Your Claims Questions Answered – How do claims affect my experience modifier?

We kicked off our new video series Your Claims Questions Answered with key takeaways on your role in the claims process and how to report an injury. This week, we’re diving a little deeper into how claims can affect your experience modifier. Watch the video below and take a look at our key takeaways to learn about experience modifiers and what it means for your workers’ compensation premium.

What is an experience modifier?

An experience modifier or e-mod is a factor applied to your workers’ comp rate that is a comparison of your company’s loss experience against other employers in the same industry as you. If your company has had severe and medical-only losses, the e-mod will adjust your premium to lower the impact of those claims. Typically only mid-to-large size businesses will receive an e-mod.

How is an e-mod calculated?

The National Council on Compensation Insurance (NCCI) adjusts and rates e-mods in Texas. They look at payroll and claim history from the past three policy years to help identify potential losses. In general, employers with better-than-average loss history will see lower premium compared to the average, and employers with below-average loss history will see higher premium compared to the average.

All data is reported to NCCI, but not all losses are entered into the e-mod formula. In some cases, a small loss will have no impact or a proportionately small impact on your experience modifier.

Always report claims

A good rule of thumb is to always report your claims. Taking care of small claims on your own is not always in your best interest and most business owners are not experts in workers’ compensation law. From missing out on network savings to opening up your business for penalties, not involving Texas Mutual is not worth the risk.

The best way to manage your e-mod is with effective loss prevention and return-to-work programs. But remember, an e-mod is a pricing modifier and isn’t always a direct representation of a company’s commitment to safety. For more information on e-mods and how to qualify for one, visit

In our next installment of Your Claims Questions Answered, we’ll share our tips on creating an effective return-to-work program for your injured workers.


Regulatory Roundup, May 26

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

The National Institute for Occupational Safety and Health (NIOSH)

eToolkit is released to aide emergency responders

hazmatEmergency responders can be exposed to numerous chemicals and although many resources are available for inhalation exposures, there aren’t many for dermal exposures. NIOSH recently began promoting the DERMaL eToolkit, which emergency responders can access on a phone or tablet to receive information about chemicals. The kit holds information on health effects, exposure assessment, control measures and medical management…MORE

Mine Safety and Health Administration (MSHA)

Pre-shift examination ruling is delayed

The final rule for improving pre-shift examinations of mines was originally scheduled to go into effect on May 23. The effective day has now been delayed until October 2, which will give MSHA more time to educate the mining community, and mine operators more time to implement recordkeeping systems for compliance…MORE

Studies, resources, trends, news

2018 proposed budget foreshadows changes to safety

Dollar BillsThe proposed federal budget has been released for fiscal year 2018 and it shows a 21 percent reduction for the Department of Labor. While MSHA would receive a small increase in funds, OSHA and NIOSH are both scheduled for a decrease in resources. Labor Secretary Acosta is adamant that the budget reflects a commitment to safe jobs in a financially responsible manner, but the American Industrial Hygiene Association has voiced concerns…MORE

Earnings pressure may lead to more injuries

Harvard Business Review recently conducted a study on the relationship between workplace safety and managers’ attempts to meet earnings expectations. The study showed that companies meeting or just beating analyst forecasts had a five to fifteen percent higher rate of injuries and illnesses. The reasoning came down to higher workloads as well as cuts to safety budgets…MORE

A lesson on the consideration of mental health

The U.S. Department of Labor shared a blog post about the importance of employment to the mentally ill community. The article urges employers to provide those with mental health disabilities the same accommodations they would for an employee experiencing symptoms of multiple sclerosis or cancer treatment. Links for resources pertaining to mental health disabilities are also provided…MORE

CVSA to hold 30th annual International Roadcheck in June

TruckThe Commercial Vehicle Safety Alliance will hold their 30th annual International Roadcheck this year June 6-8. Each year the alliance focuses on a specific category of violations while inspecting commercial motor vehicles and their drivers. Although inspectors primarily conduct level-1 inspections (considered the most stringent) this year’s focus is cargo securement…MORE


Fighting fraud for Texas employers

Fraud-Meaning-and-Definition-What-is-Fraud.jpgTexas Mutual is committed to fighting workers’ compensation fraud because it ultimately hurts business owners in the form of higher premiums. As a corporate executive once noted, if workers’ comp fraud were a legitimate business in the United States, it would rank among the Fortune 500 companies.

Last year our fraud team received 1,698 fraud referrals and followed up on each one. Read about two of those recent cases below:

Humble, Texas man sentenced on workers’ comp fraud

A Travis County district court sentenced Michael Thomas of Humble, Texas on workers’ compensation fraud-related charges. The court sentenced Thomas to two years deferred adjudication, 50 hours of community service, and to pay Texas Mutual $2,630 in restitution. Thomas reported a job-related injury while working as a commercial truck driver for Casual Leasing Services, Inc. of Houston. He claimed he was unable to work as a result of the injury, and Texas Mutual began paying him income benefits. Texas Mutual uncovered evidence that Thomas was working as a commercial truck driver for another company while receiving income benefits due to his alleged disability.

Investigators call this type of scam double-dipping because the claimant collects benefits for being too injured to work when he or she is, in fact, gainfully employed. Texas law requires claimants to contact their workers’ comp carrier when they return to work.

Truck stop owner indicted for filing fraudulent claim

A Travis County grand jury indicted James Russell Williams of George West, Texas on workers’ compensation fraud-related charges. Texas Mutual insured Williams’ company, George West Truck Stop. Texas Mutual’s investigation alleged that in April of 2014, Williams reported a workers’ compensation claim for a person who was not an employee and therefore, not covered by Texas Mutual’s policy. The person was seriously injured while changing a tire at Williams’ shop. Texas Mutual paid the claim based on Williams’ misrepresentations about the injured person’s status.

Note: A grand jury indictment is a formal accusation – not a conviction – of criminal conduct.

For resources on fighting workers’ compensation fraud, visit

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, 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 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 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

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 and visit the Safety Resource Center.

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