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The art of rooting out complicated cost-building tactics and re-pricing complex bills

The healthcare industry has an uneven compensation system. Healthcare providers, by necessity, utilize complex pricing systems and strategies that inflate costs for employers in workers’ compensation. These tactics are deployed to compensate for lost income for services provided in group and private healthcare. Without a systematic and consistent medical bill review program, employers are at high risk to overpay for medical treatments, products and services.

medical-costs-freepik-webEmployers should not be burdened with overcompensating for an imperfect healthcare system when paying for occupational injury care. Risk managers must ensure that exhaustive medical bill re-pricing processes are in place to protect their organizations from overpaying for necessary occupational injury care.

Medical bill review is not as exciting a topic as, say, strategies to counter the opioid epidemic or the impact of behavioral health on workers’ compensation. But effective medical bill review is the cornerstone of an effective overall risk and claims management program. It is important to fully eliminate the risk of even one complex and high-cost bill escaping expert scrutiny and re-pricing. One missed bill could wreak havoc on an employer’s loss budget.

Once the medical bill review process for detection of every complex and high-cost bill is established, the risk manager needs to make sure the right team of multi-disciplinary experts is in place. Medical bill review expertise must include highly skilled and knowledgeable clinicians providing oversight for complex, questionable and costly bills. Clinicians review pricing line-by-line and examine accompanying documentation of care. Nurses also identify non-applicable and inappropriate fees for the treatment documented and re-price complex bills to a reasonable rate. These experts then must document the reasons why services are being re-priced, as well as the regulatory and treatment guidelines they may fall under, to help the billing provider better understand and accept payment rationale.

Consider these three proven bill review strategies:

  1. In one common area of inflation, for example, surgical implant cost is often beyond reasonable and appropriate rates. A reliable and proprietary database exists to help bill reviewers accurately re-price charges associated with surgical hardware. Risk managers must ensure their medical bill review services are utilizing this surgical implant pricing database and implement tactics for maximum re-pricing.
  2. Providers want fast compensation for services provided. That preference for rapid reimbursement allows the effective medical bill review team to create criteria for express reimbursement. If a medical bill meets the scheduled cost criteria, the provider is offered reimbursement within a set amount of days for agreement to compensation discounted to a reasonable rate. Express reimbursement is a fair, reasonable and consistent strategy to secure additional discounts below fee schedule, usual and customary and PPO network reductions.
  3. Finally, the most costly and complex bills should always be pulled for specialty review and negotiation services, in which highly trained, specialized negotiators access targeted bill re-pricing information and agree to discounted compensation with the provider. Documentation of the negotiated agreement is accurately and consistently written to prevent a provider from later disputing the payment.

Employers receiving consistent, justifiable and well-documented complex bill review discounts have behind-the-scenes bill review systems, processes and skilled experts in place who work to re-price every bill at reasonable and appropriate rates. Risk managers: check the pulse of your medical bill review service. Ensure that it provides excellent clinicians, specialty reductions for items like surgical implants and skilled and knowledgeable negotiators to address the most complex bills.

Mary Beth Sanford, Managing Director

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apple-1051018_1920-pixabayCMS now permits some old MSAs to be re-approved

Before this week, the Centers for Medicare & Medicaid Services (CMS) had a simple philosophy: Parties get one bite at the apple when it comes to CMS approval. However, on Monday, CMS released an updated Workers’ Compensation Medicare Set-Aside Portal (WCMSAP) users’ guide that outlined a new process to have older Medicare set-asides (MSAs) reviewed and approved for a second time. This can be industry-changing, as CMS, for the first time, is allowing us a second bite at the apple. CMS calls this new process an “Amended Review.”

There are a few conditions to the Amended Review (from section 12.4.3 of the guide)

  1. The MSA must have been submitted between one and four years from the current date
  2. Cannot have previously requested an Amended Review
  3. The change in the MSA amount must be 10% of the approved MSA amount or $10,000 (whichever is greater)

Despite these limitations, this new process will allow us to submit a previously approved MSA for re-review where before this was not a possibility.

Practical impact

Parties can now go back into their inventory of recently (1 to 4 years) approved MSAs and determine if the approval was too high to facilitate settlement. If it was, current medical and prescription drug records can be reviewed to determine if the MSA can be significantly reduced. If it can, the new Amended Review process may be beneficial.

Pro tip

We only get one chance to reduce the MSA, so make sure all involved parties are relatively close to settlement at the time of the Amended Review. This will allow the parties to act quickly once the Amended MSA is approved.

Michael R. Merlino II, ESQ, SVP, Medicare Compliance & Structured Settlements

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sparklers-1845065_1920pb-webWhen in the Course of human events, it becomes necessary for one people to dissolve the political bands which have connected them with another, and to assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature’s God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.” These are the opening words of the Declaration of Independence and with these words our nation was born on July 4, 1776.

This time of year, we mark that declaration with celebrations, picnics, friends and fireworks. And for most, the days around the 4th are spent relaxing and being with family. But for many in the fire and investigation services, the 4th of July also brings extra work from people using fireworks.

Fireworks start an average of 18,500 fires per year, including 1,300 structure fires, 300 vehicle fires, and 16,900 outside and other fires. These fires cause an average of $43 million in direct property damage.   And while many states and localities have outlawed fireworks in some manner or another, the damage done from people misusing fireworks has not decreased in recent years.

To understand the problem, we need to look at the types of fireworks and causes of these fires. There are two grouping of fireworks. The first type includes fountains, sparklers and smoke bombs, which are legal in many municipalities and can be found for sale on many street corners during the holiday. When used as directed, these fireworks can generally be considered safe – the key is using them as directed. The second group of fireworks includes mortars, rockets, firecrackers and roman candles, which will leave the ground and/or explode. While many states have laws in place that allow the sale of these devices, most areas outlaw their use.

Fires caused by fireworks generally happen for one of three reasons:

  • Combustibles were too close to the fireworks
  • Firework remains were improperly disposed
  • Fireworks landed on combustible materials

Sparklers and fountains, while typically safe, can create problems when people either use them in manners not intended or in a location close to combustibles. Many fires have occurred when the person using them decides to light the fireworks next to wood chips or close to a building. One fire recently investigated was caused when the teenage occupants decided to have a “sparkler war” and were lighting sparklers and throwing them at each other. The ensuing trip to the emergency room caused that game to come to a quick end.

Many fires have occurred when the homeowner is done with their festivities and decides to clean up the remains. Most people do not realize the need to soak remaining cardboard tubes in water before placing in a trash can. Due to the types of chemicals and materials used to make the sparks and colors, the tube is treated in a manner so the fire sprays from the end and does not just explode. Once the fireworks have finished, embers can sit inside the tube for a considerable amount of time. If the homeowner places these tubes, boxes and papers inside their trash bin, the glowing embers can now ignite other fuels. Unified Investigations has been called to assess many of these fires where the homeowner placed the full can either next to the building or inside the garage. The ensuing fire then creates another show for the neighborhood that no one wants to see.

The axiom of what goes up must come down also relates to fireworks. When people send bottle rockets, mortars, etc. into the air, they have no idea where they will come down. And, like their legal counterparts, these devices will be hot when they land. One fire investigated by Unified was the result of falling bottle rockets that lit the roof of a barn on fire. Neighbors saw the fire while it was still small, but due to its location, efforts to extinguish it were in vain. The fire destroyed the barn and the house next to it. During the investigation, multiple dozens of rocket remains were noted on the ground and houses surrounding the involved building. All the fireworks were sent skyward by one house in the neighborhood having a party. The homeowner having the party ended up with both criminal and civil charges because of the incident.

When investigating firework-related fires, the investigator needs to account for not just the actions of those involved, but also the actions of people down the block. A neighborhood canvas will assist in determining the location where the fireworks originated and possible responsible parties for subrogation. The scene examination should also reveal the presence of the firework containers and tubes.

We at Unified hope you have a safe and peaceful 4th of July weekend. If you choose to do so, please enjoy fireworks responsibly.

Kevin Reilly, IAAI – CFI, Senior Investigator

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Paid family leave and paid parental leave are currently key topics for employers as they look to expand benefits for their employees. Recently, San Francisco introduced a paid parental leave ordinance and New York announced a new paid family leave benefits law. These new regulations include some elements that take effect July 1, 2017. Below is a brief summary.

bibSan Francisco

The San Francisco paid parental leave ordinance (SF PPLO) impacts all San Francisco-based employers with more than 50 employees nationwide. For example, a company with 1,000 employees across the U.S. and 25 working in San Francisco would be required to provide benefits to their San Francisco team as of January 1, 2017. Employers with 35 or more employees are required to comply beginning July 1, 2017 and employers with 20 or more employees on January 1, 2018.

The law requires employers to provide six weeks of supplemental paid parental leave to employees working in San Francisco for the birth of a child, and the placement of a child for adoption or foster care. Employers must provide up to 45% of supplemental pay so that, when combined with California paid family leave (CA PFL) benefits, employees will receive up to 100% of their normal gross weekly wages (subject to CA PFL maximums). The leave must be completed in the first 12 months after the birth or placement of the child.

Eligibility requirements:

  • Employee commenced employment with the covered employer at least 180 days before the start of the leave
  • The employee performs at least eight hours per week of work in San Francisco for the employer
  • At least 40% of the employee’s total weekly hours for that employer are in San Francisco
  • Employee must be eligible for and receiving CA PFL for baby bonding

One way that employers can comply with (or be exempt from) the SF PPLO is by providing equivalent benefits under their existing paid parental leave policy. Employers should review their policy to be sure it satisfies the following minimum requirements of the SF PPLO:

  • Applies to all employees regardless of (for example):
    • Full-time/part-time status
    • Salaried/hourly
    • Union/non-union
    • Exempt/non-exempt
  • Provides 100% of pay up to six weeks for bonding with a newborn, an adopted child or a foster child
  • Eligibility for leave cannot be greater than 180 days of employment prior to the start of the leave
  • Applies equally to mothers and fathers
  • Applies equally to primary and secondary caregivers

Another way employers can comply with the SF PPLO is by handling it under their California Voluntary Disability/Paid Family leave plan.

The following items would need to be taken into consideration before determining if this is a viable solution:

  • Perform a feasibility study if the voluntary plan is funded with employee contributions
  • Amend the CA voluntary plan to include a separate class for SF employees that would pay 100% benefit
  • Provide written notice to all employees of plan change; including the option to opt out of voluntary plan
  • File revised plan document and employee notice to EDD for approval

If employers are not able to cover the SF PPLO obligation under their existing paid parental leave policy or CA voluntary plan, then they must create a separate policy and process to comply with the ordinance.

For more information on benefits, eligibility, supplemental payments and intermittent leave, along with frequently asked questions, please see the Paid Parental Leave Ordinance on the City and County of San Francisco website.

The benefit details and compliance requirements of new paid leave laws can be complex. If your company has questions or concerns related to the new San Francisco ordinance, please contact your Sedgwick client services director.

New York

On February 22, 2017, regulations for the New York Paid Family Leave Benefits Law (NY PFLBL) were released. After the initial comment period, a revised and updated draft amendment was published on May 24, 2017, which has just closed for further public comment. The proposed regulations can be viewed here; we will continue to update you as the amendment is finalized.

The NY PFLBL will become effective on January 1, 2018 and employees will receive benefits to:

  • Care for the serious health condition of a family member, including a spouse or domestic partner, child (biological, adopted, foster or in loco parentis), parent, grandparent and grandchild
  • Bond with a new child during the first 12 months after birth, adoption or foster care placement
  • Care for a spouse, parent or child as a result of military exigency

The weekly benefit is scheduled to gradually increase in subsequent years and is based on a percentage of New York’s statewide average weekly wage (AWW). Below are the percentages for the weekly benefit:

  • January 1, 2018: 50% of weekly wage for 8 weeks
  • January 1, 2019: 50% of weekly wage for 10 weeks
  • January 1, 2020: 60% of weekly wage for 10 weeks
  • January 1, 2021: 67% of weekly wage for 12 weeks

The benefits are designed to be fully funded by employee contributions, which will be deducted from the employees’ pay. Funding rates have been finalized and are set at 0.126% of the employee’s average weekly wage (capped at the NY state average weekly wage of $1,305.92) or $1.65 per week. Employers can begin payroll deductions as of July 1, 2017.

Full-time employees are eligible after 26 consecutive weeks of covered New York employment and part-time employees are eligible after 175 days of covered New York employment. When an employee returns to work, they must be restored to the same or a comparable position that they had prior to taking PFLBL.

Sedgwick is prepared to support customers for whom we administer statutory disability claims in New York to help them comply with the PFLBL. Pending the release of the final regulations, we recommend that employers:

  • Evaluate their employee demographics to determine whether any employees meet the eligibility criteria
  • Engage with a benefits consultant and/or legal counsel for guidance on policy/plan development including updating employee handbooks or leave material to include the PFLBL
  • Prepare their payroll functions to add another deduction for the PFLBL
  • Prepare to maintain the employees’ existing health coverage for the duration of the PFLBL

For additional information on eligibility and benefits, please see New York’s paid family leave program on the New York State website.

>  This article was originally published in the edge magazine, issue 7. Click through to read additional thought leadership from our experts.

Sharon Andrus, Director, National Technical Compliance, Disability Administration

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HRMR-blog-MaleySedgwick supports Healthcare Risk Management Week June 19-23
Sedgwick’s healthcare risk management team works alongside healthcare risk managers to reduce risks and improve safety by delivering cost-effective claims, productivity, managed care, patient safety, risk consulting and other services. Taking care of people is at the heart of everything we do. Caring counts.

Providers today are transitioning to a value-based world. Financial rewards are no longer reaped based upon the volume of services provided, sometimes regardless of necessity or outcome, but instead upon positive patient outcomes and pleased consumers. Accountability for patients’ total experience is being vigorously enforced and has risen to the forefront of providers’ responsibilities. Healthcare models are changing to focus more on the health and well-being of populations, rather than on the “break-fix” model of treating individuals primarily when they experience acute episodes of illness. Emphasis is on patients’ clinical, financial and emotional status, as well as their expectations, which are assessed on an ongoing basis. The needs of specific populations and cultures must be carefully considered.

The healthcare organization-provider relationship has also changed. Institutions, once focused on pleasing providers as a strategy for maintaining and growing market share, have shifted gears to become patient-centered instead of provider-centered.

For many providers, this transition is challenging. They must actively participate in cross-disciplinary teams, often as leaders, to implement measures designed to continually improve upon the value, cost and quality of patient care.

New attitudes and new models of care

Value-based reimbursement for services has gradually gained ground, but now is moving ahead full steam. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) forged the way for value-based payments, laying out specific payment plans for healthcare providers. Plans emphasize clearly that cost control and quality care are necessary in order for payments to be approved. As a result of the sea change focused on value versus volume, providers must change their methods and, most importantly, adopt a new mindset. They must actively partner with healthcare institutions to establish, promote, and practice within a culture of safety. These transformations in business models and ways of thinking require new skills and education. Many providers, anxious to understand the complexities of the new healthcare environment are going back to school, both literally and figuratively.

New roles, new job skills, new insights

The role of “physician executive” is fast becoming one of the most important roles in the healthcare paradigm. Innovative educational programs are preparing physician leaders and other providers to focus upon the importance of quality over quantity, patient safety and process improvement. These programs are often designed to take the provider out of his or her comfort zone by exposing them to the experiences of other industries, such as manufacturing, engineering, finance and even the airline industry.

A very strong focus has been placed on the impact of systems versus individual actions. Healthcare organizations now realize that poor outcomes can be improved when process improvements are identified and acted upon swiftly instead of blaming an individual for a patient harm event. This is not news to risk management, quality and patient safety professionals. However, concepts that promote the reduction of patient harm are not necessarily well-known to others practicing within the healthcare profession. Many clinicians may have seen risk management, patient safety and process improvement as administrative functions secondary to their provision of clinical treatments.

The role of risk managers, patient safety and quality professionals has changed, too, with increased emphasis on demonstrating value and quality. A major responsibility for these professionals is to teach all levels of healthcare workers how to implement safe, standardized and evidence-based processes that enable health interventions to reach those who need them on a timely basis. Proactive, innovative means to accomplish safety goals are imperative. Data collection is important, but the actions taken following the observance of trends and/or system breakdowns make the difference in ultimate outcomes. Herein lie the greatest challenges. Actions risk management, safety and quality professionals must take to help others embrace the value paradigm include the following:

Educate – Share knowledge regarding the science of patient safety, the principles of risk management and methods of process improvement. Multidisciplinary forums, including those used after serious safety events such as root cause analyses, present an ideal opportunity to share knowledge and problem-solve as a team.

Engage – Let team players know “what’s in it for them.” Value-added services are designed to eliminate waste and streamline activities. A more efficient and joyful workplace can equate to happier employees, better communications and better patient outcomes.

Strategize – Help members of healthcare teams and departments set goals through the establishment of benchmarks that support positive patient outcomes. For example, establishing objectives to reduce infection rates can support both patient safety goals as well as financial targets through reduced readmission rates.

Promote – Secure leadership support and make it well-known that providing value to patients is part of the overall mission and vision of the organization. Use social media, newsletters, broadcast emails, job fairs, posters and other means to keep the focus on providing value to patients.

Evaluate – Implement realistic success monitors and use technology to ease the workload as much as possible. Modify measures as changes occur so they remain meaningful and applicable to patient care and workflow.

Innovate – Support new technologies. Innovation is a clinical and cost imperative. Examples of innovations include artificial intelligence, virtual reality, telehealth and biosensors and trackers, to name a few. Innovations that target, track, prevent, monitor, and treat illnesses demonstrate value. Risk management and patient safety professionals can assist in the determination of return on investment when decisions are made regarding the purchase of new technologies by factoring in the likelihood for reduction in patient harm, improved patient outcomes and patient satisfaction.

Celebrate – Create reward systems to recognize providers, staff, teams and departments that are promoting value and achieving established goals and positive outcomes for patients.

Sustain – Build in systems that check for “slippage” in improvements.

The bonus

Risk management, patient safety and performance improvement efforts are bolstered by new mandates to demonstrate value. Now, goals are better aligned, and with the dedicated efforts of healthcare staff working in teams, costs can be controlled, the patient experience will be ultimately positive and outcomes improved – the overarching aim of value-based healthcare.

> Read more from Robin and other professional liability, healthcare risk management and patient safety experts in our Risk Resource newsletters.

Robin Maley, RN, MPH, MS, CPHRM, CPHQ
SVP, Healthcare Risk Management and Patient Safety

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3D laser scanning: Essential technology in forensic science and claims

When it comes to the claims industry, documentation is essential. In order to come to a conclusion regarding the cause of a fire, traffic accident or product failure, it is crucial for forensic investigators to document in a clear and effective manner. Today, technology plays an important role in improving the quality, speed and quantity of evidence collection; an investigation can be concluded with a higher amount of certainty in a shorter amount of time. The use of 3D scanning technology allows investigators to preserve a permanent, digital copy of a scene that can be viewed virtually via computer. Investigators can conveniently observe evidence, navigate throughout different environments, and take measurements as if still onsite.

What is 3D laser scanning?Focus fire 2

There are several 3D scanning technologies available on the market today, and among the most useful for the forensics industry are 3D laser scanners. 3D laser scanning is the process of capturing millions of points of data and converting them into a virtual environment, or point cloud. These point clouds are used to produce highly accurate and realistic 3D computer models for use in many applications.

Unified employs a laser scanner that works by emitting an infrared laser at a surface which is then reflected back to the scanner. The distance from the object to the scanner is calculated by analyzing the phase shifts in the wavelength between the emitted and returning light. This technology is capable of collecting data at a rate of nearly 1 million points per second at accuracies under 2mm at a distance of 1,000ft. In addition to measuring distance, the scanner takes high-resolution photographs which are used to assign a color value to each individual point allowing for the creation of realistic, full-color point clouds.

Why 3D laser scanning?

damaged vehicleAt typical loss sites, investigators must often choose which parts of the scene are relevant to the investigation and then proceed with documentation accordingly. Often, evidence may not be deemed relevant until late in the analysis, at which point the scene or vehicle may have been changed, making measurements impossible to collect. By creating a digital copy of the scene, sensitive evidence can be preserved that may otherwise be compromised over time. Additionally, there are always “missing photographs” from an inspection that may add value to an investigation. This is no longer an excuse. By taking a comprehensive scan of the scene, typically all potential information of interest is captured and available for future use.

Traditional investigations are generally completed using a combination of tape measures, measuring wheels and photographs. Having so many tools can make documenting large, complex scenes in a timely manner very difficult. In contrast, 3D laser scanning provides more complete and accurate information in a fraction of the time. Each and every collected data point can be referenced and measured much more efficiently using specialized software. The scanner can also easily collect dimensional information that is difficult to gather due to sheer size, accessibility or safety concerns.

3D scanning technology has been around for several decades and has widespread acceptance across a variety of industries. A few examples include forensic and criminal investigations, product design and manufacturing, land surveying, medical science, film and video game production, and the documentation of historical artifacts. Companies use laser scanning to increase efficiency, provide faster turnarounds on projects, reduce labor costs, and add value to customer deliverables. Accuracy and speed lead to predictability, which in turn brings about increased profitability.

How Unified uses 3D laser scanning

  • Creation of 3D walk-throughs allowing juries/audiences to be immersed in an environment; witness points of view can be replicated and incidents can be reenacted in real time
  • Complete documentation of complex dimensional information for vehicle crush, building damage and burn patterns
  • Creation of 2D and 3D building layouts, industrial projects and traffic scenes
  • Scans of evidence, such as vehicles or other objects of interest, which can be placed in separately scanned environments to explore hypothetical scenarios
  • Scans used to increase the accuracy of calculations in engineering simulations for accident reconstruction, structural analysis and fires

Investigations have been changed forever thanks to advanced technologies like 3D laser scanning. Efficiencies and advantages can be realized when information needed by investigators is readily available for future use, no matter what happens to the evidence or the scene. If you would like to learn more about different technologies that Unified Investigations & Sciences is using to enhance our investigations, visit our website at www.uis-usa.com or read more in our previous blog posts.

Please feel free to reach out to us with questions and ideas in the comments section – we love to hear from you.

Seth Behrens, P.E., Forensic Engineer and Nic Cheek, Forensic Consultant
Unified Investigations & Sciences, Inc., a Sedgwick company

 

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Can pizza really change lives? (Those of you who can’t live without pizza probably answered with a resounding yes.) This week, a few colleagues and I had the opportunity to visit a very special place where every slice of pizza served gives back to the commuAlpha_Pizzeria_Pizzanity, sparking a continuous circle of change for those on both sides of the counter.

Last April, Sedgwick partnered with an exceptional organization called the Alpha Project, which provides work, recovery and support services to those motivated to achieve self-sufficiency. The organization was working to open a pizzeria that would be housed in, and eventually supported and staffed by the residents of San Diego’s Alpha Square, home to more than 200 formerly homeless individuals.

One year later, Alpha Pizzeria opened its doors to the San Diego community; this week, we helped the restaurant celebrate its grand opening and raise awareness in the local neighborhood by hosting an evening of free pizza and soft drinks, courtesy of Sedgwick. Our San Diego-area colleagues and other friends joined in the fun. We sampled quite a few menu items and can attest that the food is delicious!  This is, in large part, thanks to local Chef Alex Caraballo, who stepped in to develop recipes and a menu that deliver outstanding flavor and quality to the patrons. Watch the video below to hear from Chef Caraballo about how the partnership developed.

Chef_CaraballoWhat truly sets Alpha Pizzeria apart from the competition is its underlying mission to empower people to regain their footing and to live independently and with dignity. The residents of Alpha Square can now learn basic culinary and restaurant skills in the on-site pizzeria and industrial kitchen. After completing six weeks of training, they can either join the staff at Alpha Pizzeria or pursue gainful employment at other San Diego establishments.

At the event, I met Margaret, an Alpha Square resident who is starting the restaurant training program this month. As she shares in the video below, she never imagined she’d be homeless and in need of a place like Alpha Square. Her desire to find a purpose for getting up each day and doing meaningful work is inspiring. People like Margaret affirm the importance of our financial support and commitment to being present at Alpha Pizzeria. The event was a terrific representation of our caring counts philosophy.

We were honored to have a plaque installed in the restaurant that recognizes Sedgwick’s support. Jay Ayala, managing director of our western region casualty team, was on hand to accept the acknowledgement from Bob McElroy, Alpha Project’s CEO and president. Jay was quick to point out that financial support alone doesn’t solve problems; rather, it takes continual investment in helping people to effect change and make goodness happen in a community.

LeviLevi was the first person to arrive at the event and join us for pizza, and hearing his story was among the most moving aspects of my experience there. He came to apply for a position. Levi told me that the Casa Raphael program, also funded and run by the Alpha Project, helped him put his life back together after a string of addictions. He shared that his life is not perfect, but whose is? Levi is in an infinitely better place than before the Alpha Project came into his life; like many others, he talked about how the organization had saved his life and that he will forever be grateful for their care and support.

Everyone who attended was inspired and encouraged by the stories of people like Margaret and Levi. The Sedgwick delegation felt the warmth and love of all those present for the celebration.

I will leave you with a challenge. Wherever you live, there are worthwhile organizations in need of your time and talents. Sedgwick colleagues demonstrate on a daily basis the power of giving back to our communities because caring counts. Give back just one hour per week or month, and you will surely reap the rewards. We must give while we can because, like Margaret and Levi, we may suddenly find ourselves on the receiving end. Pay it forward today; you will be glad you did.

Jonathan Mast, social media director, Sedgwick

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Wdriving-933281_1920-pixabay-when it comes to getting the attention of the media and the public, not many things work better than an unfiltered, celebrity mugshot. When Tiger Woods was arrested on Memorial Day for driving under the influence, his mugshot and the story of his arrest became easy fodder for the media. The man once known for being unstoppable on the golf course was found in a stopped car, asleep in the early hours of the morning. While it is easy to assume that anyone arrested for a DUI with a rough looking mugshot like Tiger’s must have been drinking, this was reportedly not  the case with Tiger. And it may have been hard to believe when Tiger himself dismissed alcohol as the culprit early on after the news broke. Yet according to the police report, Tiger blew a .000 on his breathalyzer. Tiger was not driving drunk. Tiger was driving drugged. And drugged driving can be just as deadly.

While it’s unclear exactly what regimen Tiger was taking or what drugs led to the interaction (some of the drugs listed on the police report are incorrect as they either don’t exist, are amazingly misspelled, or have been off the market since 2004), this appears to be another example of strong medications used in combination impairing one’s ability to drive. The one drug listed on the police report that is currently available by prescription only and recognizable is Vicodin, or otherwise known in generic form as hydrocodone in combination with acetaminophen (Tylenol). Vicodin, a commonly prescribed opioid, is known to cause drowsiness, something that is only amplified when given with other medications like a muscle relaxant (a type of medication commonly prescribed after back surgery which Tiger had last month).

And like many other celebrity stories that include opioid and/or prescription drug use, stories like this can often help illuminate more specific issues connected to the current overutilization problem we are realizing in the U.S. Tiger’s DUI should appropriately point our attention to the issue of drugged driving and the fact that it is not uncommon. A recent report by the Governors Highway Safety Association shows us that for the first time, fatal auto accidents are now more likely to involve drugs than alcohol. Per the report, in 2015, of those fatally injured drivers who were tested for drugs (57%), 43% tested positive for drugs of some kind. Out of those fatally injured drivers who were tested for alcohol (70%), 37% tested positive. And perhaps just as sobering as those statistics may be, is the realization there is no current breathalyzer available to check for someone’s consumption of the various prescription medications that could cause these types of interactions and impair driving. (It is also interesting to note that, of all the discussion that marijuana is a “safer option” compared to other prescription medications like opioids, marijuana was present in roughly one-third of the positive tests for drug use.)

Employers must be aware of how these strong medications, and their interactions, can greatly impact injured workers and their ability to work at their desk or in a warehouse, as well as their ability to drive.  My team  works daily to ensure the injured workers we advocate for are getting the most appropriate medications for their injury, and for the correct duration. The issues of our current opioid epidemic and drugged driving communicate the same message – their impact can easily reach beyond the person taking the medications and change not just the individual’s life and health, but also the lives of their families, friends and communities. For additional information and support resources, visit the Drug Enforcement Administration (DEA) website. If you have specific drug-interaction questions or observations, feel free to reach out to us in the comments.

Dr. Paul Peak, AVP, Clinical Pharmacy

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quality-1257235_blogTom Peters the business guru, thought leader and author of the #1 national best-seller In Search of Excellence, says “Excellent firms don’t believe in excellence – only in constant improvement and constant change.”

Excellence is something all businesses talk about and aspire to. But how do you achieve excellent performance and results? Now that is a tougher question to answer. One starting point is to identify meaningful performance metrics across your industry that pinpoint and measure the most important predictors of outcomes and to compare or benchmark your performance against your industry’s standards and your peers. Benchmarks can serve as a basic quality measurement tool for improving performance, and thus outcomes. Tracking over time will further allow you to continuously measure your performance, and hopefully improve from one time period to the next.

At the recent Workers’ Compensation Research Institute (WCRI) annual conference, one such industry performance measurement was discussed: the rate of attorney involvement in workers’ compensation cases. Preliminary findings indicated that, among the states surveyed, the median average national rate of attorney involvement in workers’ compensation cases was 36%.

In most instances, when workers are supported and cared for through the workers’ compensation process, they feel less need to seek attorney representation. Non-litigated claims also typically close more quickly and cost less. For these and other reasons, this metric becomes a significant measure of performance as an indicator of care and advocacy for the worker, overall cost of the claim, and the speed with which the injured worker is returned to full function and the case resolved.

Sedgwick has a core philosophy of caring counts℠; we believe in advocacy for the injured worker throughout the claims process. Sedgwick is also committed to industry best practices and takes continuous quality improvement seriously. The Performance360 (P360) team within Sedgwick under the leadership of Darrell Brown, Chief Claims Officer, is charged with measuring performance against standards and leading internal efforts to make continuous improvement in claims performance resulting in improved outcomes for both the injured workers and our client employers.

Using the above example to demonstrate how to benchmark for excellence, the P360 team compared companywide performance for attorney involvement in claims against the industry average to determine how Sedgwick compares to the industry performance benchmark. Sedgwick’s claims colleagues provide excellent service on each claim within our caring counts philosophy and deserve tremendous recognition for their professionalism and commitment to service. This commitment in part directly makes a positive impact on lower litigation rates.

This one example of a benchmark is significant for three reasons.  First, it quantifies how we are currently doing. Secondly, it compares current performance against industry performance, and finally, it identifies a benchmark to begin the process of working to achieve even better results in the future. Continuous improvement means never being satisfied with current performance – you can always do better.

Aristotle said, “Quality is not an act, it is a habit.” Thus, ingraining quality into everything we do is a habit and a reason why the P360 team was created. Much like a garden, quality also requires constant attention and tending, so that it grows throughout the organization.

What are the next steps in achieving quality and excellence through benchmarking? The benchmark standard is known, and the organization’s current performance is also known.  In this case, next steps are to identify what actions can be taken to impact the influencers causing some workers to feel they need legal representation for their claims, and then to take specific actions to address those issues and concerns. Improved quality and outcomes can be tracked and measured by the benchmarking standards. Future benchmarking will provide a new measurement, reflecting our efforts to continuously improve quality and performance outcomes and directly benefit injured workers and our clients.

A closing thought from Jack Welch, who served for more than two decades as the CEO of General Electric when the company’s performance and value increased more than 4,000%. “An organization’s ability to learn, and translate that learning into action rapidly, is the ultimate competitive advantage.” Learning to continuously grow and improve quality and performance is one of the many things we do at Sedgwick.

Jon Wroten, Senior Vice President, Regulatory Compliance & Quality, Sedgwick

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Article2_Circle_Rotation-768x768Most workers’ compensation claims do not start out as complex. They become complex over time due to specific drivers that increase costs and duration. Being able to recognize and resolve these drivers at the right time will help reduce a claim’s likelihood of becoming complex. Read on to learn how to recognize risk factors and pick up some tips on how you can have greater impact in changing the trajectory of potentially complex claims.

Litigation

It is no secret that litigation is a key driver of claim complexity, cost and duration. A California Workers’ Compensation Institute (CWCI) survey shows:

  • Claims with attorney involvement are eight times more expensive
  • Lost time days are three times higher
  • 90% of litigated claims result in permanent impairment

Strategies and tools around litigation avoidance are critical. An injured worker can become anxious about their recovery and the ability to sustain themselves and their family. Being an advocate for the injured employee can make all the difference. Providing excellent customer service, making claim decisions faster, facilitating effective meaningful communication and following through with impactful actions will reduce litigation. Take the time to learn about the person at the heart of the claim and find ways to best address their needs and alleviate concerns. It is important to customize your approach and resources for the individual injured employee.

Opioids

Another well-known cause of complexity is opioid utilization. In an interview with DMEC @Work, Dr. Teresa Bartlett of Sedgwick reported the following data:

  • According to the Centers for Disease Control and Prevention, 78 people die every day from the opioid epidemic
  • Sedgwick’s data shows that 56% of injured workers take opioids and, on average, have a 53-week increase in claim duration when opioids are involved
  • 60% of individuals taking an opioid for 90 days will still be taking them 5 years later

In response to the opioid epidemic, several states have enacted formularies, prospective utilization review, limitations on the first fill and enforcement of tracking systems like CURES and ISTOP. Sedgwick provides an effective approach through our complex pharmacy team in recognizing harmful prescribing trends and working with physicians in weaning injured workers off of opioids. These are all necessary mitigation strategies, but ultimately the best approach is to stop potentially harmful practices at the source. Initial efforts should be focused on utilizing good quality physicians and holding them accountable. Sedgwick’s provider benchmarking and search tool helps in identifying physicians we know will do the right thing by their patients. It also flags physicians that have adverse prescribing habits. We want to line up providers who share the same goal: to help the injured worker receive the best possible care and get them back to being healthy and productive.

Comorbidities

The existence of comorbidities adds another layer of complexity to a claim. A two-year study was recently conducted by Harbor Health on injured workers with obesity, hypertension, history of drug addiction and tobacco use. It found the following:

  • Claim durations increased by 76% for claims involving multiple comorbidities
  • Incurred costs increased by 341%
  • Temporary total disability (TTD) days increased by 285%
  • Litigation rates increased by 147%, and jumped to 224% when addiction-related issues were present
  • Surgical rates increased 123%

An optimal recovery demands early intervention and a holistic approach. Coordination with clinical resources is necessary in understanding and articulating what is related to the injury, what is pre-existing and what is complicating recovery. That is why our team of experts coordinates with all stakeholders and maps out a more holistic treatment plan to secure recovery and achieve our goals.

Psychosocial issues

Much like comorbid conditions, unidentified psychosocial issues will lead to increased costs and delayed recovery. A recent study presented by The Hartford and Optum shows:

  • Duration increases 57% when the injured worker is depressed
  • 10% of claims with psychosocial issues cause 60% of claim costs
  • 97% of depressed patients have a second comorbid condition

We can best support individuals dealing with psychosocial challenges by changing our approach in helping them cope with an injury. As discussed with litigation avoidance, advocacy can have a significant impact in successfully managing their claims. Also, we need to start taking a more holistic approach and focus on the whole person when promoting a return to health. Cognitive behavioral therapy can be a useful tool. For instance, at Sedgwick we utilize the expertise of our team of behavioral health specialists, who play a key role in assisting injured workers with management of psychosocial issues and coping skills during the recovery process.

Understanding the basics of complex claims can help you in accessing the right resources to avoid or mitigate these root causes. If you have questions or comments for our complex claims unit please leave us a comment and we’ll be glad to research.

Eddy Canavan, VP, Workers’ Compensation Practice & Compliance

Read additional Sedgwick thought leader articles on complex claims in our edge magazine: