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LMSA-NFMSA-questionsOn September 1, CMS hired Capitol Bridge, LLC to be the new review contractor for MSAs. According to CMS employees that we’ve spoken to, the transition is currently underway. The old contractor is staying on for an indeterminate amount of time to help with the transition. We expect the transition will take anywhere from 60 to 90 days. Based on our prior experience with a change in MSA review contractors, this may have a significant impact on CMS approved MSAs.

First, we expect that CMS will soon announce a formal process for a Liability MSA approval process. You can read more about our concerns in our prior blog post: It is happening: LMSAs (and NFMSAs) are almost here.

Second, during the transition to a new review contractor we have to determine how long it is going to take to obtain CMS approval. Can the new contractor maintain the 30 to 40 day approval process that is currently maintained by outgoing contractor? Or will things slip back to the 6 month approval process we had to endure several years ago?

Third, and most importantly, how will the new contractor allocate for MSAs? Each prior contractor has had its own methodology of allocating MSAs. Will the new contractor’s methodology increase or decrease MSAs? Will the new contractor follow state law as required by the WCMSA Reference Guide? How will the new contractor handle the newly instituted Amended Review process?

It will probably take the industry about six  to 12 months to obtain concrete answers to these important questions. In the meantime, obtaining CMS approval will be an interesting endeavor as we all try to figure out the methods and processes of this new player in the MSA world.

Michael R. Merlino II, ESQ.
SVP of Medicare compliance and structured settlements

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A portrait of opioid use disorder

gardening-1645815_1280_pbRead part one of Rachel’s story here.

Rachel was once a vibrant gardener, grandmother and worker. Regrettably, following an injury, she became one of a growing number of those suffering from opioid use disorder (OUD). According to the Centers for Disease Control and Prevention (CDC), OUD has grown faster among women than among men in recent years. CDC VitalSigns reported earlier this year that every three minutes, a woman goes to the emergency department for prescription pain-killer misuse or abuse.

However, Rachel’s employer worked with a new claims administrator to implement a drug intervention program that utilized a data analytics tool designed to identify claims with adverse prescription drug trends. This tool quickly identified Rachel as at risk. Her case was flagged because of conditions including multiple prescribers, long-term opioid use, polypharmacy (the simultaneous use of multiple drugs for one patient) and a complicated drug regimen.

Portrait-of-OUD-CDC-callout

John, the new adjuster assigned to the case, agreed that a referral was badly needed. Reema Hammoud, PharmD, was assigned to review the case and put together a weaning plan. Rachel resisted because the pain she experienced was real and the withdrawal symptoms she had experienced when she previously tried to stop taking the opioids were intolerable. Dr. Hammoud identified two conditions of Rachel’s case: 1) analgesia, an opioid induced sense of pain that escalates pain sense and increasing dosage requirements over time, and 2) dependence, a state in which an individual only functions normally in the presence of the drug. When the drug is withdrawn, several physiologic reactions occur. This is known as the withdrawal syndrome. In the case of an opioid, withdrawal can be very serious and the abuser will use the drug again to avoid the withdrawal symptoms.

Rachel’s primary care physician read Dr. Hammoud’s assessment and weaning recommendations and agreed. Rachel’s resistance was extremely strong in the beginning, so John and Dr. Hammoud collaborated frequently.Dr. Hammoud advised Rachel of what to expect and recommended ways to deal with the withdrawal symptoms. Opioids dosages were slowly tapered to minimize withdrawals, and Aubrey, a nurse case manager, was assigned to provide pain coaching.

At the beginning of the weaning period, Rachel made dozens of threatening phone calls to John, Dr. Hammoud and Aubrey. However, over time and with team support, Rachel found that her motivation for self-improvement gradually grew, and John, Aubrey and Dr. Hammoud began to see Rachel emerge from her dependency. At the end of the weaning period, Rachel called each member of the team to say thank you for helping her get her life back.

Today, Rachel once again takes walks with her grandchildren, her garden is thriving, she has a new sense of awareness, and she is very grateful for her changed life.

As this example shows, employers can be societal leaders in the effort to eliminate the opioid epidemic, which is now officially a national emergency. Following a few simple steps can save and restore lives and close cases like Rachel’s:

  • Enact automated indicators to identify adverse drug trends.
  • Enable PharmD’s to provide expertise in developing weaning plans.
  • Connect the adjuster, any assigned nurse, and the PharmD to provide collaborative support.

Authorize only safe and appropriate prescription drugs via routine pharmacy utilization review.

Dr. Reema Hammoud, PharmD, BCPS, Director, Clinical Pharmacy 

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Homeowner_Storm-damageAs I write this blog, it is hard to believe that another catastrophic hurricane is approaching our shores. Like everyone else, I am still trying to grasp what happened in Texas with Hurricane Harvey.  I know all our hearts go out to those who have lost so much and have such a long road ahead to regain normalcy. I am proud of our colleagues and our contractor partners who are, and will continue, working tirelessly to provide honest support to those who need our services.

I want to share some tips – to help those recovering now, post-Harvey, and to those facing Irma’s potential threat – on what can be done to protect your property in the hopes that even just one person will take these precautions and need less post-recovery help.

Pre-storm tips

#1: Your safety is the number one concern

Please heed warnings to evacuate and head to a safe place. We have seen this time and time again where people think they can ride out a storm, resulting in serious consequences. We have also all seen instances where rescuers put their own lives in harm’s way to save those who do not heed warnings in time to evacuate.

#2: Things to check

  • Do you have adequate supplies on hand?
    • Food
    • Water
    • Medicines
    • Fuel for your vehicle or generator
    • Power sources such as chargers, pre-charged external power supplies, batteries
    • Contingency plans for pets (Your pets are part of the family. Do you have a plan for your animal friends?)
  • Are your facilities and home secure before you leave?
  • Have you stored important papers or documents in a waterproof, fireproof safety deposit box?
  • Do you have an exit route that will likely be safe? Do you know where you will go?

#3: Be mindful of personnel data 

Have contact information accessible for your own immediate family and, if you own or manage a business, your employees, including their phone number, text preferences, email address and their nearest relative.

#4: Know your insurance coverage

You should know what your coverage includes before a storm hits. It is important to review insurance coverage each year and make sure you are really covered for certain events. Many in Texas are finding out, unfortunately, that their policies did not include the needed flood protections to help ease recovery from the current unprecedented and unexpected circumstances.

Post-storm tips

#1: Protect your property

Take reasonable steps to protect your property from further damage. This could mean boarding up windows and salvaging undamaged items. Your insurance company can tell you what they will pay in order for you or a contractor to further mitigate damage.

#2: Start the cleanup

Always be careful when entering a damaged structure. If there appear to be serious structural issues, don’t enter, but rather contact local officials or professional contractors to assess the premises. Report downed power lines or gas leaks. Keep electricity turned off if the building has been flooded.

When starting the cleanup process, be careful, and use protective eyewear, gloves or other gear if available. Temporary repairs should focus on creating a safe environment and protecting your property from further damage. Cover broken windows, damaged roofs and walls to prevent further destruction.

Save receipts for supplies and materials you purchase. Keep damaged items or portions of them until the claim adjuster has visited, and consider photographing or videotaping the damage to document your claim.

#3: Select a contractor to help with recovery and repairs

You should talk with your insurance company about the coverage available for your loss and available resources for repairs. When selecting a contractor for emergency services, water mitigation and rebuilding, you should be careful to select a reliable, licensed and bonded contractor with experience in the specific type of work.

Be mindful of the rights and protections afforded consumers as they deal with recovery and repair. For example, the Texas Department of Insurance (TDI) released a Commissioner’s Bulletin on Hurricane Harvey – Recommending Building and Repair Contractors. The bulletin shares reminders about rules of misrepresentation, good faith claim settlement practices, as well as entitlement of those insured under a homeowners or dwelling policy to have their home repaired by a provider of choice. For additional TDI bulletins and information, their website is a continued, reliable resource.

Vericlaim Repair Solutions can assist you with finding certified contractors in your area by calling 800-587-4243, or you can submit a request through our website at www.vericlaimrepair.com.

Again, I want to emphasize that safety should be the most important thing to consider both pre- and post-loss. Buildings, furniture, personal effects and memorabilia are important, but most can be replaced or repaired. Your life cannot.

I am very grateful that our colleagues are able to help people as they work through these difficult times. It is never our desire to see devastating storms occur, but it is our honor to help in times of need. We pride ourselves on doing the right thing and, above all, showing that caring counts in all we do.

Please be safe and let us know how we can help.

Ed Reis, AIC, FCLA
President, Vericlaim Repair Solutions

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gardening-1645815_1280_pbRachel enjoyed gardening and canning vegetables. She enjoyed cooking, taking walks and spending time with her grandchildren. After she was injured at work, she was optimistic about making a speedy recovery. She was 53 years old and had always stayed active and healthy. But pain persisted with physical therapy so her primary care doctor prescribed cyclobenzaprine, a muscle relaxant, along with tramadol, an opioid for pain. Diagnostic tests occurred and surgery followed.

Then, Rachel’s neurosurgeon prescribed hydrocodone/APAP 5-500 mg, another opioid, twice daily. A drug reassessment was not done and, with now two prescribers, she was taking more than one opioid. Years passed with persisting pain and another prescriber added to the mix without drug reassessment across prescribers. Rachel was now on a pain regimen that included multiple opioid pain relievers, including Fentanyl patches for chronic pain.

Rachel’s morphine equivalent dose was 225 mg per day. Guidelines recommend that dosing not exceed 50 to 90 mg of morphine equivalents per day. According to the Centers for Disease Control and Prevention (CDC), someone like Rachel with a drug regimen over 100 morphine equivalents per day faces more than nine times the risk for overdose compared to patients taking 20 mg or less of morphine (or an equivalent) per day. Moreover, Rachel’s daily pill burden increased her risk of overdose because she sometimes forgot the number and combination of pills she was taking from day to day. Also, her sense of pain was sometimes so severe that she would take more than the prescribed number of opioids.

Rachel’s garden was now overgrown from lack of care and her grandchildren had become alienated by her despondency. She was suffering from a condition that nobody had ever told her about. She had opioid use disorder. Opioid use disorder (OUD) is a typically chronic, relapsing illness in which patients misuse prescribed, diverted or illicitly obtained opioid medications. Unfortunately, Rachel’s condition was not unique. In 2016, the CDC says that 26% of patients within the U.S. health system who had been prescribed opioids for more than 90 days met the criteria for OUD.

Portrait-of-OUD-CDC-callout

In our next blog, I will tell the rest of Rachel’s story and share steps that can be enacted to prevent unnecessary suffering and death.

Dr. Reema Hammoud, PharmD, BCPS, Director, Clinical Pharmacy 

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wc-savings-freepikWorkers’ compensation is a “no fault” system. Every state has laws and regulations mandating the prompt reporting of all injuries and accidents. Most of these laws are in place to protect the rights and benefits of injured workers. What many employers do not realize is that immediate reporting of all injuries can actually be a magic bullet that helps reduce their workers’ compensation costs.

Barriers to reporting

A significant barrier to reporting of claims is the economics of workers’ compensation. Workers’ compensation claims are expensive. In some organizations, the losses can impact the company’s experience rating modification and coverage costs, impact the company’s risk management budget, reduce the profitability of the division or can impact the bonuses of the front-line supervisors and managers. As a result, an unintended message can be sent to workers that they are discouraged from reporting accidents.

Economics of delayed reporting

Employers can face additional fines and penalties for late reporting, but that is not the only economic impact of delays. In a recent study, the National Council on Compensation Insurance (NCCI) showed that delayed reporting can increase workers’ compensation claims costs up to 51%. The study also reported that the longer a claim goes unreported, the more likely it will be to involve litigation, also increasing overall claims costs.

Safety (investigation)

One of the most important benefits of immediate reporting is the ability to determine where there was a safety program failure and what could’ve been done to help prevent the accident.  Forensic analysis of all accidents helps employers significantly reduce their claims frequency.

Compensability (investigation)

In workers’ compensation, few things are more vexing to employers than believing a claim is not legitimate, yet it is accepted as compensable. Delays in reporting of claims can make it significantly more difficult for the claims administrator to accurately determine if the claim is legitimate. As time goes by, potential witnesses may not be identified, witnesses’ memories become fuzzy, hard evidence can be spoiled. There are differing statutes of limitations in each state. If claims are not reported to the claims administrator immediately and denied within the appropriate timelines, it is possible that some will be considered compensable as an operation of law.

Improved medical control and better medical outcomes

Immediate reporting of claims improves the timeliness and quality of medical care. This helps reduce the number of lost time days, as well as reduce the exposure for permanent disability. In many jurisdictions, it is possible that delays in providing care can void the employer’s control of medical care. Providing quality care at the right time also helps reduce litigation rates.

Prompt and accurate benefit provision

Immediate reporting allows the claims administrator to provide prompt, accurate benefits to injured workers. This signifies to the workers that the employer cares about their health and safety and reduces the potential for litigation.

Subrogation

Immediate reporting allows the claims administrator to identify potential subrogation cases and preserve evidence involving a third party.

OSHA compliance reduced

Immediate reporting of all injuries increases the ability for the company to comply with Occupational Safety and Health Administration (OSHA) reporting requirements and avoid exposure to penalties and fines.

Operations best practices

What should employers do to encourage prompt workers’ compensation claims reporting, speed recovery and avoid increased friction and costs?

  • Establish a precedent: Upon hiring, as part of the intake process, educate every employee that they are required to report all injuries immediately.
  • Message from the top: The chief executive and management staff should regularly reinforce the importance of prompt reporting of all injuries.
  • Revisit financial incentive programs: Look carefully at financial incentives within the organization which might unintentionally cause a delay in the reporting of claims. If there are charge-back programs in place, it might be wise to increase the charges for late reporting and lower the charges for claims which were reported immediately.
  • Analyze gaps: Any delayed reporting should be analyzed to determine if there is a gap in the education process. Treat these cases as an opportunity to educate.

William Zachry, Senior Fellow, Sedgwick Institute

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trip-fall-24108_1280pbIn a recent License Appeal Tribunal (LAT) decision between a claimant and TD Insurance Meloche Monex (D.S. and TD Insurance Meloche Monex #16-000131/AABS), it would seem the stranger the circumstances, the wider the allowance to access Ontario accident benefits. This most recent decision (which is final, no appeal possible) has determined that running along the sidewalk, tripping and striking a parked car is now deemed an “accident” by definition.

In this case, the injuries are catastrophic in nature. The man involved had consumed alcohol and was running home in the early hours of September 27, 2015. He ran onto the lawn of a private residence, tripped over stone blocks, lost his balance and fell head first towards a car parked in a driveway. There were no witnesses to the incident. The claimant sustained severe injuries, including paralysis below the armpits, complete loss of bowel and bladder control, difficulties swallowing along with facial lacerations and fractures.

According to the claimant, he struck his face and body against the parked car and this entitled him to statutory accident benefits issued under an Ontario automobile policy. The insurer, TD Insurance Meloche Monex, took the position that the definition of “accident” had not been met. They indicated that the injury stemmed from a fall against the pavement and this caused injuries.

Experts opined on the various bio-mechanics of the fall, the vehicle, the claimant, etc., but at the heart of the decision was the definition of “accident” itself. The policy defines “accident” as:

“An incident in which the use or operation of an automobile directly causes an impairment or directly causes damage to any prescription eyewear, denture, hearing aid, prosthesis or medical/dental device.”

Prior case law was reviewed, Amos v. Insurance Corporation of British Columbia, which outlined the Purpose and Causation Test. Did the accident result from the ordinary and well-known activities to which automobiles are put? And was there some causal relationship between the claimant’s injuries and the ownership, use or operation of the vehicle, or was it merely incidental or fortuitous?

The LAT decided that the expert reports were sufficient to determine that the claimant struck the vehicle which caused his injuries. Regardless that the vehicle was parked and the claimant was running, tripped, and fell, the LAT determined that this incident does meet the definition of “accident” and allowed the claim to be advanced for statutory accident benefits, which could top $4 million over the claimant’s lifetime (depending on the eligibility for disability benefits). It is unclear if a tort claim was being advanced in this incident.

Lesson learned: Park vehicles in a garage.

Laurie Walker, CIP, CRM
SVP, Director of Operations, Canada

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IoT-communication-1927706_1920-300x200The Internet of Things (IoT) has made a revolutionary impact on the automotive industry. Just like our smartphones, our cars have become smart cars, more commonly referred to as connected cars. Modern automobiles have the ability to produce, capture, store, process, analyze, and transmit large amounts of data to assist drivers and provide information – telematics. This data can be stored within the vehicle or transmitted to the cloud, the manufacturer or a designated insurance company.

With the increased intelligence of vehicles, forensic investigators are finding new data available to support their investigations and to verify their findings. Research is required to determine what data is available in a specific circumstance. A forensic investigation of an auto-related event generally relies on these three types of data:

  • Driver (driver data and inputs such as steering, braking, acceleration)
  • Vehicle (equipment and safety systems activation, maintenance records)
  • Environment (weather, road conditions, traffic)

We are seeing different devices and industries beginning to utilize connected technology and telematics to capture and make use of these types of data. Here are several examples of trends we are seeing now and what may be coming in the near future that could be very useful for forensic investigations.

Telematics devices

Late model vehicles may be equipped with a manufacturer-exclusive telematics system like GM’s Onstar, Land Rover’s Icontrol, Mercedes Mbrace and Ford’s SYNC. Additionally, there is an abundance of aftermarket telematics solutions that can plug into the on-board diagnostics (OBD) connector under the dash for vehicles with a model year of 1996 or newer. They can sync with a smartphone and provide the same data newer vehicles capture. Inexpensive and easy to install, they are used by insurance companies, fleets and even parents of teen drivers.

Car sharing

Companies like ZIP Car and Car2Go make full use of connected car technology. A customer uses their mobile phone to locate, reserve, and unlock a shared car. When done, they leave the vehicle parked in a designated spot for the next person. This is advantageous for the customer because they will only be charged for the time and miles driven, which are all calculated using the equipment installed in the vehicle.

This data can also be used to help forensic investigators when researching criminal matters, especially when questionable information is presented. In accidents, data can help forensic investigators determine who was driving the car when the accident occurred. In a specific recent case, investigators looking into a hit and run accident with critical injuries involving a shared car used the data to reveal that the listed driver of the shared car was lying when she reported that she was hijacked and the car stolen just minutes prior to the accident. Forensic investigators were able to obtain GPS location information and other data that contradicted those statements. When confronted with the data, the driver admitted that she falsified the story.

Fleet operations

Companies with large fleets of vehicles are finding unique ways to use technology to help improve their business. They can reduce costs and investigate any events that occur – even help reduce or eliminate false claims – by introducing cameras into their telematics programs. Camera footage is streamed to the cloud to provide a historical record, if needed. For example, tow truck companies are adding cameras to their fleets so they can defend claims that the tow truck driver damaged a person’s vehicle when in tow.

Usage-based insurance (UBI)

UBI has grown in popularity. Data is collected from a vehicle monitor, which includes speed, harsh breaking, miles driven, common routes and parking location of the vehicle at night. The insured must agree to have data released to the insurance company and, in return, they receive discounted insurance based on the analysis of the information.

Self-driving technologies

As we look to the future of car manufacturing, is exciting to see the possibilities of cars having 5G WiFi capabilities within the next couple of years. This technology will allow vehicles with equipment such as cameras or lidar (systems that use laser pulses of light to measure and map the surrounding environment) to capture data and send it to the cloud, where it will be analyzed and sent back to the vehicle in almost real time – allowing for even more self-driving capabilities and data to be utilized for investigative potential.

Connected cars and related technology are becoming more commonplace and more affordable. Awareness of the technology and its capabilities is the first step to incorporating recognition and utility of this technology on all forensic vehicle investigations.

This is part two of our series on the emerging technology of IoT and forensic investigations. Click here to read part 1, and if you have any questions or great ideas to share for future posts, please contact us – we want your input!

Michael Hoffman, MSFS, IAAI-CFI, District Manager
Unified Investigations & Sciences, Inc., a Sedgwick company

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WCI-image-2017Because of its relevance at the intersection of workers’ compensation, leave of absence and federal laws like the Americans with Disabilities Act (ADA) and The Family and Medical Leave Act (FMLA), the accommodation process requires a careful and thoughtful approach. Employers often offer light duty or transitional work programs for workers’ compensation claims; however, many times, these options are inconsistently applied to employees on disability or leave of absence. Regardless of the nature of the injury, ADA regulations apply. To maintain compliance, there is a need for consistency among employers in their approach to accommodations and return to work across both occupational and non-occupational injuries and illnesses.

The interactive process

The process for determining if an employee has a disability and whether reasonable accommodations can be implemented is called the interactive process. Typically, this involves a dialogue between an employee and their supervisor, human resource representative or ADA coordinator, and takes into account the advice of healthcare providers. An employee can – but does not need to – request an accommodation to trigger the interactive process; the employer’s obligation begins whenever they become aware that an employee has a disability or suspects that a person may have a disability that is causing problems with work. Also, employees may be on a leave of absence – either occupational or non-occupational – and exhaust their entitlement. In these situations, the employer is obligated to begin the interactive process. Delaying or avoiding the interactive process places an employer at risk.

The steps

The Job Accommodation Network (JAN), is a service of the U.S. Department of Labor’s Office of Disability Employment Policy, available at www.askjan.org. It offers many valuable resources for employers as they navigate accommodations. As recommended in a JAN publication called “The Interactive Process,” follow these steps to support a compliant interactive process:

  1. Recognize an accommodation request or a duty to start the interactive process. Employees may request an accommodation or indicate they are having a problem performing work activities and that the problem is related to a medical condition.
  2. Gather information. Employers need to determine what information is needed to assess the employee’s situation. In some cases, no additional information is needed whereas, in others, it may be necessary for the employee to talk with a healthcare provider to determine the impairment and restrictions. Obtain a job description that outlines the tasks the employee is performing
  3. Explore what accommodations might be available to the employee and identify what environmental modifications could be made. Ask the employee what kind of accommodation would be helpful to complete job-related tasks.
  4. Choose the accommodation. If you have three or four options, JAN recommends asking the employee which option is preferred. There may be times when an accommodation is not reasonable for the employer to accommodate.
  5. Implement the accommodation. Ensure the selected option works as intended and offer assistance throughout implementation as needed.
  6. Monitor the accommodation. Check to ensure the accommodation is working. Also, recognize accommodations are not permanent. Business processes, existing technology and employee conditions change, and those may impact the effectiveness of the accommodation.

Accommodations and return to work will continue to be complex and challenging for even the most experienced risk and benefits professionals. As employers support colleagues with occupational and non-occupational injuries and illnesses, it is important to remain informed on current laws and proposed regulations while maintaining a thorough understanding of organizational policies and procedures. Collaborate with other professionals, break through silos, talk to experts, and use resources like www.askjan.org, www.dol.gov, and www.eeoc.gov. Consistency is key.

Join me, along with my fellow panelists, as we further explore this topic at WCI’s Annual Conference next week in our session “Return to work best practices.” If you have questions or are looking for additional accommodation support, leave us a comment or search our related resources on the blog.

Bryon Bass, SVP, Disability and Absence Practice and Compliance, Sedgwick

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The consequences of initial care direction

bulls-eye-1044725_1920-pbAccurate initial care direction can make all the difference in the outcome of a workers’ compensation claim. When experienced clinicians are engaged and referencing proven triage guidelines, their guidance bolsters treatment safety, accurate diagnosis, and documentation of items that may delay recovery, such as comorbidities, and fosters lasting return to work. The primary purpose of any triage service should be to recommend the correct level of care, and proven triage guidelines are critically important in providing direction. Some triage providers may claim high rates of sending injured employees to self-care; however, if what an employee really needed was to see a healthcare provider, inflated self-care is not a benefit for the employee or the employer. Transparency is key when taking a look at self-care conversion rates, as it gives the employer insight into the validity of triage recommendations.

Protection from long-term cost

The best way to evaluate the accuracy of initial treatment direction is to measure claim development 15-30 days later to ensure effective recovery and continual productivity. Third party administrators have the long view of cases and can see incorrect self-care recommendations causing long-term cost and absence from work. For example, Sedgwick reviewed client programs that moved from a triage company using home-grown guidelines to triage services using proven Schmitt-Thompson guidelines for self-care or treatment recommendations. Our analysis showed that 10-15% of the cases receiving self-care recommendations had 20-50% higher average temporary total disability days. Inaccurate front-end self-care recommendations cost the employee and the employer down the road.

The introduction of telemedicine: Delivering accuracy and saving time

Telemedicine is a quickly expanding service that will continue to grow for occupational injury care. As another tool in the clinical consultation process, telemedicine referral protocols and best practices should also be based on Schmitt-Thompson guidelines. Injured employees may be directed to one of the following treatment options: self-care, telemedicine or in-person care.

Important information about the employee gathered during triage can be passed along to the telemedicine provider to make the online experience faster and more efficient. Potential technology delays can also be mitigated through the clinical consultation triage process, keeping the treatment experience seamless and eliminating pathways that may otherwise cause the injured worker confusion or disengagement.

Injured employee satisfaction

In our own experience launching telemedicine for Sedgwick customers using clinical consultation services, we’ve received positive feedback. Since telemedicine was added as a treatment option, more than 60% of injured employees using the service have responded to post-visit surveys and they have all scored the experience with four or five stars, on a scale of one to five. Consistent and proven triage protocols can make all the difference, and consistent clinician guidance and qualification of the injured worker for telemedicine is a critical first step for a successful experience. The overall process is simple.

graphic for accuracy is a commodity

Provider benchmarking

In-person care referrals should be qualified via proven protocols, but provider choice is also critical. To take one step further in delivering accurate care, clinical consultation nurses  should use benchmarking information whenever possible to match an injured employee with a local provider proven to get the best outcomes in occupational injury care and return to work facilitation. At Sedgwick, we see 73% earlier return to work and 40% faster claims closure when an injured worker is matched with a 4- or 5-star medical provider.

Remember, consistently pairing an injured employee with the correct initial care following an injury is a critical foundation for a safe, effective recovery. It is important to follow stringent and proven guidelines to make sure accuracy prevails. Is your own program evolving to include the latest protocols and care options to best support your employees? Share your experience in the comments and let us know if you have questions

Andrea Buhl, MSN, RN, FNP-BC
SVP, Clinically Integrated Medical Program

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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