From WorkCompCentral comes this entertaining news – one of the ‘stars’ of the TV show AxMen got busted for work comp fraud. [sub req]
No, he wasn’t spotted hosting a Mensa meeting.
The alleged fraudster, one Jimmy Smith, has been receiving what appears to be PPD benefits (that’s permanent and partial disability for you non-work comp geeks out there) for over three years. According to the L&I’s (the Washington state work comp fund) fraud blog, Smith had two injuries back in the mid-nineties, injuries so severe that he no longer could work.
Jimmy’s just a good ole boy with a green heart and a sense of history: “I’ve got a thing about not killing tress, I’m a fourth generation logger, and I figured this would be a way to give back what my ancestors prob’ly took.” Yep, he’s a bigger than life figure, and he knows it “we’re normal guys, doing extraordinary things”.
Looks like one of those ‘extraordinary things’ was cashing disability checks while running a logging operation. And Jimmy wasn’t just sitting behind a desk. Nope our hero was out there every day, pushin’ and pullin’, cussin’ and a-yellin’, showing the young guys just how it was done.

Jimmy’s the guy in the water pulling on the rope…
Jimmy wasn’t just managing and directing. In one of the shows, Mr Smith put on SCUBA gear, jumped into the water, put heavy chains around logs, and ran a winch and a boat to drag the logs up out of the river. Not exactly “sedentary” activity – the highest exertion level he had alleged he could handle when filing for permanent disability.
He even shows his scars – one where his diaphragm was ripped loose, another from what he says was a compound fracture of both bones in the lower leg – and describes the injuries in detail, quite proud of his dedication to being “the best there is.”
Hard to see how anyone could work at a job as strenuous and exhausting as underwater logging after those horrible injuries – Jimmy’s one tough guy.
He’ll need to be, because his next starring role may be in ‘Lock-Up’.
The Ax-Men part of Jimmy’s reality TV star run may be coming to an abrupt end. Court documents indicate he’s facing over ten years of potential jail time and fines of over twenty thousand dollars.

Didn’t hear anything in Coventry’s earnings call yesterday about workers comp – even though it accounts for about three-quarters of a billion dollars in revenue and somewhere’s north of $85 million in margin – for Coventry.
Turns out I didn’t listen close enough – workers comp was mentioned twice during the call – once when discussing the Louisiana suit, and the other when describing what new CFO Randy Giles will be doing for the next few months (he’ll be “splitting his time…” between workers comp and Coventry’s six other businesses).
I’ve discussed Louisiana before – and made no secret of my view that Coventry’s been severely…mistreated…by the courts.
It is indeed encouraging to hear the new finance chief will be learning the work comp business – although Workers Comp chief David Young’s amply demonstrated his ability to squeeze ever more margin out of the sector, another pair of eyes may be helpful. As long as they aren’t accompanied by questions such as: “how many members do you have?”
My sense is Coventry’s work comp business has been squeezed just about dry. Price increases and assertive contract negotiations on the one hand, with ongoing issues with data quality – and the downstream negative impact on revenue – on the other have pushed the numbers pretty close to stasis. Emerging alternatives, brutal competition, declining claims frequency and increasing provider negotiating leverage will make 2011 a tich tougher than 2010.
Or perhaps more than a tich.

For your entertainment pleasure, I bring you Jon Coppelman’s post on an Illinois workers comp arbitrator who
– fell on courthouse steps, injuring most of his extremities
– filed a claim for “post-traumatic carpal tunnel” – anyone have the ICD 9 for that???
– ruled on carpal tunnel cases for 230 prison guards who claimed carpal tunnel syndrome from turning keys in sticky locks…
very, very entertaining.

At the end of this year, Greg Krohm, currently Executive Director of IAIABC, will be retiring. I’ve come to know Greg over the last few years, and am only sorry it has taken this long to cross paths.
Greg is one of the nominees for this year’s LexisNexis 2010 Notable People in Workers’ Compensation – and I can’t think of a more qualified candidate.
I’d encourage all to acknowledge Greg’s many contributions to the work comp world by casting their ballot for him here.
A tip of the hat to Safety National’s Mark Walls for the head’s up; his Linked-In group is the leading social networking site for WC professionals

After my post earlier this week re PMSI naming Pat Sullivan to lead their Ancillary Services DIvision, I was contacted by Gould and Lamb (currently the leading MSA vendor) who took exception to my characterization of their recent history, to wit:
“I didn’t include Gould & Lamb in that list [of companies likely to ‘push ahead’ of their competitors], as I’ve heard several times they’ve had challenges on the technical side that may have contributed to the management shakeup last fall. We’ll have to wait and see if the issues are resolved.”
Not exactly a full-fledged assault on the company, their capabilities, or prospects for the future. At least I didn’t think so. I read it a couple more times, and thought it was actually pretty mild.
G&L’s reaction was…not exactly nuanced. After multiple emails to and fro and after a call from their corporate counsel to which I took exception (Tip – if you want to get along with media, do NOT have your attorney call the writer), I asked G&L to address the specific quote from the original piece.
Here’s the relevant parts of their response, with my observations.
G&L – “We have made a substantial investment in technology and talent and as such have developed the most successful reporting technology in the industry and we have not had any technical problems on the G&L side… It is important to note that G&L not only offers an excellent reporting solution, but we have been actively working with CMS in the development of a reporting solution for the industry as whole.”
Paduda – As I noted in the original post, I heard from several sources that one of the reasons for the ‘management shakeup’ was delays and higher than expected costs associated with development of their reporting application. G&L clearly states they had no technical problems. I leave it to the reader to make their own decision; I’m not expert enough in this issue to make a definitive statement one way or the other.
2) “As we have experienced no technology issues, it stands to reason that “technology” was not part of the decision to make a change in the executive leadership at G&L. It was necessary to make changes at the executive level for reasons other than G&L products/ services or technology.”
Paduda – In an earlier message, G&L had noted issues with vision, strategy, and direction led to the replacement of staff last year; turnover in the sales staff was also noted. Again, G&L’s response differs from what I’ve been told by other sources.
G&L – “Clearly, your sources are not “credible” as the information you have regarding G&L represents rumor and is grossly inaccurate. I would also like to add that Lloyd’s [a recent deal where G&L will handle reporting for Lloyd’s syndicate members) isn’t ” just any deal” and the fact that they vetted G&L competitors speaks to the lack of technical problems they identified in our program.”
Paduda – With all due respect to G&L, I’ll continue to assess the credibility of sources on my own. Undoubtedly I’ll make mistakes from time to time – mistakes which I will disclose (and be reminded of each time I see Rob Gelb). In a case such as this where there’s no definitive ‘answer’ (unlike the Gelb situation) I’ll put out what information I deem appropriate and trust the reader to use her/his judgment.
G&L – “As a reporter of information you are also aware that the most reliable source of information is directly from “the source”.”
Paduda – In some instances that’s undoubtedly true, but in many others that hasn’t been my experience, nor the experience of ‘real’ reporters. (I don’t consider myself a ‘real’ reporter, but more an observer and commenter).
For example, Woodward and Bernstein didn’t take Nixon’s word at face value. Sports Illustrated’s reporters aren’t taking Lance Armstrong’s word at face value. Companies, politicians, individuals, heck even consultants ‘spin’ the story to suit them, or perhaps more kindly, to fit their perspective.
I don’t mean to imply G&L is in any way similar to those examples, but rather to use those examples to make the point that the ‘source’ is often not the most reliable source of information. I’m hoping to continue the dialogue with G&L as time permits.
What does this mean for you?
A couple things.
First, media relations are best handled cordially and gently. Veiled threats are rarely productive. (he said with careful understatement)
Second, Don’t take anyone’s word – unless you know and completely trust the individual – as truth. That includes mine. I will continue to report and opine here, and I sincerely hope I am always right. I also know that I won’t be – and I’m sure you’ll let me know when I’m not.

Last week’s post on guidelines elicited quite a bit of discussion – both public and private, with many vendors/suppliers/writers weighing in on the subject of what works; the practicality of guidelines and the various research methodologies and their validity.
I had a conversation yesterday with a very well-respected researcher that made me realize the post missed a critical point – without the statutory/regulatory ability to enforce/use/require/mandate/give weight to guidelines, they’re nowhere near as useful as they should be.
That’s not to say guidelines without legal ‘enforcement’ authority aren’t still helpful – there’s solid evidence that suggests sharing guidelines with providers can lead to altered practice patterns over time. I worked with a PBM client some years ago on a project involving sending letters to physicians with prescribing patterns that were well outside norms (primarily lots and lots of Schedule II drugs); there was a statistically significant change in prescriptions in the 90 days after the letters went out. Not huge, but significant.
For guidelines to really be effective, adjusters, PBMs, and employers:
a) need statutory/regulatory language that provides ‘weight’ to guidelines that meet stringent criteria in determining what drugs are appropriate
b) must provide the treating provider with claimant- and condition-specific guidelines if and when they disagree with the course of treatment prescribed by the treating doc
c) should be required to discuss the options with the treating provider, with a pharmacist or physician tasked with reaching out to the provider and provide those guidelines when requested
d) need to have the statutory/regulatory authority to not pay for drugs if the treating provider doesn’t respond or refuses to alter treatment in the face of accepted guidelines.