A high-level overview of the WC claims process and tangible tips to help employers better manage their employees' comp claims to reduce overall costs.

1. Work Comp 101: The Nuts and BoltsWork Comp 101: The Nuts and Bolts
Executive Claims Consultant: Dan NevarezExecutive Claims Consultant: Dan Nevarez
1350 Carlback Avenue, Suite 200
Walnut Creek, CA 94596
License # 0564249

2. Dan’s experience as a Workers’ Compensation adjuster and defense attorney allow him to skillfully
assist you on both litigated and non-litigated claims. He will act as your advocate and provide timely
service to all commitments while taking an aggressive and proactive approach in the claims
monitoring role. He is also available to assist you with any claims management issues or concerns.
Prior to joining Heffernan, Dan spent the last 5 years in the Workers’ Compensation industry both as
an adjuster and defense attorney for a major carrier, handling claims and making appearances before
the Workers’ Compensation Appeals Board of varying complexity. Now that he is positioned on the
broker side with Heffernan Insurance Brokers, Dan is perfectly situated to help clients navigate the
complex California Workers' Compensation system. Dan is licensed to practice law in the state of
California and all United States District Courts of California.
Dan graduated from the University of Notre Dame Law School with his Juris Doctor and from
Chapman University with his BA in Political Science. A native of Southern California, Dan is an avid
runner and sports fan. He currently resides in Pasadena, CA, with his wife, Carla, and their sons,
Decker and Nelson.
Dan Nevarez, Esq.
Executive Claims Consultant
Los Angeles, CA

3. California Workers’ Compensation is a no-fault benefits
system that is designed to provide medical treatment, lost
wages, and other benefits to employees who suffer work-
related injuries.
- This presentation will provide you with a big picture
understanding of the life of a workers’ compensation claim.
More importantly, it will provide you with tangible ways you
can reduce your costs by managing your employees’
claims properly!

4. Risk Management Division
Employee
is injured
Claim is
investigated/
accepted/denied
Medical
Treatment
Medical
Condition
Stabilizes
Settlement/Closure

5. Risk Management Division
What Can You Do Before a WC Injury?What Can You Do Before a WC Injury?
(Section 2)(Section 2)
• Know the employees you have and the jobs they
do!
• Job descriptions/requirements/task analysis
• Emphasize safety with all employees and
management
• Work to create a safety culture
• Communication is key!

6. Risk Management Division
What Can You Do Before a WC Injury?What Can You Do Before a WC Injury?
(Section 2)(Section 2)
• Establish a great relationship with your
occupational clinic!
• Provide the clinic with all of your job
descriptions
• Make sure they know your willingness to offer
modified duty
• If you’re not getting the results you want, speak
up and shop around.
• Be the squeaky wheel!

7. Risk Management Division
What Can You Do Before a WC Injury?What Can You Do Before a WC Injury?
(Section 2)(Section 2)
• Implement an Effective IIPP Program! (We
Can Help.)
• The Injury and Illness Prevention Program
(IIPP) is a basic written workplace safety
program.
• An effective IIPP will improve safety and health
in your workplace and help reduce costs overall
by involving all employees, identifying
workplace hazards, correcting those hazards,
and providing effective training.

8. Risk Management Division
What Can You Do AFTER a WC Injury?What Can You Do AFTER a WC Injury?
(Section 3)(Section 3)

9. Risk Management Division
What Can You Do AFTER a WC Injury?What Can You Do AFTER a WC Injury?
(Section 3)(Section 3)
Supervisor/HR
-Call Medical Triage Service if available
-Direct employee to occupational clinic for medical treatment
-Provide the DWC-1 Claim Form
-Authorize treatment at the clinic
-Complete incident report
-Report the incident to the carrier
-Evaluate the opportunity for modified duty
-Maintain communication with the employee AND the insurance
carrier adjuster

10. Risk Management Division
What Can You Do AFTER a WC Injury?What Can You Do AFTER a WC Injury?
(Section 3)(Section 3)
Employee/Injured Worker
-Report injury/incident to the supervisor ASAP
-Call medical triage service if in place
-Complete incident report
-Complete claim form
-Attend all medical exams/physical or occupational therapy
-Provide medical slips to employer
-Maintain communication with employer AND insurance carrier
adjuster

11. Risk Management Division
What Can You Do AFTER a WC Injury?What Can You Do AFTER a WC Injury?
(Section 3)(Section 3)
Medical Provider
-Evaluate employee, address diagnosis, treatment plan, and work
status
-Communicate that diagnosis and treatment plan to the employee
-Communicate the work status to employer
-Schedule follow up exams
-Facilitate ongoing treatment
-Work with employer on return-to-work program/options

12. Risk Management Division
What Can You Do AFTER a WC Injury?What Can You Do AFTER a WC Injury?
(Section 3)(Section 3)
Insurance Carrier
-Set up claim and make initial contacts with injured worker,
employer, and medical clinic
-Verify work status and issue appropriate benefits
-Follow up with clinic regarding work status
-Maintain communication with injured worker and employer
regarding the status of the claim
-Push claim to resolution

13. Risk Management Division
What Can You Do AFTER a WC Injury?What Can You Do AFTER a WC Injury?
(Section 3)(Section 3)
A Note on First Aid Treatment and Claims:
Effective January 1, 2017, the Workers’ Compensation Insurance
Rating Bureau (WCIRB) amended the Unit Statistical Rating Plan
requiring all first aid claims be reported to them regardless of who
paid the medical fees. The intent of this amendment is to clarify and
solidify the WCIRB and the California Department of Insurance’s
(CDI) position on this topic – that all claim dollars must be reported.

14. Risk Management Division
What Can You Do AFTER a WC Injury?What Can You Do AFTER a WC Injury?
(Section 3)(Section 3)
Suggested Workflow for First Aid Claims
• Send your injured worker to your pre-designated occupational clinic for
treatment.
• Contact the occupational clinic while the employee is en route, to remind them
you have a first aid program and would like treatment within those guidelines to be
considered if appropriate.
• Confirm with the occupational clinic where they should send their resulting
medical bill(s). If you choose to pay the medical treatment directly, please be sure to
report the payment amount to your carrier.
• Immediately report the claim to your workers’ compensation carrier.
• Check on the wellbeing of your employee throughout this process and keep in
contact with your claims administrator.
• Should the injury exceed first aid guidelines, immediately provide the injured
worker with a DWC-1 claim form and complete the 5020 Employer’s Report of
Occupational Injury or Illness and forward both to your claims administrator.

15. Risk Management Division
Denied Claims/Litigated Claims/WhenDenied Claims/Litigated Claims/When
A Claim Goes SidewaysA Claim Goes Sideways
Denied Claims
Claims are often denied for a number of valid reasons. When a claim is
denied and an injured worker disagrees with the denial, they have options.
One option is to obtain legal representation. An applicant attorney will send
his client to a workers’ compensation doctor outside of the MPN to treat on a
lien basis.
The costs of liens and non-approved medical treatment in CA, can often be
exponentially more expensive than a claim that is accepted and proceeds
along the normal path.
Litigation costs also increase the cost of claims by multiple factors.

16. Risk Management Division
Denied Claims/Litigated Claims/WhenDenied Claims/Litigated Claims/When
A Claim Goes SidewaysA Claim Goes Sideways
Litigated Claims
When claims are litigated, not only does the claim cost more to resolve, but the claim
stays open and active much longer. It is not uncommon for litigated workers’
compensation claims in CA to be open for 2-4+ years.
California is an extremely liberal, worker-friendly state. Workers’
Compensation judges routinely view evidence in the light most favorable to
the injured worker. Therefore, litigated claimants often receive more benefits and
are provided more opportunity than non-litigated claimants.
Applicant attorneys work on a contingency fee basis, so they are financially motivated
to get the largest settlement possible for their clients. A key strategy to accomplish this
is to drag the claim on as long as possible.

17. Risk Management Division
Denied Claims/Litigated Claims/WhenDenied Claims/Litigated Claims/When
A Claim Goes SidewaysA Claim Goes Sideways
Fraud v. Abuse
Many of the workers’ compensation claims filed today may be exaggerated by
employees and their attorneys. However, as an employer, it is important to understand
the difference between the terms Fraud and Abuse.
Fraud can be defined as: Any person who makes or causes to be made any knowingly
false or fraudulent material statement or material representation for the purpose of
obtaining or denying workers’ compensation benefits or payments.
Abuse can be defined as: Claims which may include any one or more of the red flags
indicated on the next slide.

18. Risk Management Division
Denied Claims/Litigated Claims/WhenDenied Claims/Litigated Claims/When
A Claim Goes SidewaysA Claim Goes Sideways
Red Flags of Workers’ Compensation Fraud and Abuse
If the injured employee:
•Claims injuries that are inconsistent with facts about the accident
•Provides multiple versions of how the accident occurred
•Refuses medical tests or examinations to confirm an injury
•Stays out of work longer than the doctor prescribed
•Protests excessively about a modified position or returning to work
If the accident or illness:
•Lacks witnesses
•Occurs late on a Friday afternoon (especially if not reported until Monday) or early on
a Monday morning
•Is not associated with the employee’s job duties
•Occurs in an area not frequented by the employee
•Is not reported in a timely manner

19. Risk Management Division
Denied Claims/Litigated Claims/WhenDenied Claims/Litigated Claims/When
A Claim Goes SidewaysA Claim Goes Sideways
Investigation of Suspicious Claims and Social Media
Many employers become suspicious of claimant’s due to rumors, witness statements,
social media postings, and generally odd behavior on the part of the claimant. As an
employer, it is important to stay in communication with an injured worker. If you
have any of these concerns, immediately report them and share your
concerns with your insurance carrier.
Note: The carrier will usually require an “articulable reason” to conduct surveillance
or other investigation techniques.

20. Risk Management Division
Experience Modifications and FiscalExperience Modifications and Fiscal
ImpactImpact
California's workers' compensation experience rating system is a merit
rating system intended to provide employers a direct financial incentive to
reduce work-related accidents.
An experience modification, which is expressed as a percentage, compares the loss or
claims history of one company to all other companies in the same industry that are
similar in size. Generally, an experience modification of less than 100% reflects better-
than-average experience, while an experience modification of more than 100% reflects
worse-than-average experience.
Bottom Line: The higher the mod, the higher the premium. The lower the mod, the
lower the premium!

21. Heffernan Insurance Broker’s
Risk Management Division
• Expert Claims Consulting (WC/GL)
• Triage Services
• Return to Work Program
• First Aid/Incident Tracking Support
• HIB’s Risk Management Platform
• Loss Control Assistance
• Human Resources/Labor Law
Support

22. Heffernan Insurance Broker’s
Risk Management Division
Your Executive Claims Consultant will…
•Advise our clients on how to manage their Workers’
Compensation claims.
•Review specific claims and, where appropriate, advise the claim
examiners to either take a more proactive course of action and/or
advise if they feel claim reserves are excessive and note any claims
which should be closed.
•Coach clients and on how to proactively manage claims.
•Deliver contracted claims reviews to discuss various aspects of
specific claims. During the Claim Review all parties strategize for
the best possible claims outcome. Unit Stat Claim Reviews
specifically focus on the adequacy of the reserves and if any files
can be closed prior to the Unit Stat Filing.

23. Any Questions?