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nwcdc-blog-2016Nearly all businesses have interest in consumer experience. Whether you fly an airline, shop at a retailer, visit a website, or frequent an eatery, businesses care about your perception of their services and the products you consume. Negative experiences result in loss of business, and potentially sales for a competitor. Designing protocol inclusive of user experience has advanced from the automotive and technology industries to a broad spectrum of business verticals, including healthcare and insurance. Never before in my 25-year healthcare background has patient experience and patient engagement been more prevalent in design discussions and outcome reviews. Without a positive experience, patients will not engage in their health by way of treatment adherence and compliance.

Approach

This shift in focus from simply delivering care to understanding how the patient consumes care and feels about their care has lead heath systems and payers to focus significant strategic and operational resources on experience. Patients are frequently referred to as consumers, given that they are actively researching health options and purchasing their care directly. Employers are especially focused on their employees’ experience, whether it is within an operational team, the company as a whole, or the organization’s employee benefit offerings. Companies understand employee experience translates to employee engagement and directly reflects satisfaction and retention.

Adoption

Early adopters of advocacy-based claims management in workers’ compensation have jumped on the consumer experience bandwagon. Employers and payers are creating claims models to improve the experience of the consumer – the injured worker. Workers’ comp is complex and often difficult for someone without much experience in the system to understand. Stakeholders often address regulation and follow a required process with injured workers rather than truly focusing their attention on the worker’s needs. The vernacular used in workers’ compensation can be intimidating and cause confusion and mistrust. Do we think about the injured worker as a consumer of the goods we are delivering? An injured worker’s experience will impact their level of engagement with medical treatment, their return to work, and the long-term ramifications for the employer.

Advancement

I am grateful for the opportunity to present at this week’s National Workers’ Compensation and Disability Conference with three employers focusing on advocacy-based claims management during our session titled “The Advocacy Approach: Helping Injured Workers for Successful Claims Results” on Wednesday, November 30 at 2:30 PM. Denise Algire of The Albertson’s Company, Scott Daniels of Comcast, Bill Wainscott of International Paper and I will explore advocacy in workers’ compensation and share real examples of how advocacy is front and center in their benefit programs. We will review factors to consider when designing a program, various advocacy claims models and measurement outcomes. We hope to see you there and look forward to your ideas to help us advance the advocacy conversation.

Kimberly George, SVP, Corporate Development, M&A, and Healthcare

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fraud-hacker-grinchAn old CONfidence fraud has found its way to the insurance business. Customers, consumers and adjusters should all be aware and alert of a new variant of the traditional “advance fee” fraud and identity theft confidence scheme that is affecting hundreds of thousands of people annually.  The developing trend involves fraudsters, typically from outside of the U.S., having obtained a claimant’s telephone number and making contact to “con” them out of their money and personal information.  Here is how it works: the caller, representing themselves as an agent for the insurance carrier or TPA, makes contact with the claimant to allegedly settle their general liability or workers’ compensation claim. The caller offers to settle the claim for an unusually large amount, which excites the claimant. The claimant is asked to provide personal information and send a settlement fee, usually $2,500 in cash to a Western Union account. The result, the fraudster receives the advance fee and the claimant gets nothing!

Happening in the insurance arena

In addition to the settlement scheme discussed above.  The insurance industry has seen its checks stolen in the U.S. mail delivery process and then counterfeited by fraudsters. The counterfeit checks are sent to claimants and others usually for less than $10,000; some of the checks are for claims settlements others for Craig’s List or other purchases.  The amount of the counterfeit check is always for an amount in excess of the actual amount due. The individuals realize the check was for an overpayment and they contact the fraudster who instructs the individual to deposit the check (which is counterfeit) into their bank account and send the difference to them via Western Union. The result, within a few days the counterfeit check is charged back to their account and the money that was sent to the fraudster – for a double loss.

Tips for avoiding advance fee schemes

Things that seem “too good to be true” probably are!  Customers, consumers, insurance company and TPA colleagues and others should follow common sense and good business practices, such as:

  • Know with whom you are dealing before making a deal
  • If you do not know the person or company, learn more
  • Be wary if someone asks you to pay money in advance of a transaction
  • Make sure you understand every business agreement; if terms are complex, consult with a friend, your bank, an attorney or the Better Business Bureau
  • Do not sign nondisclosure or circumvention agreements

Sedgwick consumers, customers and colleagues should report suspected fraud to fraudissues@sedgwick.com.

R. A. (Andy) Wilson, CFE, CPP, Vice President, Fraud & Compliance

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2015-dea-drug-fact-card-1At Sedgwick, we are committed to steering people away from opioid addiction and finding solutions to returning them back to healthy, productive lives. However, the lure of such drugs can begin even before entering the workforce and experiencing an unfortunate injury leading to the prescription of an opioid. This was exhibited last week in the following critical update from the Drug Enforcement Agency (DEA). Please read this important information; I feel strongly that, as part of our commitment to caring counts, we must alert the industry and the general public of this dangerous substance and do all we can to keep it out of the hands of the next generation entering the workforce.

DEA update

The DEA took swift action November 10 by temporarily classifying the designer drug “pink” or “pinky” a Schedule I drug; this order went into effect on November 14. This means it is now in the same class as heroin and LSD. Schedule I drugs fall under the Controlled Substances Act for drugs with no medical use. The importance of this move by the DEA is that it is now illegal to sell this drug on the internet in the U.S. Many states had passed legislation to make the drug illegal for purchase, and the DEA move is helpful in limiting its availability online. The agency will make a decision next year if the drug will permanently remain on the Schedule I list.

Pink is a synthetic opioid which has been widely available online at very inexpensive rates to purchase; although now illegal, as of this blogging, I see it can still be bought online at a cost of $28 for 60 tablets. This drug is also known as U-47700. It is 700 times more potent than heroin.

Opioid addiction can start early

So far, pink/U-47700 has been the suspected cause of death for 46 people, primarily in New York and North Carolina – some of them young teenagers who thought it would be fun to get high.

Be aware: law enforcement agencies have confiscated versions of the drug in powder form and tablets that mimic pharmaceutical opioids. Pink/U-47700 got its name from the pink-purple hue derived through its processing, but has also been found in other forms, sometimes mixed with other drugs such as heroin and fentanyl. For example, Ohio law enforcement confiscated 500 blue pills earlier this year that initially appeared to be short-acting oxycodone, but tested officially as U-47700. (1)

Synthetic drugs are very commonplace and widely available on the internet for purchase as long as a person has access to a credit card. They are manufactured in other countries and shipped to the U.S. It is very easy for companies who manufacture these drugs to tweak them just enough and slightly change the name to continue to sell them on the internet.

We need to be very aware of what our children and teens are ordering online.

Teresa Bartlett, MD
SVP, medical quality, Sedgwick

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https://www.workcompcentral.com/events/awardsThis past week, the workers’ compensation industry came together in Burbank, CA to celebrate the 2016 Comp Laude Awards. Comp Laude was created by the late David DePaolo, WorkCompCentral founder and CEO, on the premise that workers’ compensation does a lot of good things for people experiencing the misfortune of a workplace injury or illness. For two jam-packed days, attendees were busy learning from one another, networking, and sharing ideas and projects focused on improving the workers’ compensation experience, along with congratulating the Comp Laude honorees.

The Alliance of Women in Workers’ Compensation hosted a day-long claims track, which focused on advocacy-based claims management, as part of the event. Employers and stakeholders shared their insights into creating and operating within an advocacy model. Advocacy puts caring, listening, and empathy at the forefront of the claims process. Panelists acknowledge the system is complicated to navigate and often intimidating. Early adopters of advocacy are reworking the vernacular used with injured workers, rewriting the letters they send, and working diligently to communicate more effectively with injured workers.

I was humbled and deeply touched by the fireside chat held with injured workers. In this panel we heard from three injured workers and a spouse; they shared their injury and recovery stories and, with passion and care, shared how they felt the system could improve. A panelist formerly on narcotics for 12 years was told by his medical and case management team he was as good as he would get. Yet, when a fresh carrier team evaluated his claims, rehabilitation was an option – and two years later he goes to the gym daily and is medication free. As society wraps its arms around those diagnosed with cancer, having a work injury is taboo unless the injury is catastrophic from the start and all resources are offered to support the injured worker and family. Has the payer community given up on injured workers with a desire to get better?

As Cindy Cassidy, Assistant Manager, Sedgwick, shared with me, “Rarely do claims professionals get to put a face to the claim and truly understand the impact of the injury on the worker’s life as well as their family’s lives. All the injured workers who spoke drove home the importance of communication, even when the news wasn’t what they were hoping to hear.”  Another Sedgwick colleague, Brittani Drost, Claims Representative, reflected, “I was greatly moved by the fireside chat and thought it was an incredibly important section of the event. It’s important to be reminded of and revitalized for the main purpose of workers’ compensation, which is to help people. Sometimes, the overwhelming rules and regulations, the juggling of tasks and deadlines that this industry requires can wear a person down. During the advocacy panels and the fireside chat, I greatly wished I had some way to broadcast it live to my colleagues at home, primarily to encourage them with the reminder that what they do every day does matter, and people do appreciate the time and effort they put in with every claim.”

Another highlight of the event was the People’s Choice Award presentation. Each presenter shared an impactful six minutes on their topic and the audience voted for their favorite. Sedgwick’s own Jay Ayala, managing director, shared his thoughts on diversity and inclusion (D&I). Unlike most D&I conversations, Jay’s powerful message hit on two groups of diversity we do not normally think about, hiring those with disabilities into the claims environment, as well as single parents. The audience voted Dwight Johnson, Soule Innovations, the People’s Choice Award winner. In a way, Dwight has become the face of Comp Laude and in his raw, open, honest and heartfelt approach, he reminded us all to care – care for the injured worker, care for each other, and care to be better.

The audience learned about the growth of Kids’ Chance nationally and a Kids’ Chance scholarship recipient from California shared her story about growing up with a parent impacted by a work injury and what this has meant to her life. Her story is compelling; Kids’ Chance creates a future that might not have happened otherwise, Kids’ Chance creates opportunities, and Kids’ Chance cares and supports their scholarship recipients when there might be few others in position to do so.

As I reflect on my experience at Comp Laude, I have a renewed appreciation for advocacy, and designing programs to improve the experience for stakeholders – both claims professionals and injured workers. Comp Laude allows the industry to come together, set our logos aside for the event, and focus on being better together.

Kimberly George, SVP, Corporate Development, M&A, and Healthcare

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Last week I posted that CMS appeared to have altered the zero dollar MSA approval process. This caused a great deal of discussion and activity. This has resulted in CMS releasing the following bulletin indicating that no  changes will be made to the zero dollar MSA program until it publishes changes:

October 31, 2016 – Announcement regarding Current Workers’ Compensation Review Contractor Procedures and Request for Approval of Zero-Dollar Medicare Set-Aside Amounts

CMS recently received inquiries regarding procedural changes in the way that CMS’ Workers’ Compensation Review Contractor (WCRC) reviews proposed zero-dollar Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) amounts.  CMS determined changes had transpired without prior notification. Effective immediately, the WCRC will utilize procedures that were previously in effect.  CMS continually evaluates all policy and procedures related to WCMSA reviews and will publish any pending changes when or before they go into effect.

Therefore, we are in a “wait and see” holding pattern until CMS publishes some additional guidelines. The good news is that we can confirm CMS is approving zero dollar MSAs as expected under the current system. Sedgwick has been in touch with CMS and we will provide  feedback to CMS about how the proposed changes will adversely  affect the settlement process.

Please watch for additional updates as we continue to provide you with the most up to date information. Please feel free to leave questions or concerns here and I will do my best to answer your questions.

0d65914Michael R. Merlino II, ESQ.
SVP of Medicare compliance and structured settlements
Sedgwick

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c4e8a4e2-6152-4909-b3fa-d4591c09d421-largeIn this age of connected technology and communication, it is easy to lose track of the benefits of onsite, in person claims adjusting and investigation. In the property claims business, I have long recognized that there are still many benefits to our model which is based on in person work that simply cannot be accomplished remotely. Consider the following:

Personal touch

The moment you meet someone in person, you begin developing a personal relationship. While the seed that is planted in that first meeting may never grow, the process of going through a first party property claim is often part of a traumatic personal event. For the life span of the claim, the adjuster will be discussing the financial (and other) consequences of the loss with the insured. Even in adversarial circumstances, a skilled adjuster can build close personal relationships with insureds and consumers that can have a significant positive impact on their experience.

Accuracy

Good investigation is essential to good claims handling. The more you know about the circumstances and people involved in a loss, the more you are likely to make  good decisions about what to include in the claim, and how much to pay. Consider the contrast between a phone conversation and the conversation you would have in person in the insured’s living room? Or, contrast the information you get in an email with the information you get from walking through someone’s flood damaged home.

Thoroughness

There is a wealth of information to be gained from good field inspections. One example of how this works is that in many cases neighbors will approach and offer up details about the loss and parties involved. This is information that you will never get electronically.

Reliability

There is no better testimony than eyewitness testimony. While email exchanges create a written record, emails are brief, and easily taken out of context.  A field adjuster’s notes are a written record of their eyewitness inspection. The context is clear and can be backed up by the djuster’s testimony.

Technology may provide many opportunities to improve efficiency, but it is a mistake to overlook the effectiveness and benefits of a proper field investigation.

These four corner stones are key to our field adjusters at Vericlaim.

I would like to hear from you about your own personal experiences where field adjusting made a difference.

Stuart Ryland CPCU
Western Regional Vice President
Vericlaim

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For the past several years, we have been successful in obtaining zero dollar MSAs approved by the MSA review contractor. The case, however, had to meet very strict criteria:

  1. The case was denied;
  2. There had to be no payments for indemnity;
  3. There had to be no payments of medical; and
  4. No prior indemnity settlement;
  5. Provide some medical records (if so requested by the contractor)
  6. Signed release from the claimant

If we had those six items and the case met the CMS review thresholds then 100% of the time the zero dollar MSA would get approved. The process was working perfectly.

Over the past week, however, we obtained verbal confirmation from the review contractor that the process is changing.  In addition to the above, we are also going to have to provide one of the following:

  1. A court order indicating that the employer is absolved of further obligation to pay medical.
  2. A doctor’s note indicating that the claimant didn’t need any further treatment.
  3. Medical records from the claimant’s private doctors showing that he/she is not treating for the alleged WC injury.

This new requirement will minimize the effectiveness of the zero dollar program if (1) the verbal representations are accurate; and (2) it is implemented as described.

Why? Well quite simply CMS is requiring so much proof that no MSA would be needed. If the employer obtains a court order that states the employer is no longer responsible for future medical treatment or if a doctor states no further treatment is needed, then why do an MSA at all? If either of these items are available to the employer, the responsibility to pay for future medical has been extinguished. Since there is no risk of transferring an future medical expenses to Medicare, then the employer case can close the case or settle without an MSA.

The last item is interesting and it could be used in limited situations. It is possible that there exists a situation where item number three could be used to secure a zero dollar MSA, but it will probably be in limited situations.

The beauty of the current process is that it provided an avenue to obtain a zero dollar MSA where the parties were in a grey area as to whether an MSA needed to be funded or not. The proposed process, however, requires so much proof that the parties probably would never need an MSA to begin with.

Sedgwick will continue to monitor this situation as it continues to develop.

0d65914Michael R. Merlino II, ESQ.
SVP of Medicare compliance and structured settlements
Sedgwick

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mentalhealthAprilRisk managers should always be aware of injured worker opioid use across their open claims and make sure that there is persistent clinician involvement with prescribers.

I am a complex pharmacy management nurse for Sedgwick. I want to share one of the many examples I see in day-to-day support for individuals who are prescribed opioids.  One of the injured workers I was assigned to help was on several expensive medications for headaches: an opioid pain reliever, a sleeping pill, a medication for depression and a pill for erectile dysfunction.  I was overwhelmed with the list of medications and realized when taken together they posed a dangerous risk to the patient. The doctor also indicated that the patient admitted to drinking alcohol. The implications for the man’s overall health and safety were alarming.  I intervened immediately by trying to contact the physician and writing him regarding my concerns.

Next I identified an inconsistent urine drug screen, positive for opioids not prescribed and negative for the prescribed opioids and showing high alcohol levels. Shortly after that the patient had an accident during physical therapy and requested an increase in opioids. The doctor increased the medications without question. Making matters worse he also added two muscle relaxers, a stimulant due to drowsiness, and another sleeping pill.

At this point, the physician was still not responding to my continuing outreach so I sent a follow up letter outlining the health safety concerns.  After a few more days of persistent follow up on the phone, the doctor called me.  He had reviewed my letter and agreed with each of my points about the dangerous medications and the urine drug screen results. He outlined the changes he intended to make. I was overjoyed! Persistence had finally paid.

The doctor decreased the medications immediately and began the weaning process until all medications were discontinued completely. After the doctor addressed the non-compliance issues with the patient and shared his plans for the medication regimen, the patient decided to settle his claim.  Even though the road to success was long and provided many obstacles along the way, perseverance was the key to success.

Abby McBroom
RN Complex Pharmacy Management Nurse
Sedgwick

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October is fire prevention month and this year the theme is:
Don’t wait – Check the date! Replace smoke alarms every 10 years.

The National Fire Protection Association estimates that nearly two-thirds of deaths from home fires occur in properties without working smoke detectors. (1)

Genesis of fire prevention month

In May 1919, to observe past fire tragedies – such as the great Chicago fire – and to prevent future tragedies, the Fire Marshals Association of North America sponsored the first National Fire Prevention Day.  This event began an annual observance as a way to keep the public informed about the importance of fire prevention.

Thfiremonthbloge proclamation of fire prevention week

In 1920, President Woodrow Wilson issued the first national fire prevention day proclamation.  Since 1922, fire prevention week has been observed the second week of October, from Sunday through Saturday. Since 1925, every United States President has signed a proclamation declaring fire prevention week as a national observance.

The smoke detector

This year’s theme is Don’t wait – Check the date! Replace smoke alarms every 10 Years.  Generally, smoke detectors are round and approximately six inches in diameter.  There are two types of smoke detectors: optical or ionization. Smoke detectors can be individual battery-powered units that can be mounted in any location, or several interlinked powered units with battery backup that can report to a fire panel. (2)

Age matters

Smoke detectors should be replaced 10 years from the date of manufacture, which is located on the back of the alarm. The best way to remember to change out your smoke detector is to write the “change date” on the plastic housing with an indelible black marker.

Mounting is critical

Smoke detectors should ideally be mounted on the ceiling in the hallway near sleeping rooms, as well within each sleeping room above the doorway.

Don’t wait – Check the date! Replace smoke alarms every 10 years. A few minutes of prevention can result in saving your life and the lives of those you love.

If you have questions or concerns if your residence or business is properly equipped please leave us a comment or question.

References

  1. “Learn About Smoke Alarms”. USFA.FEMA.gov. 2014-06-03. Retrieved 2014-08-22.
  2. NFPA-101

Lorne Brunner, MS Forensics,  IAAI-CFI, Unified Investigations & Sciences, Inc., a Sedgwick company

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October is National Disability Employment Awareness Month (NDEAM), a time devoted to exploring disability employment issues and celebrating the many and varied contributions of America’s workers with disabilities. Reflecting the important role disability plays in workforce diversity, the national theme of this year’s NDEAM observance is #InclusionWorks. In line with Sedgwick’s commitment to fostering a diverse and inclusive workplace and supporting the full potential of people with disabilities in our society, we are proud to participate in this annual observance.

Approximately 39.9 million people in the U.S. have some kind of disability. Many disabilities—such as serious illnesses or chronic health conditions, sensory limitations, mental health issues and intellectual/cognitive disabilities—are not immediately visible or apparent. These facts and figures highlight demographic information about people with disabilities, and this historical timeline documents the individual achievements of people with a variety of disabilities, plus legislation affecting legal opportunities for equality and inclusion.

Here at Sedgwick, we well know that the ability to work gives people a sense of purpose, allows them to support themselves financially, and improves their physical and mental wellbeing. Through our daily work on behalf of customers, our colleagues play a critical role in advocating for individuals with a variety of disabilities as they navigate the health care system, family and medical leave, workplace accommodations and transitioning back to work after an injury or illness. We are in the unique position of shaping the experience of millions of Americans with disabilities; by demonstrating that caring counts, our colleagues alleviate the sense of intimidation and exclusion that consumers with disabilities may feel.

Here are just two of the many stories at Sedgwick that I am proud to share with you that demonstrate our commitment to employing individuals with disabilities.

adamfitz In 2008, when Adam Fritz was 21 years old and about to enter his senior year of college, a table slipped off a truck in front of his motorcycle and struck him, flinging him off his motorcycle and onto the freeway. He sustained a spinal cord injury and was told he’d never walk again. Working with researchers at the University of California at Irvine, he has defied the odds, taking steps in a laboratory with the help of cutting-edge technology that combines virtual reality and brain-computer interfaces. While Fritz waits for the technology to gain FDA approval and be made available for everyday use, he gets around in a wheelchair and spends three evenings a week at physical therapy to keep his body in prime shape. (Click here for more on his personal story.)

A couple of years ago, Fritz’s friend—a colleague in our Riverside, California, office—encouraged him to apply for our Industry Advancement Program (IAP). He did and was accepted. Sedgwick was able to accommodate all of Fritz’s accessibility needs at our Riverside location and make his workspace as comfortable as possible. He is now a successful claims representative handling workers’ compensation claims for a major hospital system in the San Diego area.

“I came into the claims industry as a blank slate with no experience,” Fritz said. “Going through the IAP set me up well for the position I’m in now. Because of my personal experience, I have a unique understanding of the challenges people face after an injury severe enough to change the rest of their lives. I feel for them because I know what they can expect, and I can empathize more with their situation.”

Fritz is an especially committed and hard-working colleague with tremendous hope for the future, despite his current physical limitations. That’s exactly the kind of person we want taking care of our customers.

Ibenn line with our commitment to creating employment opportunities for individuals with disabilities, this past summer Sedgwick invited Ben Halvorson, a mainstreamed high school student with Down syndrome, to work as an office support apprentice for the pharmacy management team. “Ben demonstrated the spirit of Sedgwick as he worked diligently each day,” said Cindy Jaggers, VP of national utilization review and clinical pharmacy. “He became an inspiration to us all, as he was so excited to be able to work at Sedgwick. The company’s openness to considering people with disabilities for employment opportunities is absolutely the perfect expression of our caring counts philosophy.”

In reflecting on his summer internship, Halvorson wrote, “I really liked my job because it made me feel so busy. I worked so hard on the two computer monitors at my desk. I did the reports and copied email to my supervisor. I really liked to fill in whatever was needed for the group. Everyone made me feel welcome at Sedgwick. Thank you for letting me have this experience; it was really excellent!” (Halvorson’s story was featured in a Sedgwick-sponsored video for SRVS, a nonprofit provider of services for individuals with disabilities in West Tennessee.)

Differing abilities are part of the healthy diversity that not only makes Sedgwick a great company, but also brings tremendous value to our society. This month and throughout the year, we applaud our colleagues with disabilities for sharing their unique talents with us and recognize the wide-ranging achievements of individuals with disabilities.

Bob Blankenship
Group Chief of Staff
Sedgwick