Claims Administration Strategies
Introduction
There are many things that an agency and the claims coordinator can do to
help in managing workers’ compensation costs and the amount of lost time
for their injured employees. SORM is actively pursuing these goals and is
available to assist in achieving them.
Prompt Reporting
Once an injury has occurred, it is important that the injury be reported
to SORM immediately. The claims coordinator should work with the supervisors
to rsemind them that early reporting of injuries is crucial to the investigation
of the accident, evaluation of the claim, and management of the claimant’s
medical care appropriately. It will ensure that proper medical care is started
quickly and will allow the claims adjuster to start benefits in a timely
manner.
It is also important that the claims coordinator timely report to SORM when
an injured employee returns to work. Supervisors need to relay this information
immediately, along with information about sick and annual leave used to
prevent overpayment of income benefits.
Frequent Contact with the Employee
Studies show that frequent contact with injured workers can help to
return them to work sooner than if there is no contact. When the employee
feels that their employer is concerned about their recovery, they
will mentally recover sooner and be more likely to return to work.
SORM recommends that claims coordinators call each injured employee
once a week to keep records up to date and to keep the employee informed
on agency happenings. Claims coordinators should also encourage employees’
supervisors to call injured workers about returning to work. Please
refer to SORM’s Risk Management
for Texas State Agencies guidelines.
Return-to-Work Programs
SORM is a valuable resource that assists in assessing health and safety
risks and makes risk control recommendations to eliminate and/or reduce
losses. However, some accidents and injuries will occur. When an injury
occurs, it is then incumbent upon state agencies to help the injured employee
to return to work as soon as possible.
A number of state agencies and private companies have had success with structured
return-to-work programs. A successful program can greatly benefit both employees
and state agencies. These programs involve maintaining frequent contact
with the employee and medical provider, providing a modified work environment
and/or work assignment, or providing alternate-duty assignments that return
the employee to the workplace within his or her temporary medical restrictions.
These measures assist the employee in maintaining a positive attitude and
reduce the costs associated with a lengthy absence from work.
Return-to-work programs allow injured employees to work within their abilities
and within temporary medical restrictions. During this time of work restriction,
the employee is said to be on modified or alternate duty. The employee may
be doing their regular job with modification or they may be assigned alternate
responsibilities unrelated to their usual job. Along with programs aimed
at loss prevention and loss reduction, the return-to-work program can lower
the agency’s workers’ compensation costs and reduce the necessity to hire
additional staff. Providing the injured worker with an opportunity to return
to the workplace in a productive capacity will encourage the worker to return
to their regular position much sooner. Although some job modification and/or
accommodations may need to be made, many positions can be modified with
very little expense.
Please refer to SORM’s guidelines regarding return-to-work programs
in Risk Management for State Agencies Volume III, Section
One, Chapter 5.
Each agency’s Americans with Disabilities Act (ADA) coordinator may also
have additional information on the topic of reasonable accommodations for
persons with disabilities as defined by the ADA.
Health & Safety, Wellness, and Risk Management Programs
The Legislature has mandated that state agency risk management programs,
health and safety programs, and return-to-work programs must be developed
and implemented in accordance with SORM’s guidelines, per Section 412.051,
Texas Workers’ Compensation Act. These programs must be approved by SORM.
Bona Fide Offers of Employment
A bona fide offer is a written offer of employment delivered to an employee
during the period for which benefits are payable. Bona fide offers of employment
should be made once the employee has been released to modified duty as reported
on the DWC-73 form by a doctor. Bona fide offers of employment can greatly
reduce a claim’s cost by getting employees back into the workplace to perform
duties not threatening to their injuries. Workers are likely to return to
their full-time positions more quickly if they take on a modified-duty job
rather than staying home. Claims coordinators must coordinate bona fide
offers of employment with their agency’s human resources staff.
The written offer must clearly state the following:
- The position offered and the expected duration of the offered position;
- The duties of the position;
- That the employer is aware of and will abide by the physical limitations
under which the employee or his treating physician have authorized the employee
to return to work;
- The maximum physical requirements of the job;
- The wage; and
- The location of employment.
- The training that will be provided, if necessary for the position being offered.
DWC considers the following items when determining whether an offer of
employment is bona fide:
- The manner in which the offer was communicated to the employee;
- The physical requirements and accommodations of the position compared
to the employee’s physical capabilities and that training that will be provided, if necessary for the position being offered; and
- The distance of the position from the employee’s residence.
Employment is “geographically accessible” to the injured employee if it
is within a reasonable distance from the employee residence unless the employee
proves with medical evidence that their physical condition precludes traveling
that distance.
If the employee returns to work or is cleared for the work by their physician
but refuses to accept the work, income benefits may be suspended.
It also is important that SORM receive copies of all correspondence dealing
with a bona fide offer of employment. Therefore, always send the adjuster
a copy of the letter when the letter is mailed and when an employee’s response
is received.
January, 2005
Updated Sample Letter for Bona Fide Offer of Employment available here.
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