Download
1 / 78
800 likes | 1.04k Vues
Claims Management 101. Robert M. Sklar, BS, CRCP, ARM. So Why and I here at 8:15?. What is involved with a Workplace Injury Claim How does the claim evolve – good vs. bad What does Safety have to do with these claims Why should I care? What are the financial drivers
E N D
Claims Management 101 Robert M. Sklar, BS, CRCP, ARM
So Why and I here at 8:15? What is involved with a Workplace Injury Claim How does the claim evolve – good vs. bad What does Safety have to do with these claims Why should I care? What are the financial drivers What impact can I have on claims What can I learn from claims data What priorities should I have based on my claims data
But Wait! • I am just the Safety Person. Does this really matter? • If you are just the “Safety Guy”, No! • If you are a Safety Professional, Than Yes! • A Safety Professional is a part of the organizations Risk Management team, like it or not!
Regulations on the Increase 2009 HIPPA COBRA IRA TRFARA FMLA ADA FSLA FRA OSHA HMO MSHA ERISA EEO FDA EPA FUTA ADEA MSSA LMRA IRS FLSA FICA Case Law Common Law FRA OSHA HMO MSHA ERISA EEO FDA EPA FUTA ADEA MSSA LMRA IRS FLSA FICA Case Law Common Law EEO FDA EPA FUTA ADEA MSSA LMRA IRS FLSA FICA Case Law Common Law LMRA IRS FLSA FICA Case Law Common Law 1900 Case Law Common Law Common Law
Safety • Identifying hazardous working conditions • develops strategies to eliminate or mitigate the identified hazard. • Provides accident injury and illness profiles and data • Identify accident trends, sources, and factors that contribute to occupational injuries and illnesses • Safety training programs: • Workplace violence Driving • Ergonomics Lifting & Moving • LOTO HazCom/HazWopper
What does Safety have to do with Claims? • Everything! • Claims are the result of failure. • Management of Claims is managing failure! • Failure to act in a Safe Manner • Failure to maintain Proper Housekeeping • Failure to use proper PPE • Failure to Drive or Work Safely. • Failure to adhere to Safety Policies
Workers’ Compensation - Defined • A law in each U.S. state that requires employers to assume obligation for employee injuries and some occupational illnesses, as defined, that “arise out of and in the course of employment.” • Such obligation applies regardless of fault. The obligation can be satisfied by an insurance policy or by an approved self-insurance plan.
Workers’ Compensation • Medical Treatment • Payment of lost wages • Payment for medical expenses • Return to Work Program • Vocational / Occupational Rehab • Legal Expenses • Psych Expenses • Permanent Disabilities • Claim Settlement • Lifetime claims
Let’s talk about Claims • Where does a claim start? • Employer Knowledge • Personally Reported • Verbal or Written • Evidence of Medical Treatment • “Oh yeah, he did say he got hurt, but never told me it was work related….” “So I never reported it.” • Sometimes your first notice is a Petition or legal action.
Definitions • DOL = Date of Loss (Date of Injury) • LT = Lost Time - When more than x days off work • TTD = Temporary Total Disability • The temporary wages paid during time off (66 2/3) • PLUS any medical bills (statutory coverage) • TPD – Temporary Partial Disability • Can work limited duty but not full time • Partial Benefits are paid to supplement wages • MMI = Maximum Medical Improvement • The doctor deems your as well as your going to get • No further improvement is ever expected
Definitions • RTW = Return to work • The employer can accommodate the employee’s restrictions and provide some form of job to the employee (can be temporary or permanent) • AWW = 13/26/52 Week Average Weekly Wage • The employee’s gross salary for 52 weeks prior to the injury is added and then divided by 52 to derive the average weekly wage.
Definitions • IW – Injured Worker, Claimant, Applicant • EE – Employee • ER – Employer • DC – Defense Counsel • AA – Applicants Counsel
How does a claim start? • You've done it a thousand times. • It comes naturally to you. • You know what you're doing. • I don’t need to worry about that. • I can take care of myself. • Etc. • Etc. • Etc.
What is a Acute Injury / Traumatic Injury? 1. A traumatic injury is a wound or other condition of the body caused by external force, including stress or strain. 2. The injury must occur at a specific time and place, and it must affect a specific part(s) or function(s) of the body 3. Must be caused by a specific event or incident, or a series of events or incidents, within a single day or work shift + =
Cumulative Injury or Occupational Disease? • An Occupational Disease is a condition produced by the work environment over a period longer than one work day or shift. • The length of exposure, not the cause of the injury or the medical condition which results, determines whether an injury is traumatic or occupational. Examples: The condition may result from infection, repeated stress or strain, or repeated exposure to toxins, poisons, fumes or other continuing conditions of the work environment, carpal tunnel from daily use of computer keyboard, etc.
How does a claim start? • Employer Knowledge. • Once the employer has knowledge than a claims MUST be filed with your insurance carrier / TPA. • Even if you think it is False / Fraudulent • Employer may be aware of accident • Local Manager or Supervisor • Some States – Treating Physician can initiate a claim by filing a treatment form. • Late reports can result in penalties against the employer
Benefits of early claim notice • Provides baseline / time line for claim investigation • Documents incident facts while they are fresh • Witnesses • Symptomology • Recovery potential • Identification of Red Flags • Direct Care
Investigation of Claim • Employer and Insurance Carrier investigate claim • Contact Employee, Supervisor, Witnesses, review medical reports, policies, etc. • Adjuster from Insurance Carrier/TPA may call and take recorded statements (Not all States) • Determine if REDFlags exist? • Make a decision to Accept, Delay, Deny or take other action. • Often anything other than accept Litigation.
Claim Process – Red Flags • Horseplay • Unauthorized activities • Assaults • Timing • Delayed reporting • Conflicting evidence • Outside activities • Nature of injury • Treatment
Suspect Fraud? • Refer to SIU • Refer to State Insurance Commission Usually want to deny the claim and let the Applicant prove their claim in court. Prepare for Litigation – you need to defend your denial
Directing Care • Established relationship with Occupational Medicine Clinics • Some states you can tell the worker where to treat • Medical Management • PPO • MCO • MPN • Workers will try to treat with friendly doctors • Keep out of work • Delay medical reports
Directing Care • Options against malingerers • Independent Medical Exam (IME) • Nurse Case Management • Compensability review • Current condition denial • Partial denial • Do not authorize further treatment • Legal review
The Workers Comp Claims Process • Three point contact by adjuster: • Contacts employer • Usually the reporting Manager (Investigation) • Contacts “Gate Keeper” Doctor • Confirms the injuries (Any Red Flags) • Contacts employee • Statement / Recorded Statement • Adjuster starts running diary • Administration of claim • Medical payments, drug payments, rehab etc • Case Management, Litigation, Claim Determination
Compensability Decision • Injury vs. Occupational Disease • AOE/COE • Pre-existing, Major Contributing Cause • Presumptions • Operational / Employment issues – WC is not a dumping ground for bad employees • HR Issues • LP Issues Make sure to SHARE information
Claim Decision – Time Critical • Your Carrier / TPA reviews the claim and determines what benefits the employee should receive. TPA notifies the employee by mail and by phone whether claim is accepted, delayed, or denied. • If the injury is delayed or denied, employee can file for disability benefits (STD) or State Benefits from EDI or Similar Programs. • If the injury is approved as work related and the employee receives a temporary disability check from the Carrier / TPA if the employee remains out of work. • If the injury is approved and the employees remains at work, medical care is continued.
Accept Claim • You pay for everything • Benefits are issued based on State Specific criteria • Loss Time Payments are generally 66 2/3% for Average pre-injury wages • Light duty needs to pay at their pre-injury wages • Provide treatment, move case toward closure
Deny the Claim • Litigation • Go Away • Some claims can be denied even after initial treatment • May still have some payments on the claim • Litigation adds 30-40% to the value of the claim • Improper Denials – Recent RICO Case
Retaliation Claims • Workers will get hurt • Workers will get terminated • Workers will hire attorneys • Workers will allege that their termination was a result of filing a Work Comp Claim. THE BURDON OF PROOF WILL NOW BE ON THE COMPANY TO PROVE OTHERWISE
The Workers Comp Process (Timeline of Events) DOL – Employee is injured or claims Occupational Inj. L.T. – Employee is injured badly enough to remain out of work for more than x days. Now considered a lost time claim. Dr. determines employee to be T.T.D., P.P.D., or allows the employee to return to work with modified work restrictions.
The Workers Comp Process (Timeline of Events) Employee reaches M.M.I. - If employee can R.T.W. Dr. gives employee an impairment rating. If employee cannot return to work (due to employer’s inability to accommodate or Dr.’s determination) Dr. gives employee a vocational disability rating.
The Workers Comp Process • Doctor’s Physical Impairment Rating (RTW) • The doctor’s impairment rating is a percentage of impairment to the body as a whole. This percentage indicates the amount of the body that is not functional after the injury. Example: The employee has a back injury that requires surgery. He reaches maximum medical improvement (MMI) and the doctor gives him an impairment rating of 5% to the body as a whole which means that the employee has lost 5% functional capacity of his body as a result of this particular injury.
The Workers Comp Process • A Vocational Rating – This is a percentage of all jobs available in America that the employee can no longer perform after his injury. It is based on: • Loss of access to jobs • Loss of earnings potential • It also takes into account such factors as age and education • THIS IS A VERY SUBJECTIVE PROCESS • Lump sum payment is calculated using: Value = AWW x 66 2/3 x Voc Rating x n weeks (State Dependant) AWW – average weekly wage prior to injury n – statutory coverage in number of weeks
The Workers Comp Process (Timeline of Events) • Claim Settlement Value: • Return to Work (RTW) – The employer can provide the employee with a job. The Claim Settlement Value is based upon a formula that includes the doctor’s physical impairment rating only – Low Settlement Value • No Return to Work – The employer cannot provide the employee with a job. The claim settlement value is based upon a formula that utilizes a vocational disability rating i.e. not the doctor’s impairment rating – High Settlement Value
Return to Work • Goal of early and safe Return-to-Work • Return the worker to suitable employment with little or no loss of earnings • Employer’s Responsibilities • Contact worker ASAP after accident • Maintain the communication • Attempt to provide suitable work • Provide all information to Adjuster • Benefits can be terminated if you Offer and employee refuses work
Return to Work • Suitable employment • Productive • Available • Medically approved / appropriate • Within worker’s physical ability • Within worker’s skill set • Will not slow recovery • Not demeaning • Restores pre-injury earnings close as possible • Temporary or Permanent (ADA)
Safety Violations • Some states allow for the reduction of claim benefits or even denial if the Injured Worker violated safety policies: • Must have known about them (training) • Employer makes reasonable efforts to enforce • Employee or Employer intentionally violated rule • Injury is proximate cause to violation
Safety Violations • CA +/- up to 50% • GA up to 100% reduction (denial) • FL up to 25% reduction • OH Penalties against Employer up to 50% + $ 50K • NC +/- 10% • MO 25-50% reduction These are examples, each state is different. There is nothing that prevents you from taking corrective action with the employee.
What does the claim data tell us? • What is driving the costs of claims? • Frequency? • Medical Costs? • Severity?
Why is Looking at the Most Expensive Claims Important? • Traditional approaches to workplace loss prevention and safety focused on decreasing the number (frequency) of accidents to reduce the costs of WC. (OSHA Likes This) • Data from Insurers and Company Management indicates that more effective prevention and cost control might come from identifying and preventing those factors (costs) that turn an average claim into one of the most costly.
Why is Looking at the Most Expensive Claims Important?National Data All WC Claims Claims Costs Insurer data indicates that 15% of WC Claims make up 85% of the total Comp. Costs
Most of the 15% had noted Surgery Issues: Multiple Surgeries Failed Surgeries Predominance of Back Surgery Many noted Psychological Elements: Stress Anxiety Suicide Chronic Pain Syndrome Insomnia Psych ED Most Costly Claim Trends
Most Costly Claim Trends (Age Distribution) • Age range is 24-63 Average age is 41 Median age is 40 • The age group of 30 - 39 represents over 1/3 of the costliest cases.
Gender Comparison Frequency (Fx) and Cost ($) • When comparing cost to frequency, why do men make up a greater proportion of the most expensive claims? • Can research on this trend tell us how to reduce costs? Fx = Frequency Analysis $ = Cost Analysis
Most Costly Cost Distribution by % of Cases • Case cost ranged from $284K to $1044K • Average cost was $388K • Median cost was $343K • Why do over half of the most expensive claims range between $300K and $400K??
