1171 explain both sides please

[tweety00]

1)1171 Intestesting how you say employer/ carrier .. so are you saying that the EMployer has ALOT of say in How the employee is treated ...


2) Or does the 3rd party carrier not involve the employer since they are paying the carrier for the service ??
3)How about explaining just how this "mods" work as in x amount ofmoney paid ..

4)I would like to understand Just how much the employer is paying for the w/c coverage ... Verse what I pay for private health insurance through BB .
See I am trying to understand Both sides of the story !

5)You said its based on payroll or am I lost !?

[Pooh]

tweety

The company I worked for was self insured - so lets say that they paid the first 1/2 million themselves.

Basically this included doctors and PA visits on site, PT visits for the injured workers and occupational therapy. The company I worked for had all of this on site so workers could still work and attend therapy then go back to work.

Any on site nursing staff is not counted as part of the figure - but counted toward payroll itself as preventative treatment.

Once an injured worker goes off site for treatment, then the TPA gets involved in the care for some of the employees. Not all - I was just one of the lucky ones that got assigned a NCM from the TPA. For CTS normally a nurse from the plant would act has the NCM for those employees. It depends on the severity and what the consider the dollar amount of the case actually.

Now the checks will be issued from the TPA. For TTD they are normally already issuing the checks out of the set aside fund that the company has set up just for that. (If I remember correctly) So say if they figure on site treatment will cost roughly $100K a year - then they have a set aside with the tpa of $400K.

As far as control of who you see - they still have control over who you see to an extent. Remember, there are still state laws involved here. So if you have no patient/doctor relationship going on - and you are sent to another doctor and they want to switch you to a different ortho lets say - with good reason - then if the TPA puts you back to the one that lets say won't listen to you and that you don't trust - then you can go to court to see the doctor that was recommended by the doctor you just seen. Most don't want to waste time in courts so will approve the new doctor if they are on their approval lists.

Hope this helps some from what I have learned

[1171]

I use the "emlpoyer slash carrier" word combination a lot (employer/carrier) because all states allow self-insurance -- like pooh described -- and the degee of separation between comp decisions of carriers and employers ---like you suspect ---is significant

Unless the employer is very large, they are insulated for the most part, from the decisions of the carrier/adjuster. The largest policyholders have account reps who keep the employer's management and HR dept upto date on high cost claim activities.
smaller accounts get little say in how claims are handled.

experience modifications are accounting methods that use complex mathmatical formulas to raise and lower an employers rate and therefore premium based on how much worse then average or better then average their past losses compare.

employer's premium is calculated by multiplying the payroll in a classification times the rate times the exp. mod e.g.
$600,000 x 3.41 x .88
where $6ooK is the payroll for the classification (say "drivers") and 3.41 is the state-wide rate for all drivers and .88 is that employers experience modification (less then 100 is better then normal and above 100 is worse then normal)


does that help?

[chrischris]

1171, Being nicey nice has earned you 4 Stars! Ok, enough already!!!!!!! It's not you!!!!!!!! BTW: What are the new medications you are taking? One smiley here and there would suffice. Just my opinion, which is usually off the wall!

[tweety00]

Yes thank you 1171 It does help to somewhat understand
and hint hint the smileys really do help !! lol
So If the employer has a bunch of Small injuries does that raise their mods then

or is that just their tactics about trying to keep theaccidents down low ?

I mean most of the times the tiny stuff doesnt need to even be reported .. Ive had hot water go allover my front but didnt turn it in since I knew it was going to be something that wouldnt heal and not cause any lost
Or am I wrong about the small stuff .. since here they dont need to turn it in untill you have been taken off work right ?iowa 4 days off !

[Dallas307]

Just a note- I also sell WC-frequency and shock claims drive a modifier-so a company can have a lot of small claims and drive the mod- or just one serious claim and drive the mod--a combination is real dangeruos to a mod.
Also 1171 the state sets the rate however in addition to the mod carriers are allowed to file and all do get diveation factors. This means they can discount the state rate up front and are also allowed to give additional discounts- for example if I have no diviation and have the straight rate our company can take a relativity discount up to 40%- when we filed for a 15% diviation we can cut the state rate and we are still allowed up to a 40% discount after that. this 40% can go either way-meaning a carrier can also add up to 40% to the premium- this is what makes the market competitive-the company I work for only sells and handles WC policies--we are very strict in what we write and many compaanies will not write companies less than x amount of premiums- others will write only big premiums- and some have to write all but also an excess carrier who writes over the WC policy has a say in many risk. I hope this was not too confusing

[tweety00]

the firstpart helped me Dallas so thank you
Now you say that a bunch of small claims will drive up the mod .. or 1 big claim will do the same ..
So doesnt the w/c know just how much this would be based on the drs reports as to If its going to be amajor claim right away ..
So is that why they offer a fast settlement hoping that you just want out of the system before you find out that
AFTER you settle that your own insurance isnt going to cover anything the rest of your life on the injury right ???
Personal ??? How can the employer not carry insurance and how do they get away with it ..
Shouldnt this show up someplace if they didnt have it .. or canthey just sweep it under the table when They finally buy insurance ?

[Dallas307]

Tweety- there are so many things that do so many things- there are 2 I think states that are monopolistic------- let's not go there for now
Texas is not a mandantory WC state- meaning every other state demand WC coverage
The employer has pretty much no say-only opinions-in a settlement truly- even if they have a large deductible ( some think the are self insured-they are not they just have a large amount of money being paid out of the company) IC claims people do not handle claims based on underwriters or sales or mods-they are so far apart from each othere- if they work as a team in the selling of a policy that is a good thing- but- once there is an injury underwriters have nothing to do with the policy until renewal and the reaccessment of a mod and loss frequency
Here it is very dangerous not to have WC because the company can be sued and that is a whole different and financial issue
but as for as settlements go in TX there are no settlements and you will have life time medical for that injury----------------other states take your rating then throw in money to buy back your future medical ---- my personal suggestion would be that if you are not medically stable and you are in need of years of medical- never settle out your medical unless you ar getting an annuity and a medicare set aside option--- also not sure how many stes can do this but here an employer can choose to pay benefits out of thier pockt on a voluntary basis- and then tell the IC I can not do this any more- please take it from here- but the case is reported and we (IC) will do the investigation and follow the case the entire time-----I may be over your thought process but trying
we the experianced know how to reserve a case- meaning- can tell how much a claim is going to cost- so we set reserves to cover that injury-any changes in the medical processs can change the outcome of the resves set aside to handle the case-----------people need to remember that WC premiums are based on this as well as the mods-------so frequency of 15 less than 1000 dollar claims is just as a dip into a mod as 1 milllion dollar case-
WC premiums are based in just that for your companies-----think about your car insurance the premium may be guess- 1200 a yr but if you get into a wreck and the claims is 65K then if the claim is your fault then your premium will go up----------I had a fire in my house 3 yrs ago the entire claim was 240K----- my home owners policy is like 1300 a yr------ my premium did not got up-----------not my fault------ cars the same if an accident is your fault your premium will go up- am I confusing you more?

[tweety00]

I do follow you Dallas I get it ..
It just so frustreting that employers dont care only care about the ool mighty dollar ..
But then again the way the world is now bucks get you places not value of life , or kindness , etc
So think of this like buying a policy just its for care of someone else who bottom line is do it ascheap as possible .
save the buck ..
Thats really sad !
Just thought of this though , when i buy this policy I do have some say as to how much for eachtype of coverage that I wanttopay for .. extras that I can add on ..

Darn it bites to be this smalltown girl who thought the world was fair lol sorry venting ... must let the anger goo keep repeating this lol

[ksgirl]

Hey Tweety, nothing wrong with feeling anger. We just have to try to keep perspective. I have about had it with my insurance adjuster. Thankfully my attorney is going to start dealing with her. The only thing is, he wants to get us in a three way conversation Monday to find out why I haven't received a check in over a month!