Paying an injured worker’s medical bills out of pocket: What could go wrong?

If you’ve ever caused a fender bender, you may have weighed the option of asking someone to settle with you rather than going through your insurance company. While it might make sense when the damage is limited to a vehicle, it’s much riskier when a person’s health and wellbeing are involved. Still, some employers choose to pay for seemingly minor medical care out of pocket, without involving their workers’ comp carrier. In these employee/provider small-claim arrangements, the employer signs a formal, binding contract making them directly responsible to pay for the services rendered. The employer also submits the insurance carrier’s contact information to the health care provider. The provider then sends all medical bills directly to the employer, as well as a “for information only” copy to the insurance carrier.

While the law allows small-claim arrangements, they are not always in employers’ best interests.

Employers may be paying for non-compensable claims
Insurance carriers investigate accidents to determine whether claims are compensable (claims eligible for compensation) under the Texas Labor Code. By paying for claims out of pocket, employers do not give carriers the opportunity to conduct investigations. Consequently, employers may be paying for non-compensable claims. They may also be paying for co-existing conditions the carrier would have uncovered during an accident investigation.

The law allows health care providers to bill employers their usual and customary fees. Insurance carriers, conversely, reimburse providers according to the Texas Department of Insurance, Division of Workers’ Compensation medical fee guidelines, which are typically much lower than usual and customary fees.

=, Many insurance carriers also offer workers’ compensation health care networks. In these networks, carriers negotiate rates with providers and those rates are generally lower than usual and customary charges.

Minor injuries can get worse
Assume an employee cuts his finger. After the accident, he goes to the doctor, gets five stitches and returns to work the next day. What if a week later, the employee gets a secondary infection that requires a hospital stay?

The point is that minor injuries can get worse, and their associated costs can skyrocket. If the policyholder reports the accident to the carrier, the carrier will manage the claim and act on the policyholder’s behalf. If not, the employer’s costs could pile up quickly.

Employees could be denied care
If an employer owes a provider for a previous claim, the provider may turn away the employer’s injured workers until the employer pays the bill. An injured worker’s health is always the first priority after an accident, and this is an obstacle that could keep them from getting the care they need.

Policyholders assume an administrative burden
Under the Medicare, Medicaid and State Children’s Health Insurance Program (SCHIP) Extension Act (MMSEA), carriers that provide liability, no-fault and workers’ compensation insurance, as well as employers who pay their own claims, must identify the Medicare beneficiary status of claimants and report claim data quarterly to the Centers for Medicare & Medicaid Services.

Insurance carriers comply with MMSEA requirements on employers’ behalves. Employers who pay claims out of pocket are responsible for complying with the requirements. This added administrative burden leaves less time for running a business.

For more information on this topic, visit the small claims page at texasmutual.com, and consult these sources:

Regulatory Roundup, May 19

Regulatory Roundup is a weekly compilation of employee wellness and safety news.

Occupational Safety and Health Administration (OSHA)

‘Volks’ rule is re-introduced

This week, Democrats introduced The Accurate Workplace Injury and Illness Records Restoration Act. The bill would bring back the recordkeeping rule that was overturned in April and clarified employers’ obligations to record and maintain logs for five years. The legislation required OSHA to issue a new regulation within 180 days. Additionally, it amends the six-month statute of limitation on citations and instead starts the six-month clock when OSHA identifies a continuing violation…MORE

OSHA plans to propose extension of electronic submissions

OSHA recently updated its recordkeeping page to state that electronic submissions are not being accepted at this time. The administration also intends to propose an extension of the July 1, 2017 deadline by which employers are required to submit their Form 300A electronically…MORE

The National Institute for Occupational Safety and Health (NIOSH)

May edition of Research Rounds now available

This month’s edition of NIOSH Research Rounds is now available. Research includes: a link between work-related styrene exposure and asthma and lung disease, an evaluation of fit-testing systems, a method of testing for bacteria in foods, and a study of diesel exhaust and other health risks in fire stations…MORE

The American Society of Safety Engineers (ASSE)

ASSE has a plan for OSHA

In the midst of ASSE considering a name and logo change, the society has also been preparing a set of recommendations for OSHA to increase its ability to better protect workers on a tighter budget. The recommendations were vetted by safety professionals and encompass a shift from being compliance-driven to becoming an organization focused on analyzing and removing workplace dangers…MORE

Studies, resources, trends, news

Inaugural Safe + Sound Week to be held in June

OSHA, the American Industrial Hygiene Association, ASSE, National Safety Council and NIOSH teamed up to host the first Safe + Sound Week, June 12-18. The event is aimed at raising awareness of the value of successful safety and health programs. There are free events being held across the country, and employers are encouraged to join in and start their safety programs or energize an existing one…MORE

ISEA releases a new version of fall protection guide

The International Safety Equipment Association (ISEA) updated its’ Personal Fall Protection Equipment Use and Selection Guide to accommodate the recent OSHA rules for walking-working surfaces as well as fall protection in general industry. The document walks through the process of developing a program, selecting proper equipment and using it correctly. It’s available for free in a PDF document…MORE

Your Claims Questions Answered – What do I do if an employee gets hurt?

In our new YouTube video series Your Claims Questions Answered, we address the most commonly asked claims-related questions. We covered your role in the claims process recently on the blog. Next up, we are discussing what to do when an employee gets hurt while at work. Watch the video and take a look at our key takeaways below.

Address the employee’s health

If an employee is injured on the job, the first thing you should do is assess the situation and determine if it is an emergency. Call 911 if needed and make sure the employee gets timely care to facilitate a quick recovery.

Using the Texas Star Network can help employees get the care they need and can help you manage claim costs. Injured workers can search for a treating doctor, pharmacy, or specialist through the Texas Star Network’s provider portal online or through the Texas Star Network’s mobile app.

Report the claim to Texas Mutual

To report an injury, we will need a DWC-1 Form known as the Employer’s First Report of Injury or Illness. We’ve made it easy to report claims to Texas Mutual online, by phone, fax or mail. Whichever way you choose to report, it’s best to make a report as soon as you can, so Texas Mutual can help you with the claim. The law allows employers up to eight days to report the injury.

Keep open lines of communication

Open communication supports a culture of safety by empowering employees to voice their concerns. Make sure employees know how to report safety hazards and how to access the resources they need to be safe on the job.

In the event someone is injured on the job, getting them back to a productive life is always best. Stay in touch with the employee throughout their recovery to help mitigate their feelings of isolation and maintain team comradery.  A return-to-work program can be started before an injury occurs. Visit the Return-to-Work page at texasmutual.com for more resources.

Training and preparation

There are steps you should take to be as prepared as possible for when a workplace injury occurs. Making safety a habit starts with providing the right training for your employees to do their jobs safely. Texas Mutual has free resources available for you and your employees including webinars and e-Learning online training courses.

Assign a point person to take the lead during injury incidents and create an action plan that is accessible for your employees. Practice drills can help your workplace prepare for an emergency situation and can help you identify any shortfalls in training.

Keeping these tips in mind will help you be prepared when a workplace injury occurs. Next in the Your Claims Questions Answered series, we’ll cover how claims affect your e-mod.

Your Claims Questions Answered – What’s my role in the claims process?

When a worker is injured on the job, an employer may have a lot weighing on their mind. Determining the next steps shouldn’t be one of those things. At Texas Mutual, we provide you with the resources you need to understand the claims process and help employees get the care they need so they can recover and return to a productive life. That’s why we launched a new video series called Your Claims Questions Answered, which addresses the most commonly asked claim-related questions quickly and clearly. In this six-part series, we’ll cover your role in the claims process, reporting an injury, experience modifiers, return-to-work programs, the medical network, and reporting fraud.

To kick off this series, watch “What’s my role in the claim process?” and review our highlights below on how to manage your claims.

Keep an open line of communication with Texas Mutual and the injured employee. This helps the injured worker from feeling isolated, increases trust and fosters loyalty. Check in with the employee to let them know you care about their recovery. A little bit of encouragement goes a long way to motivate an injured worker to get back on their feet.

We’re here to help you and the injured worker throughout the whole process. Our licensed claims adjuster will be there for the injured worker every step of the way. As a large carrier, we’ll work to keep your claims costs down and we can help you to create an injury recovery plan. You can also login to texasmutual.com to check the latest status of a claim.

Build a return-to-work plan. Injured workers out six months or more have only a 50 percent chance of ever returning to work. Implementing a return-to-work plan engages the worker and saves you money. For more resources, visit the Return-To-Work page at texasmutual.com.

Stay tuned for our next installment of Your Claims Questions Answered where we will discuss how to report an injury, or take a look at the whole series now. For safety resources to help you prevent workplace injuries, login to texasmutual.com and visit the Safety Resource Center.

Regulatory Roundup, May 12, 2017

Regulatory Roundup is a weekly compilation of employee wellness and safety news.

Occupational Safety and Health Administration (OSHA)

Minnesota senator introduces worker safety bill

This month, Senator Al Franken introduced the “Protecting America’s Workers Act,” which would update the Occupational Safety and Health Act and improve workplace conditions. The bill would extend OSHA coverage to currently excluded workers, strengthen penalties as well as worker rights and enhance antidiscrimination laws. Senator Sherrod Brown from Ohio and Senator Elizabeth Warren from Massachusetts are co-sponsors of the bill…MORE

National Safety Council (NSC)

2017 injury facts are in

The NSC recently released its 2017 edition of Injury Facts and although workplace fatalities increased, the number of deaths is not rising as quickly as incidents away from work. Transportation-related deaths are still at the top of the charts at 41.2 percent of all workplace fatalities. However, the NSC is also starting to focus on the increasing problem of fatigue and its relationship to unintentional injuries…MORE

Studies, resources, trends, news

What Dale Earnhardt Jr.’s NASCAR retirement says about workplace safety

When Dale Earnhardt Jr. announced his decision to retire from NASCAR, he mentioned concerns about recent concussions and the possibility of future incidents. Another driver, Carl Edwards, also retired recently due to safety concerns. Safety professionals are drawing key lessons out of these actions, saying that safer workplaces are often more enticing than more money. Poor safety cultures lead to higher turnover, so consider improving your safety program now…MORE

North America celebrates NAOSH Week

The North American Occupational Safety and Health Week (NAOSH) was established in 1997 with an agreement between Canada, the U.S. and Mexico, and it was celebrated this week, May 7-13. During the week, employers, employees and the public are encouraged to focus on the importance of preventing injuries and illnesses in the workplace and in the community…MORE

Spending bill means OSHA is safe for 2017

Congress passed a spending bill this month that will leave OSHA’s funding unaffected for the remainder of fiscal year 2017. Additionally, NIOSH received an increase from what was originally proposed. The Mine Safety and Health Administration received a small cut overall. Future funding for all agencies is still unclear, but quite a few organizations have been sending letters to the House and Senate requesting that funding remain close to current levels…MORE

Texas Mutual cyclists complete 150 mile trek and raise $52,000 for multiple sclerosis research

At Texas Mutual, we not only give back to the communities that we serve, but also empower our employees to make a difference through charity.

Making it to the finish line in Austin

For the fourth year in a row, Texas Mutual participated in the BP MS 150, a charity two-day bicycle ride from Houston to Austin that took place the last weekend of April.

In addition to the ride itself, Texas Mutual’s MS 150 team has been fundraising for the cause for weeks. The team raised $52,000 and counting, while the MS 150 as a whole surpassed its $16 million goal.

While many riders are drawn to the team camaraderie, the physical challenge, and the philanthropic mission, for Texas Mutual Claims Supervisor Jennifer Abrams, it was personal. Her sister passed away due to multiple sclerosis so this ride, which raises money for research and treatment of the disease, is very important to her.

“I choke up with tears every time I talk about that because I’m extremely grateful for this opportunity to ride for a cause that matters to me, with the support of Texas Mutual,” she said.

In addition to our 35 riders, Texas Mutual sent 54 volunteers to the MS 150 to help our team and the event at large. They dispensed food, water and snacks, set up the overnight camp in La Grange, transported luggage, gave rides back from the finish line, and supported any riders who lagged behind from mechanical breakdowns or other problems.

This year, the riders overcame some tough weather, with heat and humidity on day one, and hail on day two that delayed the start time. On day two, riders also dealt with a headwind for dozens of miles that made for tough going.

Texas Mutual’s 2017 MS 150 riders and volunteers getting ready to depart for Houston.

The ride, which brings in 13,000 cyclists and 3,500 volunteers, has been held each year since 1985 and has been a core charitable event for Texas Mutual since 2014. Some riders are avid cyclists, like CEO Rich Gergasko, and some are getting into the sport for the first time. Either way, it’s the cause that brings our team back every year.

“I ride the MS 150 because I get to participate in an event with people of all ages and all walks of life, pushing their limits for a great cause,” said team co-captain Alan Cullen, a senior manager of IT at Texas Mutual.

Click here to learn about more about the 2017 BP MS 150 and for more information on Texas Mutual’s charitable giving, visit the Community Involvement page on texasmutual.com.

Top three tips to make safety a habit

Workplace safety is a year-round endeavor but periodic reminders of just how important it is can be a great motivator to refresh or refocus your safety efforts. This week is one of those occasions as it marks North American Occupational Safety and Health (NAOSH) week, May 7-13. This year’s NAOSH theme is “Make Safety a Habit,” which is the most effective ways to prevent workplace accidents. To start making safety a habit in your business, and among employees, take a look at our top three tips.

Safety First Sticky NoteTip 1: See something, say something.

To help build a safety culture in your workplace, empower your employees to speak up. Instill the motto “See something, say something” and review the methods in place to report concerns. Building an environment of open communication supports a safe workplace so that employees feel comfortable speaking up about unsafe practices and potential safety hazards.

It should become a habit to immediately report unsafe practices or conditions, and that starts with you. All too often, safety practices can still get overlooked even when open communication is welcomed. As an employer, it takes united leadership to begin the conversation. To embrace the “See something, say something culture,” make sure your employees know when and how to report concerns, then address the issue and show appreciation that it was brought to your attention. Encourage employees to speak directly with their supervisor, but also provide resources to report to HR or to do so anonymously.

Tip 2: Be consistent.

To keep safety top of mind, hold regular meetings. It’s important to provide consistent training to give newer employees the resources they need to be safe on the job and also avoid complacency with seasoned employees with a refresher.

Also remember that habits won’t become fully formed in a quarterly meeting.  While it’s easy to cross a mandatory safety meeting off the list and wait until the next one is due, provide resources outside of the regular meetings and enforce the safety practices you are teaching. Keep your content fresh with safety resources from Texas Mutual. We offer more than 2,000 free materials and tools for policyholders, including our new e-Learning online training program, streaming videos, interactive tools, and downloadable safety programs at texasmutual.com. Even those who aren’t policyholders can take advantage of free Texas Mutual resources at worksafetexas.com.

Tip 3: Encourage wellness.

Safety and wellness go hand-in-hand. Think of the last time you weren’t feeling well at work or didn’t get enough sleep the night before. More than likely you were not on your A-game. Taking care of our bodies by drinking plenty of water, eating a balanced diet, and staying active paves the way for happier employees and sets up employees to stay alert about safety on the job. In the unfortunate event an employee is injured, a healthy lifestyle also promotes a quicker recovery. Learn about the financial benefits of workplace wellness here: worksafetexas.com/wellness.

From empowering your employees to speak up with a “See something, say something” initiative, to being consistent in your training, and encouraging your employees to live a healthy lifestyle, making safety a habit starts with you. For more safety and wellness resources, log into texasmutual.com or visit worksafetexas.com.

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