Ohio State Fund Workers' Compensation Guide

Transcription

1 Ohio State Fund Workers' Compensation Guide

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3 Thank you for choosing CompManagement, Inc. (CMI), for assistance with your company s workers compensation administration. Founded in Ohio in 1984, CMI is a privately held organization with headquarters in Dublin and serves and operates in the Ohio community on a statewide basis. We have nearly 700 colleagues based in Ohio, with offices in Dublin, Canton, Cleveland, Cincinnati, Hilliard, Toledo and Youngstown. A leader in the industry for many years, CMI consistently strives to provide superior customer service while aiding in cost containment. We hope that this reference guide will be a helpful resource in providing you with an overview of our services and pertinent program information. Of course, we encourage you to contact any of our experienced and professional colleagues when needed we are excited to partner with you in developing this aspect of your overall risk management plan. CompManagement, Inc Emerald Pkwy. P. O. Box 884 Dublin, Ohio (614) (800) FAX (614) Workers' Compensation Guide This Workers Compensation Guide is provided to CompManagement clients for general information purposes only and should not be construed as legal advice. 1

4 How May We Assist You? Our Products Alternative Rating Programs - Ohio State Fund Group Rating Group Retrospective Rating Deductible Individual Retrospective Rating One Claim Program 100% EM Cap Drug Free Safety Program $15,000 Medical Only Program Self-Insurance CompManagement effectively manages all aspects of workers compensation claims from inception to resolution by applying industry-leading best practices in conjunction with our clients service expectations. Within our claims model, we utilize an array of cost containment measures and strategies to produce the best outcomes. Investigation, customer service, medical management, return to work, subrogation and recovery efforts, litigation management, and creative settlement techniques are all underscored throughout the life of the claim by utilizing the right resource at the right time. Our clients specific claim experience dictates which approach we recommend to control costs. A comprehensive package of ancillary services including insourced medical bill review, Pharmacy Benefit Management, disability administration, loss prevention, annual seminars, business intelligence, and internal and external audits is also provided to ensure a higher level of service. Unemployment Compensation Unemployment Compensation services include account management, program administration, claims administration, development of client personnel procedures as related to unemployment compensation, training and education, benefit charge audits, tax rate calculations including common rate programs, voluntary payments, corporate changes as they affect tax exposure, and hearing representation before the Appeals Sections of each state agency where allowed. Safety & Loss Control Risk Services provides risk, health, and safety management support services to help maintain regulatory self-compliance, improve workplace safety and enhance injury prevention. Professional experts develop an organizational specific safety program that is easily administered as well as highly effective. Assistance is available in identifying areas of opportunity within loss control, safety management/accountability, risk management, regulatory self-compliance, human resources, ergonomics, behavior modification, and drug-free workplace program development. Managed Care CompManagement Health Systems (CHS) is a dedicated provider of workers compensation managed care services (MCO services) exclusively to employers in the State of Ohio. CHS applies appropriate, cost-effective care available in a quality-driven, full-service environment. Our focus is to work with the injured worker, their physicians, and our employers to facilitate a successful return to work. In 2006, CompManagement became part of the Sedgwick Claims Management Services, Inc. (Sedgwick CMS) organization, which enables us to provide our Ohio clients with access to expanded resources including: Family Medical Act Leave Administration (FMLA) FMLA administration services were developed for comprehensive intake and processing of employee leave requests. Sedgwick CMS leave tracking services comply with state and federal regulations and are customized to meet its clients needs. Professional Liability Professional liability claims management and related risk consulting services are provided for hospital systems, medical practice groups, long-term care facilities, research and teaching institutions, medical device and pharmaceutical companies, and other healthcare organizations. Programs are based on a claims management philosophy of demonstrated effectiveness in early investigation and assessment of claims, fair and equitable settlement of meritorious claims, full and sustained defense of nonmeritorious claims, active management of the litigation process, and constructive relationships with co-defendants, insurance broker and carriers, and counsel. Credit Card / Product Warranty Claims administration and related risk management services for credit card programs, consumer warranty plans and other specialized financial products with a focus on servicing banks, credit card companies, affinity groups and other issuers and sponsors of credit cards and consumer warranties. 2

5 Table of Contents Our Products... 2 Your Ohio Team... 4 Workers' Compensation Services... 5 What to do When an Injury Occurs... 6 Common Warning Signs... 8 Ohio Workers' Compensation Insurance... 9 BWC Rating Programs BWC Discount Programs Other Cost Control Methods Coverage and Payroll Information Sample Employer's Experience Exhibit Experience Exhibit Definitions Table of Contents Glossary of Terms Forms

6 Your Team of CMI Professionals Claims Management Claims representatives evaluate claims to assist employers in taking the appropriate action. Such actions include independent medical examination, rehabilitation involvement, transitional work assignments, handicap reimbursement applications and formal adjudication (referrals for Industrial Commission hearings). All claims receive prompt turnaround, from initial evaluation for compensability through potential settlement, with careful scrutiny by our experienced claims managers. Rate & Underwriting Services Your Ohio Team Rate analysts review an employer s rates to ensure that the Ohio Bureau of Workers Compensation (BWC) have calculated them correctly. The review includes a check for handicap reimbursements, overpayments, incorrect reserve amounts, etc. In addition, studies are conducted for employers that include alternative rating plans group rating, group retrospective rating, individual retrospective rating, self-insurance, wage continuation, deductible, drug free workplace, etc. Rates and Underwriting also assist employers with underwriting questions involving payroll reporting, manual classifications, audits, transfers and acquisitions. Settlements Settlement specialists facilitate lump sum settlements for state fund claims. Lump sum settlement is a cost saving measure that helps employers reduce premiums by eliminating reserves and preventing future payments in a claim. The specialists determine appropriateness and feasibility, range of settlement and coordinate the settlement offer with the BWC, employer and the injured worker or their representative. Settlement evaluations consider the employer s individual maximum value claim limit, claim reserve, future indemnity benefits including percent permanent partial awards, and future medical benefits. Hearing Administration Representatives attend workers compensation administrative level hearings at all Ohio Industrial Commission district offices across the state presenting medical evidence, sworn statements, investigation reports, payroll records, co-workers statements, and any other relevant documents for evaluation by the Industrial Commission Hearing Officer and his/her disposition of the claim. Client Services Program Management Client Services provides face to face, telephonic, and electronic contact with State Fund clients to offer consultation on claims and cost containment strategies, relay policy activity information, and ensure overall satisfaction with our services. Our service delivery team consists of Account Executives who are located strategically across the state for immediate in-person contact as well as Client Service Representatives who conduct proactive policy reviews and quality assurance evaluations for claims management, prepare reports for clients, and provide ongoing telephonic support. Risk Services (safety and loss control) Risk Services provides risk, health, and safety management support services to clients and association partners to help maintain regulatory self-compliance, improve workplace safety and enhance injury prevention. All clients have access to telephonic consultation with a Risk Analyst at no additional charge to assist them with a variety of risk, health, and safety issues. Risk Services also provides advanced consulting services to help employers implement sophisticated risk and safety management programs as well as various BWC alternative rating programs such as the 10-Step Business Plan and Drug- Free Safety Program. 4

7 What does CompManagement, Inc. do for you? Provide recommended internal procedures for processing of workers compensation claims. Provide proactive claims management and cost containment strategies. Maintain and review detailed records of claims and awards. File requests for premium reductions/reimbursements through the second injury fund. File requests for correction of erroneous awards impacting the employer s premium. Attend administrative hearings. What should you send to us? Information New claims: incident reports, investigation report, BWC form FROI- 1 First Report of an Injury, Occupational Disease or Death All medical bills All medical reports and other medical information Any other claim medical issues Contested claims Hearing issues, hearing notices, Industrial Commission hearing orders Orders/correspondence from the Bureau of Workers Compensation: claim number notifications, notices of compensation, change in claim numbers, requests for information (completed with your response); all rating and risk account information, etc. Upon request, assist in developing a safety program. Identify claims which are appropriate for settlement. Upon request, furnish an annual analysis of all industrial claims. Upon request, review clients manual classification data for proper assignment. Review BWC audit reports (supplied by the client) and classification changes. Provide service bulletins to clients regarding changes or proposed changes in the workers compensation system. Conduct annual seminars. To CMI (your TPA) Third Party Administrator CompManagement, Inc. P.O. Box 884 Dublin, Ohio or FAX: To Your MCO Managed Care Organization Workers' Compensation Services 5

8 What to do when an injury occurs What to do when an injury occurs Procedure Checklist 1. See that medical care is provided as soon as necessary Obtain prompt medical attention for the injured employee with a Preferred Medical Provider in your MCO s network. 2. Investigate the claim Obtain appropriate incident report (general accident report or occupational disease report*) completed by employee in employee s handwriting. Obtain supervisor s investigation report or statement*. Gather witness statements, if applicable*. Review claim for "Common Warning Signs" found on page 6 of this guide. 3. Obtain medical documentation The medical documentation (BWC s MEDCO-14* is one form which can be utilized) should provide a diagnosis, relationship to injury, and restrictions, if any. Your managed care organization can assist in securing proper documentation. 4. Certification vs non-certification Claim documentation should be reviewed to determine if the employer is in agreement with the injury description and each condition listed, and then the claim may be certified. The employer should then continue to monitor this claim to ensure that only appropriate medical benefits and compensation are being paid. The employer should have a valid reason for non-certifying a claim. Rejecting a valid claim only delays recovery time and may increase your workers' compensation costs. If the employer believes the claim is invalid, information must be gathered to support rejection of the claim. If you are uncertain of your position or have questions about a claim, discuss with your CMI account manager. * These forms are available in the "Forms" section of this book. 6

9 6. Return to work protocol Obtain a list of physical restrictions in writing from the physician if unable to return to full duty (BWC Form MEDCO-14). Identify a position or tasks which meet physician s restrictions. 5. Determine if Salary Continuation is to be paid - for more information, contact your CMI representative If the injured worker is unable to return to full or restricted duty within eight (8) calendar days, discuss salary continuation program with injured worker. Obtain employee's signature on the Salary Continuation Agreement (BWC Form C-55). Obtain employee's signature on Salary Reimbursement Agreement (see instructions noted on wage reimbursement agreement). Do not file without discussing with your CMI account team. Initiate payment of salary continuation. Payment of regular salary must continue from the date of the injury. Obtain proof from payroll department of payment of salary over the time period of disability. Notify CMI account manager of salary continuation. Fax to CMI a copy of the signed Salary Continuation Agreement (BWC Form C-55) with proof of initial payment of salary. Be certain to retain proof of continuing payment of salary in injured worker s claim file in case BWC requires proof at a later date. CMI will forward the information to BWC and verify receipt. Make a formal offer of transitional duty to employee, in writing, by certified mail. Notify CMI when payment of salary continuation is terminated and/or when the injured worker returns to work. Maintain contact with injured worker. Having regular communication with the injured worker is your opportunity to follow the progress of the treatment plan. In order to continue payment of salary continuation with the intent of returning the injured worker to some form of transitional duty or to move the employee from transitional duty to his regular position, the employer should request updated medical forms. ** Suggestion: Have the injured worker obtain a completed physician s update from his physician and turn in on payday when he picks up his paycheck. What to do when an injury occurs 7

10 Common Warning Signs The following, in and of themselves, and especially when considered separately, are not a valid basis for an Industrial Commission denial of a claim; they are listed only as a frame of reference for use in conjunction with a claim investigation either at the time of the initial report of injury or in administering an ongoing claim. Injured worker has been employed by company for short period of time; accident occurs near end of probationary period Common Warning Signs Late reporting Date, time and place of accident unknown; specific details of injury not recalled Cross-outs, erasures and white-outs on report Reported Monday morning, after the weekend; or accident occurred immediately after employee s scheduled days off Minor incident becomes major injury Physical injury does not match incident or is not consistent with nature of business Injured worker refuses diagnostic procedures to confirm injury Multiple parts of body injured (especially entire back ) No witnesses to accident; or witness statements are inconsistent Employee has poor attendance record or frequent disciplinary problems; job performance declined just prior to injury Injured worker can t be reached; is never home to answer the phone or is sleeping and can t be disturbed Injured worker has moved out of the state or country, or uses a mailing address other than his/her permanent residence Injury coincides with layoffs, end of seasonal work, or plant closing (dollar amount of workers compensation benefits is generally higher for an injured worker than unemployment benefits); or injured worker is in line for early retirement Employee terminates own employment just prior to or just after injury History of similar problems; outside activities that could cause injury (i.e. sports, hobbies, etc.) Employee is known to engage in secondary or self-employment Employee was involved in a non-work related accident prior to injury (for example, a motor vehicle accident) Employee s wages were recently subject to garnishment or liens Employee made major purchases just prior to injury, or recently purchased a private disability policy Tips from co-workers Excessive demands for permanency award or lump sum settlement Immediate representation by an attorney Same attorney/doctor combination have previously handled related claims Injured worker changes physicians when a release to return to work is issued YOU HAVE A RIGHT TO QUESTION CLAIMS Your rights include contacting the BWC Fraud Section (at no cost), retaining legal counsel (at your cost), or contracting with a private investigator (at your cost). If you feel there is an issue of fraud, discuss your options with a CMI account manager. 8

11 Ohio Workers Compensation Insurance Ohio is one of very few states in which the state is the sole provider of workers compensation coverage. The Ohio Bureau of Workers Compensation is the largest exclusive state fund system in the United States and the largest single line insurance company in the world. Major Entities Bureau of Workers Compensation (BWC) The Bureau is the agency responsible for setting premium rates, collecting insurance premiums, collecting and maintaining cost records, establishing new coverage, and administering state fund workers compensation claims. The Bureau also monitors self-insured employers, adjudicates complaints against self-insureds and conducts compliance audits. Division of Safety & Hygiene A division of the BWC which provides safety services to employers throughout Ohio. Currently these services are made available at no additional cost, as the division is funded by a portion of employer premiums. Industrial Commission of Ohio (IC) The Commission is the legal entity responsible for dispute resolutions. The IC employs attorney/hearing officers who decide contested workers compensation matters in each regional office of the BWC. Premium Cost Factors The amount of premium an employer must pay to the Bureau of Workers Compensation is determined by four major factors: 1. Type of Business The amount of premium an employer must pay is primarily based upon the type of work performed by employees of the company. The BWC uses over 500 NCCI (National Council on Compensation Insurance) categories (known as manual numbers) to classify rates for each type of business operation. The base rate for each manual category is annually set based upon the cost of claims within the industry classification statewide. Generally, the more hazardous the work, the higher the rate imposed. Employers should review their manual number assignments periodically to ensure the appropriate classification and verify payroll reporting methods. 2. Number and Severity of Claims Most larger employers and all group rated employers receive a positive (credit) or negative (penalty) assessment from the base rate, based upon the number and cost of claims incurred. Employers who maintain a better than average accident record receive a reduction in the amount of premium, while those with poor losses will pay a rate higher than the base rate. 3. Reported Payroll Since the amount of premium paid is directly related to the payroll reported, premiums will naturally increase to cover a greater number of workers. Again, proper reporting of payroll to the Bureau is imperative to ensure the minimum premium liability and to protect against penalties for misreporting. 4. Rating Program Selected The employer may select from several different voluntary rating options to best meet specific needs. Any alternative program should be carefully reviewed as the financial implications, qualifications and risk involved in each option vary greatly. CMI s Rate and Underwriting Department can prepare studies for the employer to determine if a particular alternative rating program or other cost saving strategy would be beneficial in reducing the employer s premiums. 9

12 BWC Rating Programs Base Rating Merit (or Experience) Rating BWC Rating Programs Employer pays premiums at the established base rates as set by BWC for all assigned manual classifications. Base rates are the average rate for all employers in the same industry classification. Employers initially starting new coverage and employers with less than $2,000 in expected losses are base rated. Group Rating Group Rating is an alternative rating program designed by the Bureau of Workers Compensation to reduce premiums paid by Ohio employers. Group rating allows employers to join together through a sponsoring association to be rated as a group. These groups are comprised of employers with better-than-average claim histories, thus allowing employers to pay a much lower premium than they would pay on an individual basis. An employer who participates in a group rating program is not eligible for any other concurrent discounts, except small deductible and Drug Free Safety Program (advanced level). Deductible Program The method by which the BWC establishes an individual employer s premium rates. These rates are impacted by the employer s individual claim losses. High claim losses result in rates higher than the base rates, causing a penalty (debit) rate. Low claim losses result in discounted rates (credit rating). The same percentage of penalty or credit is applied to the established base rates for each manual classification assigned to the employer. Individual Retrospective Rating Retrospective Rating (Retro) is a rating plan established by the BWC where the employer agrees to assume a portion of risk (cost of claims) in return for a possible reduction in premiums. The greater the assumed risk, the greater the potential reduction in premiums. The employer pays a discounted premium initially, and then for the next 10 years, reimburses the BWC for all payments made on claims occurring during the original policy year. At the end of 10 years, the employer must also pay any remaining reserve on all open claims. Group Retrospective Rating The Group Retrospective Rating Plan is a performancebased incentive program sponsored by trade associations or professional organizations for state-funded employers. The program is designed to reward participants that are able to keep their claim costs below a predetermined amount. Employers continue to pay their individual premium; however, they have the opportunity to receive retrospective premium adjustments at the end of each of the three evaluation periods. Group Retro is not for every employer. Employers may be assessed additional premium if they are not committed to improving workplace safety and accident prevention and/or do not take appropriate action to reduce the frequency and severity of accidents involving their employees. The BWC Deductible Program helps employers lower their premiums by offering an upfront premium discount in the form of a per-claim deductible. Current deductibles range from $500 up to $200,000. The program encourages employers to focus on workplace health and safety to reduce injuries and illness. Also, employers who effectively manage their workers compensation claims and related costs will see a financial benefit. However, if an employer does not manage claim costs, the deductible can exceed premium savings. Self-Insurance Self-insurance is an alternative rating plan offered by the BWC for large employers who want to take on the responsibility of paying all compensation and medical payments for their injured workers. Self-insured employers administer their own workers compensation program and can realize potential savings in comparison to state fund premiums. 10

13 BWC Discount Programs Drug-Free Safety Program (DFSP) 100% EM CAP Program The Drug-Free Safety Program is available to base-rated or merit-rated employers. The Drug-Free Safety program provides a 4-7% discount for implementing the program, depending on the level of the program that the employer chooses. This program focuses on drug and alcohol abuse prevention, education, testing and treatment. Safety Councils BWC's Division of Safety & Hygiene sponsors more than 60 safety councils across the state, organized through chambers of commerce, trade and manufacturing associations, American Red Cross chapters or other local safety-minded organizations. These safety councils provide their local communities with quality programs addressing occupational safety and health, workers compensation and risk management education and information. Employers actively participating in their local safety council program may receive a workers compensation premium discount. This discount, if offered by BWC, can be added to any existing BWC discount program, except group rating and group retrospective rating. The EM Cap Program is designed to alleviate the cost of an employer s premium payments to the Ohio Bureau of Workers Compensation (BWC) by capping their Experience Modifier (EM) by 100% from the previous policy year. The EM is the percentage of premium that is paid to the BWC. Employers must implement portions of the BWC s 10-Step Business Plan within the first year in order to be eligible for the EM Cap. The 10-Step Business Plan is a comprehensive safety program designed to assist companies in reducing workplace accidents and injuries, and therefore reducing claims costs and BWC premium payments. One Claim Program The BWC has approved a program for private employers that had participated in a group rating plan, but are no longer eligible due to one significant lost time claim. In addition, the employer may have up to three medical only claims in the past five years. Employers will receive a discount for participating in the program if they attend BWC-approved safety or claims management courses. The program may not be available every year; BWC may make annual announcements of its availability. BWC Discount Programs 11

14 Other Cost Control Methods $15,000 Medical-Only (15K) Program Other Cost Control Methods Under current BWC rules, with formal participation in this program, an employer may pay up to the first $15,000 of a medical only claim. This "medical deductible" program can result in premium savings for some employers. For example, excessive medical-only claims can affect a small employer s group rating eligibility and cause the employer s rejection from the program. Employers enrolled in a retrospective rating plan pay losses dollar for dollar. With the 15K program, medical costs would not be charged to the employer s experience. As a result, the employer may realize a reduction in premium rates. With the onset of the mandatory reporting requirements approved by Congress in December, 2007 in section 111 of the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) an employer that participates in the 15K program must register as a Responsible Reporting Entity (RRE) with the Centers for Medicare and Medicaid Services (CMS). However, if an employer elects to have CompManagement process the medical bills, CMI will reprice all bills according to the Ohio BWC fee schedule including clinical edits, track payments up to $15,000 (or lower threshold chosen by client), and complete required CMS reporting. Please contact your CMI representative for more information on this cost savings option. Transitional Duty Salary Continuation In addition to BWC rating and discount programs, salary ontinuation is a powerful option that can assist employers in controlling premiums paid to the BWC. Salary continuation is the direct payment of lost time to injured employees by the employer. By continuing to pay a salary, the employer prevents the cost of compensation and its associated indemnity reserve from impacting the employer s rates, thereby reducing the overall costs and premiums. All claims with dates of injuries on or after 1/1/2011 will be reserved for future medical. Salary continuation is a voluntary program that should be assessed on a case-by-case basis. Given the number of factors that go into a decision to pay salary continuation, it is always best to consult with your claims team at the onset of a claim. CMI has available more detailed information on implementing a salary continuation program; please feel free to contact your account team to request our program documents. A Transitional Duty Program provides alternatives to lost time and allows the employer to keep workers compensation disability costs low. Often, with minor modification in job duties or hours scheduled, an employee will be able to return to work following the injury. Sometimes a completely different job position is necessary for the short term, but we recommend that the employer try to accommodate any physical restrictions. The idea is to return an injured employee to gainful employment activities as soon as possible to avoid the disability trap. Remember that loss of experienced employees will result in training costs associated with hiring new employees. The Bureau of Workers Compensation currently offers Transitional Work Grants to qualified employers to assist them with the costs of implementing transitional work programs. For more information, contact your CMI account team for information on Transitional Work Grants and for CMI stransitional work program guide. 12

15 Rehabilitation If an employee is legitimately injured and is going to have a significant period of disability, referral for rehabilitation is imperative. All compensation and certain medical costs incurred while an employee is enrolled in a rehabilitation program are not charged to an individual employer s merit-rated experience. Your CMI Account Executive can provide a comprehensive list of certified rehabilitation service providers upon request. Employer-Sponsored Medical Examination In a situation where all other efforts fail and the employer feels the employee is capable of returning to work, or the employee s improvement from the injury seems to have stalled, an independent medical examination may be considered. In cases where the employer s independent medical examination determines if either the injured worker can return to the former position of employment or will not medically improve further, then the issue may be referred to the Industrial Commission to determine if ongoing benefits are appropriate. Your CMI account team may suggest this option to you if this situation arises. Hearing Administration Proper representation before the Industrial Commission is an important aspect of workers compensation liability. While CMI s hearing representatives are able to handle most matters on your behalf, some cases may require the retention of legal counsel. Contesting a claim is not encouraged unless clear evidence can be obtained to refute the injury or other allegation because the hearing process will result in a delay of treatment and potentially lengthy litigation. If retention of legal counsel is necessary for Industrial Commission hearings, CompManagement provides a choice for our clients. Our excellent reputation and long-term relationships with both the Industrial Commission and the legal community in Ohio have allowed us to create a network of attorneys that only our state-funded clients are able to retain at lower and prenegotiated rates. Our Choice Legal Network is compromised of firms and sole-practitioners that cover the state of Ohio. CompManagement clients can enjoy the continuity of an ongoing relationship with an attorney or firm while still utilizing our claims management services. Handicap Reimbursement Ohio has a handicap reimbursement provision whereby an employer may obtain cost relief if an injured employee has one of 26 pre-existing conditions (as established by the state legislature) complicating the injured worker s recovery or causing the injury. By review of BWC claim files and the employer's information, tremendous savings and/or reimbursements can be obtained. CMI reviews all lost time claims for the possibility of handicap reimbursement and will file the appropriate applications on your behalf. Bureau-recognized handicap conditions: 01 Epilepsy 02 Diabetes 03 Cardiac disease 04 Arthritis 05 Amputated foot, leg, arm, hand 06 Loss of sight or vision>75% 07 Residuals of polio 08 Cerebral palsy 09 Multiple sclerosis 10 Parkinson s disease Settlement 11 Stroke 12 Tuberculosis 13 Silicosis 14 Psychoneurotic disability following treatment in an institution 15 Hemophilia 16 Chronic osteomyelitis 17 Ankylosis of joints 18 Hyperinsulinism 19 Muscular dystrophy 20 Arteriosclerosis 21 Thrombophlebitis 22 Varicose veins 23 Cardiovascular/pulmonary diseases of firefighters employed as regular members of lawfully constituted municipal or township fire department 24 Coal miners pneumoconiosis (black lung) 25 Disability due to which individual has completed a BWC rehabilitation program 26 Service connected injury Settlement of workers compensation claims provides an excellent opportunity for employers to reduce future premiums. State fund employers do not pay claim settlements directly out of pocket or on a dollar for dollar basis. Instead, the amount of settlement is added in the experience rating and the pending reserve value is eliminated. The settlement process should be approached with caution by employers. Not all open workers compensation claims should be settled; CMI examines each claim on its own merits. At times however, legal counsel may be needed for the negotiation process which could include such options as confidentiality agreements or the voluntary resignation of an employee. Other Cost Control Methods 13

16 Coverage and Payroll Information Coverage and Payroll Information Business Purchases and Transfers There are many different reasons why a business may change ownership, including the full range of basic financial decisions and personal life changes. Regardless of the reason for the change, one thing many new owners overlook is the impact on their workers compensation coverage. When a new owner wholly assumes an existing business, the Ohio Bureau of Workers Compensation transfers all of the former employer s claims and payroll experience to the new owner. Any liability of the former owner's policy will also transfer to the new owner. If the new owner purchases only a part of the business, BWC will transfer only that portion of the experience. In this case, a BWC auditor will inspect the former employer s payroll records to allocate payroll and claims to be transferred. Perhaps the biggest misconception about the sale of a business and the transfer of the claims experience lies in the designation of an assets only sale or a sale with no liabilities. Although this can shelter you from most creditors of the former owner, BWC in effect considers the claims and payroll experience to be an asset of the former company. Therefore, the transfer may have a significant impact, not necessarily negative, on your workers' compensation bottom line. If there are any recent or pending changes in your business ownership or if you have questions about experience transfers, please contact the CompManagement Underwriting Department at (800) Minimum and Maximum Reportable Payroll Payroll limits apply to the following types of individuals: Sole proprietors (elective coverage) Members of partnerships (elective coverage) An individual incorporated as a corporation with no employees (elective coverage) Members of family farm corporations (elective coverage) Ordained ministers (elective coverage) Officers of corporations (covered as any other employee) 14

17 The minimum reportable payroll will be set annually at 50% of the statewide average weekly wage (AWW). The maximum reportable payroll will be set annually at 150% of the AWW. Any wages over the 150% reporting limit are not reportable to the BWC. For the current year s limitations, call CMI s Rate and Underwriting Department at (800) Maximum reportable payroll (but not the minimum) also applies to the construction industry. The reporting limit applies only to the payroll of employees reported under a construction classification. Employers in the construction industry must calculate the reporting limit on a weekly basis for every employee. It is not an averaged amount over a pay period or over a payroll reporting period. The purpose of this change is to bring minimum and maximum reportable payroll to a level that compares with the compensation allowable based on the AWW as calculated annually by the Ohio Department of Job & Family Services. Reportable Payroll Reportable payroll includes: Wages and overtime pay Direct or third-party sick pay Holiday, shift differential and vacation pay Bonuses, commissions, tips and gratuities Severance pay Rent, housing and meals Per diem travel expenses Outright stock gifts, profit sharing paid to employees as payroll Certain retirement accounts; PERS and SERS (for public employees) Other employee remuneration Non-reportable items include: Moving expenses and relocation allowances Tuition reimbursement if job related Reimbursement for travel, food and lodging if properly expensed Accident insurance premiums Employee discounts, awards and suggestion prizes Stock options Military supplement pay Life and health insurance paid by the employer For public employees, Ohio Public Deferred Compensation Check the reverse side of your payroll report for additional information and reporting requirements. (Note: this list is general and not all-inclusive for specific questions, call OHIOBWC and press 2. ) Coverage and Payroll Information 15

18 SAMPLE Employer's Experience Exhibit Received from Ohio BWC in June each year with rates effective July 1 for private employers; received in December each year with rates effective January 1 for public employers I. Calculation of the premium rate (a) (b) (c) (d) (e) (f) (g) (h) Manual Base Rate EM% Modified Admin. Costs DFWP (0.10) Additional DFWP Prem. Rate per $1 of Number Prem. Rate [(15.26)*(d)]/100 (0.001)*(b) Payroll Reported (b)*(c) [(d)+(e)+(f)+(g)]/ RN % RN % RN % II. Calculation of the individual experience modification percentage (EM%) The following is the calculation of the limited losses to be used in the application of the experience rating formula. The figures below represent the total anticipated limited losses for an average employer of your size and industry pursuit. (a) (b) ( c ) (d) (e) (f) Manual Experience Expected Loss Expected Losses Limited Loss Total Limited Losses Number Period Payroll Rate (per 100 [(b)*(c)]/100 Ratio (TLL) (d) * (e) unit of payroll) 8380 RN $3,269, $52, $28, RN $684, $1, $ RN $525, $ $ The following is the application of the experience rating formula: (a) (b) ( c ) (d) (e) Total Modified Total Limited Ratio Credibility EM% [(c)*(d) Losses (TML) Losses (TLL) [(a)-(b)]/(b) Percent Round]+1 $4, $29, % 84% TOTAL $29, III. Experience period losses In this section are listed the claims costs for all claims affecting the upcoming experience period. The Bureau analyzes claims incurred in the first four of the previous five calendar years. Claim Number Claim Comp Payments Medical Payments Injury Handicap % Injured Worker Name Type Comp Reserve Medical Reserve Type TML YR LT $1, $1, % CLAIMANT 1 $0.00 $0.00 $2, YR MO $0.00 $ % CLAIMANT 2 $0.00 $0.00 $ YR MO $0.00 $ % CLAIMANT 3 $0.00 $0.00 $ YR MO $0.00 $ % CLAIMANT 4 $0.00 $0.00 $ YR MO $0.00 $ % CLAIMANT 5 $0.00 $0.00 $ YR MO $0.00 $ % CLAIMANT 6 $0.00 $0.00 $ YR MO $0.00 $ % CLAIMANT 7 $0.00 $0.00 $ TOTAL $4,

19 I. Calculation of the premium rate Experience Exhibit Definitions Manual These are the manual classifications currently associated with the type of business being operated. The BWC currently utilizes codes as established by the National Council on Compensation Insurance (NCCI). Base Rate The rate (per $100 payroll) set by the BWC as the base to use for all premium calculations. An EMR equal to 100 would result in an employer s premium rates being equal to the base rates (before assessments). EM% Experience Modification Rate is the total percent that is applied to the base rate to determine premium rates. If EM% is less than 100, it indicates fewer claim losses (TML) than anticipated (TLL) and will result in a credit against the base rates. If EM% is greater than 100, it indicates more claim losses (TML) than anticipated (TLL) and will result in a penalty (debit) applied to the base rates. Break-Even Factor (BEF) Group break even factor (group-experience-rated employers only) - a factor applied to an employer's group discount in order to restore equity to the BWC system. DWRF The Disabled Workers Relief Fund is a fund created to provide cost of living increases to permanently and totally disabled workers with injury dates prior to By law, the maximum assessment rate is $0.10 per $100 of payroll. Additional DWRF The Additional Disabled Workers Relief Fund is a fund created to provide cost of living increases to permanently and totally disabled workers with injury dates in 1987 and after. Administrative Cost Funds the operations of the Bureau of Workers Compensation and the Industrial Commission. The rate changes each year and is a percentage of the modified premium rate. Premium Rate The premium rate is the sum of the modified premium rate, administrative cost, DWRF and additional DWRF. II. Calculation of the individual experience modification percentage (EM%) TML The total of all Total Modified Losses charged on this experience. In other words, it is the total of all compensation, medical and reserve for every claim in the experience. TLL The experience period Limited Losses that are anticipated. TLL is based upon the historic payroll of the company and the manual numbers denoting the type of operations performed. Credibility Percent - This percent is based on the calculation of Total Expected Losses. It limits the amount of impact claims can have on small employers. Generally, the smaller the employer, the lower the Credibility Percent. Experience Period Payroll This is four-year payroll (the same four years as the injury years of claims listed in Section III) as reported by the employer semi-annually (private employers) / annually (public employers) to the BWC. Expected Loss Rate A rate per $100 of payroll set by the BWC which is used to determine Expected Losses. Limited Loss Ratio Ratio set by the BWC based on the Credibility Percent and manual number. Limited Losses Calculated by multiplying Expected Losses times Limited Loss Ratio. The total of all Limited Losses (TLL) is used to calculate an employer s EMR. III. Experience period losses Comp Payments The amount of compensation paid per claim, through the BWC survey date. (For private employers the survey date is December 31; for public entities, the survey date is June 30). Payments that are chargeable include: death benefits, percentage permanent partial (%PPD), permanent total disability (PTD), settlements, temporary total (TT) and wage loss (WL). Payments that are not charged to the experience are living maintenance (LM) and living maintenance wage loss (LMWL). Comp Reserve Prediction of future compensation costs. The reserve is based on cost drivers or factors specific to the claim and statistical models. Normally, as a claim gets older, with no new comp activity, the reserve decreases. For claims that are inactive, have been settled, or where the injured worker has died due to causes unrelated to the claim, the reserve should be $0. Medical Paid The total amount of medical payments charged per claim, through the BWC survey date. Experience Exhibit Definitions Medical Reserve Prediction of future medical costs. Medical reserves are assessed in lost time claims and as of 7/1/2010 any active medical only claims are reserved. Handicap % - If a handicap reimbursement has been granted on a claim, the percentage of reduction will be noted here. The Total Modified Losses listed for the claim will already be reduced by this percentage. 17

20 100% EM CAP Program - The EM Cap Program is designed to alleviate the cost of an employer s premium payments to the Ohio Bureau of Workers Compensation (BWC) by capping their Experience Modifier (EM) by 100% from the previous policy year. $15,000 Medical-Only ($15K) Program - An option for state fund employers in which an employer can elect to pay the first $15,000 of medical bills for medical-only claims. Compensation - Money paid by BWC or a self-insuring employer to an employee for lost wages due to a work-related injury or occupational disease. Course of Employment/Arising out of Employment - In the course of employment means that the injury must occur while the employee is performing some duty for the employer. Arising out of employment means that the injury must bear a direct relationship to the employment situation. Glossary of Terms Accident - An unforeseen incident that occurs as the result of being in the course of or arising out of employment on premises controlled by the employer, or at an employer-sponsored function. Acute - The time period immediately following an injury, which includes the time expected for normal healing and recovery. Adjudicating Committee A committee composed of three members, appointed by the BWC Administrator, that reviews requests or grievances filed by employers regarding risk or premium-related matters. Allowed Condition - A medical condition recognized as a direct result of an industrial injury or occupational disease. Appeal - A formal notification that either party is dissatisfied with the decision of the BWC or a hearing officer and wishes the next hearing level to consider the claim again and render a decision. Average Weekly Wage - The calculated average of the injured worker s earnings in the 52 weeks prior to the date of injury. This is to be paid beginning the 13th week off work, at a rate of 66 2/3 % of the calculated wage. Base Rate - A premium rate based on the average, combined claims experience of all employers in the same industry (manual) classification. Break Even Factor - Group break even factor (group-experiencerated employers only) - a factor used to calculate the premium rate for group-experience-rated employers to restore equity to BWC systems. Bureau of Workers' Compensation (BWC) - The legal state entity which administers claims, collects premiums and monitors compliance with the Ohio Revised Code and the Administrative Code. Certificate of Coverage - A certificate issued to an employer that shows effective dates of coverage. Certify/Certification - The indication by the employer that he or she has determined the injury or occupational disease to be valid and has accepted it. Chronic - Pain or disability that extends beyond the time period expected for normal recovery. Date of Injury (DOI) - The date an employee suffers an injury or contracts an occupational disease at work. Deductible Program - The BWC Deductible Program helps employers lower their premiums by offering an upfront premium discount in the form of a per-claim deductible. Disability - A change in an individual s capacity to meet personal, social or occupational demands, or statutory or regulatory requirements. Disabled Workers' Relief Fund (DWRF) - A fund that provides permanently and totally disabled workers with a supplemental stipend to offset increases in the cost of living. Drug-Free Safety Program (DFSP) - A BWC rate program which offers a premium discount to eligible employers for implementing a program addressing workplace use and abuse of alcohol and other drugs, including prescription, over-the-counter and illegal drug use. Ergonomics - The science that seeks to adapt work or working conditions to suit the worker. Experience Exhibit - A statement sent to each experience-rated employer that shows how BWC calculated the final experience modification (credit or penalty applied to the base rate). Experience Rating The method by which the BWC establishes premium rates. Premium rates are impacted by the employer s claim losses. High claim losses result in rates higher than the base rates (penalty rated). Low claim losses result in discounted rates (credit rated). The penalty or credit is applied to the established base rates as set by the BWC for all assigned manual classifications. Fee Bill - A request by a health care provider for payment of services rendered. Fraud - In workers compensation, an intentional act or series of acts resulting in payments or benefits to a person or entity not entitled to receive those payments or benefits. Full Weekly Wage (FWW) - The comparison of the injured worker s wages for the last full week worked prior to the date of injury, less overtime, and the average of the injured worker s wages for the last six weeks worked prior to the date of injury. The higher of these two figures is chosen as the full weekly wage and paid to the injured worker at a rate of 72% for the first 12 weeks of the injured worker s disability. Claim Number - A number assigned to a claim for identification. Functional Capacity Evaluation (FCE) - An assessment to determine an injured worker s ability to meet occupational requirements. 18