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 remind 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 talent management staff.

The written offer must clearly state the following:

1. The position offered and the expected duration of the offered position;

2. The duties of the position;

3. 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;

4. The maximum physical requirements of the job;

5. The wage; and

6. The location of employment.

7. 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:

1. The manner in which the offer was communicated to the employee;

2. 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

3. 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.

Employment and the sample instructions that should be sent along with the letter.
Bona Fide Offer of Employment Sample Instructions
EMPLOYEE’S INSTRUCTIONS PLEASE FOLLOW THE INSTRUCTIONS BELOW:

  1. Read carefully the attached letter. If this letter is not clear, please contact our office immediately for clarification.
  2. Submit a copy of this bona fide offer of employment to a physician for their consideration before accepting the offer and/or returning
    to work.
  3. Please check the appropriate space below indicating acceptance or denial of the offer of employment.
  4. Sign and date the form.
  5. Return the letter immediately. A phone call may be made to accept or not accept the position. Refusal to accept the bona fide job offer could result in the termination of your income benefits.

Bona Fide Offer of Employment Sample Letter
The following information should be included in the letter for a bona fide offer of employment. Also attach a copy of the doctor’s restrictions.

CERTIFIED MAIL RECEIPT REQUESTED

Dear (claimant):

Our office is in receipt of medical information from Dr.________________
outlining the restrictions under which you are able to return to work .
Our office will abide by the physical limitations as outlined by the physician.

In accordance with Rule 129.5 of the Texas Workers’ Compensation Commission,
the following information is provided to you for consideration as a bona
fide offer of employment.

1. Position title

2. Hours of duty:____a.m. / p.m. until ____a.m. / p.m.

3. Wages: $____Hourly $____Weekly $____Monthly

4. Job description, including duty hours, and maximum physical requirements
of the position (lifting and approximate lbs.; approximate time stooping,
pushing, standing, sitting, etc.):

5. Address, location, and duty hours of the offered position and approximate
distance in miles from employee’s residence:

Should you have any questions, please contact the undersigned below.

Sincerely,

At the bottom of the letter the claimant should be required to fill out
the following information.

Claimant:

____ I have read and understand the requirements of the position and accept
the position.

____ I have read and understand the requirements of the position but do
not accept the position.

___________________________________
Signature

_________________________
Date Signed