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Chapter 4: Managing Workers Compensation Claims

The cost of a workers compensation claim is directly proportional to the time it takes for injured employees to reach what is known as “maximum medical improvement” (MMI) and return to work.  MMI means that injured workers have improved medically as far are they are going to improve. 

Workers compensation claims can be controlled by: (1) using the most skilled doctor to treat a particular injury; (2) eliminating transactional delays such as waiting for treatment, authorizations or special care; and (3) reducing the number of lost workdays to the minimum required to reach Maximum Medical Improvement.

Reporting Procedures – Every department head and supervisor must know how to report an accident.  The procedure should require immediate reporting by telephone so that the claims organization can establish early contact with the treating physician.  The department head or supervisor, not the injured employee, should prepare the written accident report.

Doctors - The treating physician is the single most important factor in reducing workers compensation cost and preventing fraud.  New Jersey is one of the few states that allow the employer (or the employer’s insurer) to contract with a managed care organization (MCO).  The CEO should personally interview the treating physician along with the Managed Care coordinator and the claims adjuster to discuss the claims procedures.  In particular, review the job descriptions and requirements of critical positions and the physician’s willingness to coordinate with the local unit to release employees back to work as soon as reasonable

Maintain Contact with the Injured Employee – It is management’s responsibility to periodically contact the injured worker and express support. The major reason injured employees retain lawyers is because they are uncertain of their benefits or concerned that they are not receiving adequate medical treatment.

Develop a Transitional Plan for Each Injured Employee – Studies have also shown that many injured employees are capable of assuming their full responsibilities at an earlier date if they start a transitional plan before reaching Maximum Medical Improvement (MMI).  Depending upon the circumstances, a transitional plan includes both specialized rehabilitation and transitional duty on the job.  Other injured employees are not capable of immediately assuming full duties even after they reach MMI and may need time to build up to their full responsibilities.  Work with the treating physician and the MCO to identify what the employee is capable of doing on the job while recovering. Also identify additional rehabilitation required to get the employee back into shape after the inactivity during the employee’s disability period.

Model Transitional Duty Policy:

The (local government name) will endeavor to bring employees with temporary disabilities back on the job as soon as possible and may assign transitional duty to employees who temporarily cannot perform the essential functions of their positions because of injury or illness.  Transitional duty is not guaranteed and will not exceed _____ workdays. (Typically forty-five)  If a department already has one employee on transitional duty, it is unlikely that another employee from that department will be assigned transitional duty. 

An employee requesting transitional duty or the Workers Compensation Physician shall notify the (CEO title) as soon as the temporarily disabled employee is able to return to work with restrictions.  Transitional duty will only be assigned if the employee will probably be able to perform the essential functions of the position after the transitional duty period.  The (CEO title) will consult with the Department Head to determine if there is any meaningful work that can be performed consistent with the restrictions.  Transitional duty assignments may be in any department and not just the employee’s normal department.  The (CEO title) will decide if it is in the best interest of the (local unit type) to approve a transitional duty request and will notify the employee of the decision.  The (local government name) reserves the right to terminate the transitional duty assignment at any time without cause.

Employees may not refuse transitional duty assignments that are recommended by the Workers Compensation Physician.  In such cases, failure to report to work as directed shall constitute immediate grounds for dismissal.  If the employee believes that the transitional duty assignment is beyond the employee’s abilities, the employee may request a meeting with the (CEO title) who will render a written response within 24 hours.   

Employees on transitional duty will receive their regular salaries and are prohibited from engaging in any outside employment of any kind unless they receive prior written approval from the (CEO title).  If transitional duty is approved, the employee or Workers Compensation Physician must keep the (CEO title) informed of the medical progress.  (Optional - Employees assigned to transitional duty will be allotted time off to attend medical or physical therapy appointments but must request leave time for any other reason.)  If at the end of transitional duty period the employee is not able to return to work without restrictions, the (local unit name) reserves the right at its sole discretion to extend the transitional duty or place the employee back on Workers Compensation or disability.  This policy does not affect an employee’s rights under the Americans with Disabilities Act, the Family and Medical Leave Act, the Fair Labor Standards Act, the Contagious or Life Threatening Illnesses Policy or other Federal or State law.