal Board, the Supreme Court ruled that an employer cannot recover attorneys fees erroneously paid to an injured worker’s lawyer. The employer was ordered to pay $14,750 in attorneys fees under Section 440 after the Workers’ Compensation Appeal Board determined that it had unreasonably contested its liability. However, the Commonwealth Court reversed the decision and also overturned the attorney fee award.
The county sought reimbursement for the erroneously awarded attorneys fees, but the Supreme Court found that the General Assembly, in enacting the Workers’ Compensation Act, did not provide any mechanism by which employers can recoup erroneously awarded counsel fees once paid.
In Allison v. Workers’ Comp. Appeal Bd. (Fisher Auto Parts, Inc.), the Commonwealth Court found a utilization review doctor did not violate the due process rights of an injured worker by denying a medication and injection regimen after a treating physician failed to submit medical records to justify the treatments.The law requires physicians to mail documents to a utilization review organization (UR) within 30 days of receiving a company’s request. In past cases, the Commonwealth Court ruled that workers’ compensation judges don’t have jurisdiction to review UR denials due to a lack of medical records. This case argued that denying treatment due to circumstances outside the employee’s control when he had no way to appeal the decision was a due process violation, but the court disagreed.
In Smith v. WCAB (Supervalu Holdings PA), an employee was injured when falling items from a shelf hit him on his head. He suffered a cervical strain/sprain and received $662 per week, based on his average weekly wage. The employer filed to suspend his benefits when he refused to undergo a second surgery they deemed was highly likely to cure his disability. The judge said refusal to undergo the surgery was not a refusal of reasonable medical treatment and there was no guarantee that new treatment would decrease the disability. Therefore, he did not suspend benefits but agreed to modify based on a vocational rehabilitation counselor’s recommendations.
The counselor identified five open and available positions within the vocational and medical restriction and recommended modifying the benefits to $396.63. The court said the question of whether the jobs could serve as a basis for modifying benefits depended on whether the jobs were available to him and found that since the worker interviewed for two of the identified positions there is substantial evidence that the job is available.
In Goodman v. Schwarz Paper Co., an employee suffered a back injury and after receiving treatment was released to work with no restrictions. She later experienced radiating pain originating in her right sacroiliac and buttock and the doctor conducted a nerve conduction study, but the result revealed no abnormalities. Another doctor examined her at the request of her attorney, and opined that she had lumbar radiculopathy in addition to a traumatic back injury. He assigned a 12% impairment rating for her back and a 3% impairment rating for the bursitis, compared to the 2% assigned by her treating physician.
A trial judge found the new opinion was not enough to overcome the statutory presumption of correctness afforded to the original opinion and awarded benefits based on the 2% impairment rate. The Supreme Court’s Special Workers’ Compensation Appeals Panel agreed.
On Jan. 5, the Department of Labor (DOL) introduced a less stringent test to determine whether employers must pay their interns at least a minimum wage and overtime. The new approach involves a primary-beneficiary test and abandons a rigid test where six parts all had to be met for someone to be considered an unpaid intern and not an employee. Four appellate courts rejected the DOL’s six-part test and the newly adopted seven factor primary-beneficiary test was used by these courts.
The new standard is more flexible and aligned with court rulings. It’s expected to be easier to defend unpaid internships if they’re set up properly and there’s a good agreement between the intern volunteers and the employer. However, it is not a license to use unpaid interns without restraint. The test still exists and the question of who’s the primary beneficiary of the program – the employer or the intern – ultimately needs to be answered.
Companies that use internships should revise all program-related documentation-such as policies, advertisements and recruiting materials-to use the language of the seven factors in the primary-beneficiary test and the student intern and the employer should sign agreements incorporating the language.
OSHA is required to annually adjust civil penalties under a 2015 law that significantly increased the maximum penalties allowed for violations. In January, the maximum penalty for willful and repeat violations increased from $126,749 to $129,336. The maximum fines for other-than-serious, serious, and failure to abate violations rose from $12,615 to $12,934 per violation.
The fall agenda shows 16 regulations in three active stages: pre-rule, proposed rule and final rule – up from 14 in the previous agenda. Two rules were moved from “long-term action” status: amendments to the Cranes and Derricks in Construction Standard (now in the proposed rule stage), and Rules of Agency Practice and Procedure Concerning OSHA Access to Employee Medical Records (final rule stage).
The status of Standards Improvement Project IV, (Lockout/Tagout) the only regulation listed in the final rule stage in July, has not changed.
The new fact sheet, Commercial Fishing: Safe Housekeeping and Sanitation Practices, states that over half of the recordable injuries in commercial fishing are preventable through good housekeeping and sanitary practices.
An addition to the Fatal Facts series emphasizes the hazards of working in confined spaces on farms. These spaces include grain and feed silos, sump pits, and manure storage tanks. The fact sheet examines an incident in which a worker asphyxiated inside a whey storage tank.
Wintry weather has taken hold across much of the country and employers and workers are reminded to stay mindful of safety during snow removal activities.
International Polymer Solutions Inc. in Irvine received five citations related to failing to properly control hazardous energy when a moving machine part flew off and struck a worker in the chest, causing serious injury. Proposed penalties are $55,650.
Hadley Date Gardens Inc. in Thermal was cited for serious workplace safety and health violations following a bee swarm that stung and killed a tree worker. The company faces $41,310 in proposed penalties for failing to evaluate the worksite for hazardous bee and insect exposure, and failing to establish appropriate safety protocols, which include providing protective equipment and training.
Action Concrete Construction Inc. of Panama City Beach faces proposed penalties of $59,864 for exposing its employees to fall hazards and eye injuries.
A fatality investigation involving the death of five workers at the Big Bend River Station electrical power plant in Apollo Beach resulted in citations to Tampa Electric Co. and Gaffin Industrial Services Inc., totaling over $160,000. The fines related to energy control procedures and PPE.
Koch Foods of Gainesville L.L.C. was cited for multiple safety and health violations at its poultry processing plant, including a repeat violation for exposing employees to amputation hazards by failing to provide machine guarding. Proposed penalties are $208,977.
Stalwart Films LLC faces proposed penalties totaling the maximum allowable fine of $12,675, for the company’s failure to provide adequate protection from fall hazards. While filming the television show, “The Walking Dead.,” a stuntman was fatally injured after falling more than 20 feet.
Social Circle-based Goodyear Tire & Rubber Co. faces proposed penalties of $69,058 for exposing its employees to burn, hazardous energy, amputation, and caught-in safety hazards.
Thomson-based auto parts manufacturer HP Pelzer Systems Automotive Inc. faces penalties for safety violations and proposed penalties totaling $129,336 after an employee suffered a finger amputation.
A pallet manufacturer, New Lenox-based Supplyside USA, which operates as Prime Woodcraft Inc., faces $91,862 in penalties after an employee was injured while performing maintenance on equipment.
A mechanic, who alleged he was terminated after voicing concerns about unsafe working conditions at a bowling center owned by Lucky Strike Entertainment LLC, in Lombard, will receive a total of $40,000 in back wages as part of a consent judgment.
An administrative law judge affirmed citations against Fort Wayne-based commercial construction company, CME Corp, after a temporary employee was injured when he fell through an unguarded hole, but lowered the assessed fine to $6,500 in total penalties because of the company’s strong safety record. The company had contested the fine, arguing the opening was a point of access to the upper level from the pit and did not need to be guarded under the applicable regulations.
Schnabel Foundation Company faces $212,396 in proposed penalties for failing to protect employees against crushing hazards while they installed permanent foundation supports beneath the Woburn Public Library. A 2,600-pound rock dislodged from the foundation and fatally struck an employee.
Marshall Ingredients LLC faces over $300,000 in proposed penalties after a temporary worker suffered a hand amputation. The company was cited for failing to protect employees against amputations and other hazards at its Wolcott facility. The temporary staffing agency, People Ready, was also cited with two serious violations for lack of hazardous energy control and fire extinguisher training. Proposed penalties totaled $24,020.
Fraud or abuse that might not reach the legal requirements for criminal sanctions happens in all aspects of the Workers’ Comp system. There’s employee fraud, employer fraud, health provider fraud, attorney fraud, and even insurer and claims adjuster fraud. The good news is that technology is making it easier to detect and many states have strengthened their laws to prevent fraud. In this article, we’ll look at employee fraud and health provider fraud.
It’s important to recognize that only 1 – 2% of employee injuries are considered fraudulent and that injured employees can be scared and overwhelmed by the system and need the support and guidance of the employer to navigate to a quick recovery. But when fraud or abuse occurs it can be hard to detect and lead to unnecessary costs.
The most common types of employee fraud are faking injury claims, exaggerating injury or illness, claims for injuries incurred outside of work, failing to report earned wages while receiving temporary disability benefits, and prescription fraud, especially related to opioids. Malingering can also complicate an already complex claim and postemployment claims such as those involving cumulative trauma (CT) can be difficult for the employer to control.
Two recent phenomenon driving employees to cheat the system are expensive health care and long-term unemployment. While the evidence is anecdotal, high deductible health insurance plans, the ever-increasing costs of co-pays, and the growing uncertainty of coverage can incentivize the use of workers’ comp. In most cases, workers will have all medical costs covered and receive indemnity payments. Despite continued job growth and low unemployment, long-term unemployment persists among certain workers, and those having a tough time finding jobs that match their skill set or pay well may look to postemployment comp claims for much needed income.
There are many “red flags” that can help employers identify questionable claims and these should immediately be shared with the claims adjuster. However, proving that an injured worker is engaged in personal physical activities inconsistent with the alleged disability can be difficult. Today, a combination of the traditional approaches to fraud detection and technology make it easier and more affordable.
Have the injured worker put in writing the facts of the injury.
Do a thorough investigation of the incident, including interviewing witnesses, taking pictures, documenting PPE in use, and so on.
Make your employees comfortable with reporting suspected fraud and train supervisors in monitoring “workplace chatter.” Often, co-workers may have information or a sense that a co-worker is abusing the system.
Use surveillance cameras in offices, parking lots, warehouses, etc. According to an Employers Holdings, Inc. survey, 24% of small businesses have installed surveillance cameras on their property. There was a widely publicized YouTube video of a Florida woman hitting herself on the head with a sprinkler head that had fallen on her desk and then claiming a workplace injury.
Have a relationship with a trusted, competent occupational physician who understands your business and can foster the confidence of employees. This partnership will help identify possible fraudulent cases and control prescription abuse. Prescription fraud is easily mitigated by a doctor’s ability to check a prescription-monitoring data base, which 49 states now have in place.
Monitor social media. It’s positively amazing what people will post on social media. If fraud is suspected, investigators can use software to search upwards of 200 social media sites. Employers need to be cautious about how they employ social media tools to investigate their employees’ behaviors and be sure that the evidence is admissible in court. While social media has been allowed in some court cases, this area of law is still in its infancy. Even if the admissibility of social media is questionable, it provides an indication that video surveillance, which is more likely to be admissible because it includes a time stamp, is warranted.
Consider smart device data. In recent cases, police obtained a search warrant for the data from the cardiac pacing device in an arson investigation, a fitness tracker was used to discredit an alleged assault, and an Amazon Echo was accessed (unsuccessfully) as a witness to a murder. This area of law is largely untested, but should not be overlooked.
Check job applicants carefully. Criminal backgrounds and a history of suspicious injury claims can be good predictors of potential fraud.
For the dishonest physician, workers’ comp is fertile ground. Common examples of fraud include: submitting claims for services not provided, duplicate billing, upcoding or submitting claims for services with higher rates, unbundling or submitting claims for several services that should have been one claim, ordering excessive treatment or supplies, dispensing drugs for personal gain, receiving kickbacks in exchange for directing patients to other service providers, and operating “medical mills” with others who lack required credentials.
Some states such as California have enacted laws to aggressively pursue fraud. Since A.B. 1244, which requires the division’s administrative director to suspend any medical provider, physician or practitioner from participating in the workers’ comp system in cases that involve criminal activity or inability to perform duties safely, among other requirements went into effect Jan. 1, 2017, over 170 providers have been suspended.
Have a relationship with trusted, competent occupational physicians who understand your business and can develop confident relationships with your employees.
Vet independent medical reviews for quality. Complex claims that involve comorbidities can be feeding ground for exaggeration and malingering and often involve legal representation. According to a recent white paper by the Risk & Insurance Management Society Inc. a quality independent medical examiner (IME) can help mitigate losses. It’s important to hold an IME to a high standard.

References: v. 
 v. 
 v. 
 v. 
 v. 
 v. 
 v. 
 v. 
 v. 
 v. 
 v. 
 v. 
 v.