Erickson Living (EL) Employee Injury Management SOP EHWC version July 2017

Transcription

1 1) Prevention/Training HR provides Manager training on Injury Reporting and Transitional Duty Program HR ensures employee training (and appropriate documentation in Peoplesoft) in safe lifting/handling of residents, blood borne pathogens exposure, and other injury prevention practices as per Erickson Living policies/sop NP/OHN provides injury pamphlet at time of injury 2) Injury Reporting Injured ee must report to supervisor ASAP Supervisor immediately notifies Security/EMS to respond Security determines need for 911 care vs. referral to EHWC/HR. Ee to call CorVel Nurse Call Center for instructions when EHWC/HR closed. Security will then do a safety check using guidance from the EL Safety Director and enter incident details in Riskonnect during same shift as incident. Security Riskonnect Incident Report of employee injury/incident to be ed to EHWC, HRD, Dept Director and AED NP/HR Designee reviews Security Riskonnect Incident Report and contacts employee to obtain additional details of treatment and work status. If injury is OSHA Recordable, NP/HR Designee enters injury details in to Riskonnect for OSHA Log, OSHA 300A form and completes 301 form. 3) Injury or Incident Intake Process Employee calls CorVel 24/7 Nurse Call Center and follows instructions for seeking care, if appropriate. Employee presents to EHWC or HR and DID NOT call CorVel 24/7 Nurse Call Center. CorVel responds to ee call to 24/7 Call Center sends to community designee within 24 hours, regarding incident. Employee can call CorVel 24/7 Nurse Call Center Or HR Designee, NP or Medical Assistant enters injury details into Med. Assistant/OHN/HR Designee sees CareMC and contacts ee by phone; if treatment was rendered off site, ee to be scheduled for follow up evaluation at Does injury involves medical treatment or bills, lost work days, restricted work days, needlestick injury or is questionable? No Yes Set up as Incident Only and Close. Set up as FNOL in CareMC and submit as 4) FNOL (First Notice of Loss) Completion Process in CareMC Can be completed by NP/MA or HR Designee, if no EHWC onsite Log into CareMC Go to Landing Page Select "Incident Intake" Tile Check List of "Submitted" Incidents Under "Action" column, find incidents listed "Continue FNOL" and click on that link. Begin filling in required info. SS# needed to complete FNOL Ee's phone number Select: Appropriate Community Dept. Medical Tx is expected for FNOL Fill in required fields of information Select "Complete" button to set up as a claim. 5) Questionable Claim Claim submitted through CareMC as "Questionable Claim" CorVel supervisor to foward all Questionable claims to Lost Time Adjuster CorVel LT Adjuster to contact Community designated rep (NP, HRD, OHN) within 24 hours to review red flags or issues on claim Lost Time Adjuster to complete: 3 point contact; roundtable claim strategy discussion with NP, HRD/OHN and Adjuster within 14 days max. CorVel will conduct a full claim analysis within 30 days of receipt and notify NP/HRD/OHN by claim status of denial or accepted. 6) After Hours (or 911 Emergency) Security Response Security/EMS responds and provides First Aid Treatment and provides CorVel 24/7 Nurse Call Number Security/EMS completes all details in Incident Management report in Riskonnect same day Riskonnect Incident Report ed to EHWC, HRD, AED and Manager within 24 hours of injury HRD/designated HR manager ensures that the following are on the Riskonnect distribution list (all open ee injuries): ED, AED, HRD, EHWC and Community Managers/Directors 7) Initial Injury Management/Return to Work NP/HR Designee/OHN provides transitional duty (TD) policy and form to any external provider Treating provider determines if TD is possible and communicates in writing to ee and NP/PA; HR coordinates LOA and FMLA, if ee placed off work or refuses TD. If supervisor cannot accommodate TD, NP/OHN will notify HRD HRD/HRM will encourage the supervisor to accommodate TD or may locate TD duties elsewhere in the community. NP or Med. Assist. will remind injured ee of all upcoming appointments PT, specialists, etc. and verify appointments are kept. Page 1 Copy of Injury Management SOP EHWC Updated July 2017

2 8) Defense Strategies for Claims NP/Occ. Health/HRD Reviews new claim for "Red Flags" Incident/injury reported late by ee Ee did not report incident, but CorVel receives notice from State Changing account of incident by ee Inconsistency between ee's report of incident details vs. others (i.e. Supervisor, Security, co worker, etc.) History of multiple WC claims Pre existing conditions Concurrent litigation for personal condition (MVA, WC claim, other) Employee initially treated by ER/offsite provider and placed off work. Initial Investigation Responsibilities NP/Occ. Health/HRD: Review incident details on Security Incident Report in Riskonnect and RCA if available. Set up claim in CareMC as "Questionable" providing details in "Notes" box and call adjuster to review questionable claim. Review treatment/er documentation for accuracy of incident details and body parts Connect with HR to check on performance, attendance, job dissatisfaction issues or "rumors". If there are, convey this, as well, to adjuster. CorVel: Supervisor to review claim and assign to LT (Lost Time) Adjuster. LT adjuster to do an ISO search for prior claims, accidents/mva's LT Adjuster to obtain recorded statement from employee for all questionable and LT claims. LT Adjuster to contact witnesses by phone or obtain written statement from each witness. LT Adjuster to contact treating providers/er to obtain records and provide to NP/Occ.Health/HRD Ongoing Strategy to Manage Claim: NP/Occ. Health/HRD: Stay in touch with ee, at least weekly Ensure ee compliant with treatment Monitor Ee's TD work assignment process, including ongoing reminders to treating MD about RTW opportunities Request a CorVel FCM for all claims with 5 LT days or more Request adjuster to obtain/review Disability Duration Guidelines is recovery exceeding expected duration? CorVel: Adjuster to review medical reports and ensure current tx is limited to body parts injured. Adjuster and NP/HRD to determine if Defense Counsel (DC) needs to be assigned and notify Corporate Legal. Logic to include DC includes red flags,ongoing concerns. and delayed RTW. Conference call to be scheduled to develop claim strategy. Adjuster to contact Becky Terjung to schedule conference call to include DC, Adjuster, Corporate Legal, NP/HRD, and EL Sr. OHN. Discussion will review claim barriers and adjuster will develop formal written defense strategy; i.e. need for surveillance, social media check, IME or FCE, etc. If significant information is obtained from surveillance or social media, this must be reviewed ASAP with DC, HRD /NP and Corporate Legal. Corporate Legal and DC to determine how to present this information to employee and ee's attorney. Claim Strategy using Return to Work Program/ Transitional DutyProgram NP/Occ. Health/HRD: Obtain document from external provider with work status Off work or Light Duty. Ensure that txing provider is aware of our TD policy and procedure. Light Duty Know the restrictions; clarify with provider if restrictions are not specific. Light Duty Facilitate a timely and appropriate TD assignment HR Manager (with NP and supervising Manager) to develop appropriate RTW plan Provide timely, written notification to employee of TD assignment/work tasks with copy of TD Policy provided to ee. Send follow up written notice to employee, if employee refuses TD assignment. Off work request to assign CorVel FCM to assist with RTW process CorVel: To terminate WC benefits timely, when appropriate by State WC Laws. NP/Occ. Health/HRD or CorVel Adjuster To monitor claim over time. Other indicators that DC needs to be assigned: Additional "injured" body parts added on by ee or severity of injury exaggerated by ee. Ee refuses TD assignment Ee becomes represented by counsel; claim to be reviewed by Corporate Legal for their recommendations. 9) Root Cause Analysis (RCA) and PIRMS Reporting Director completes or ensures the RCA is completed per policy guidelines and is submitted to: NP/OHN/HRD, PIRMS Chair, and EL Safety Director the same week NP/OHN/HRD prepares and presents monthly PIRMS report PIRMS Chair ensures all RCA's are completed and reviewed by the PIRMS committee PIRMS Chair ensures action items from RCA's are completed by Director and final RCA is submitted to EL Safety Director Page 2 Copy of Injury Management SOP EHWC Updated July 2017

3 10) Ongoing Case Management CorVel ensures monthly reviews of all open claims by Adjuster with NP/OHN and HRD or designee. Review to include Multiple Injury Claims. NP/OHN will track and manage all cases with lost time or TD regardless of where ee has received treatment and whether active ee or terminated. If employee is still under our employment and not at Full Duty, they must report to the NP/PA on a weekly basis. or after each Specialist follow up appointment. If lost work time is anticipated, NP/OHN/HRD will send wage sheet to CorVel ASAP NP/OHN/HRD will also notify HR Manager immediately to prepare TD assignment and notify employee. NP/OHN/HRD also notifies employee by phone and by certified mail with a copy to CorVel. NP/OHN will see employee weekly to ensure TD appropriate and to facilitate full duty RTW If employee refuses TD or full duty RTW, NP/OHN notifies HR Manager and HRD NP/OHN/HRD notifies CorVel of non compliance and to stop payment, when possible and in accordance with state law NP/OHN/HRD will communicate with CorVel claims adjuster to determine if their field nurse case management services should also be utilized as per formal triggers If CorVel case management is assigned, NP/OHN/HRD ensures frequent communication to facilitate timely TD or FD RTW 11) IME Process IME is an independent medical exam performed by a MD not involved in the patient's care to clarify medical or return to work issues Timing: Schedule an IME through your adjuster when claim presents barriers to return to work, extended disability duration, treatment is questionable or information is lacking. If questions, call EL Senior Occupational Nurse Information: Do we have all necessary information to send to IME MD (i.e. pertinent reports, 301E incident form, purpose for the evaluation, surveillance, diagnostic tests)? Selection of IME Specialist: Adjuster to review selection of IME specialist with DC and NP/OHN to determine appropriate dr. without conflict of interests (e.g. should not be in a group practice with txing dr.) IME Process: CorVel schedules IME and sends letter and records to MD. Adjuster to notify employee by phone and letter. Report: Adjuster sends IME report to NP, HRD and Defense Counsel. 12) Ongoing Data Management NP/OHN/HRD to review CareMC data weekly and notify CorVel Adjuster ASAP re: Lost Work Time and ongoing changes in work status. NP/OHN/HRD to review the community OSHA Log in Riskonnect for accuracy and maintain Sharps Log for Needlestick injuries. NP/OHN/HRD to current, updated OSHA Log monthly to Luz Neighoff, Joselle Bamford and Darlicia Goldie. 13) Case Management Meetings NP/OHN/HRD will ensure monthly case management meetings with CorVel and HRD/HRM on all active cases and will ensure closure/settlement of cases NP/OHN/HRD will also ensure quarterly telephone meetings with CorVel, HRD and Employee Health Medical Director, EL Sr. OHN for cases >$25,000 (incurred) HRD will ensure periodic audits of medical and indemnity payments and CorVel reserves 14) CorVel Peer Review CorVel service which can be used for: 1.) Reviewing/determining appropriateness of continued treatment, if treatment is excessive. Page 3 Copy of Injury Management SOP EHWC Updated July 2017

4 15) Broadspire Invoice Approval * claims* Broadspire point contact ensures invoices have all required supporting docs prepared allocation for monthly escrow invoices and service fees allocation & adjuster review for Broadspire encrypts & sends all invoices to Erickson (CAS) along with support (can be in a separate ) Monthly escrow invoice (All claims under $ 15,000) Broadspire to use negative confirmation & send ACH notification at least 5 days before withdrawal During elapsing time CAS to allocate monthly invoices to the adequate entities by plan year End process Monthly standard escrow invoices (Broadspire guarantees each claim included in funding is under $15,000) Prefund invoices: Settlements Medical Bill Attorney Fee Service fee invoices: 2010 adjustments based on IBNR 2011 flat monthly fee *For claims after this time period, ARCH receives a premium payment from Erickson Living* Service Fee invoice (Additional review by Broadspire account manager) Prefund Invoice CAS to allocate & send service fee invoices along with allocation and GL accounts to AP include John Hall on s for approval CAS to forward all prefunds to Employee Medical Director for approval Employee Medical Director to send approval to CAS & Broadspire point contact End process Broadspire to use negative confirmation & send ACH notification at least 5 days before withdrawal During elapsing time CAS to allocate invoice to the adequate entity by plan End process 16) CorVel Claims Invoicing Process CorVel Finance Dept. sends monthly invoices for claims handling fees to ARCH for all open, closed, Medical Only, and Indemnity claims. ARCH funds the account and sends an to EL Corporate Finance. Page 4 Copy of Injury Management SOP EHWC Updated July 2017

5 17) Reserves Corvel to set reserves for all new claims within 5 days from receipt of claim. Reserves must be set using: factual information similar case history projected medical costs projected indemnity costs additional other expenses For Indemnity or Complex claims, reserves are reviewed and reassessed within 30 days, then every 90 days thereafter. Claim file is documented with rationale reflecting the change in reserve amount. All reserves of $50,000 or greater, must be reviewed by Corvel with Sr. Occ. Health Nurse and allow 5 days to pose questions. 18) Subrogation Corvel ensures subrogation potential is addressed on every claim 19) Claims in Litigation Corvel will recommend defense counsel for NP/HRD to approve, using the preferred DC list in Special Handling Instructions. Corvel will update Claim Report for all cases in which they have assigned an attorney and will to Becky Terjung Questions can also be directed to EL Counsel and EL Employee Health Medical Director Corvel will summarize and present defense strategy to NP/PA within 60 days of notice of representation and also send summary to EL Counsel and Employee Health Medical Director 20) Settlement requests by CorVel Corvel completes Litigation Settlement Form and s it to local contacts and DC CorVel will set up settlement conference call through Becky Terjung. All settlement requests must follow the process outlined below, based upon settlement amount Updates will be provided every 90 days by Corvel unless there is a significant change in the case. CorVel Account Executive will total all settlements compared to worse case scenario for Employee Health Medical Director on annual basis. Settlement authority up to $25,000 Decision maker that must review and approve settlement amount requested is Joselle Bamford, Sr. Occ. Health Nurse Prior to final settlement approval, the following individuals must be consulted: HR Director and Local Occ. Health Professional and CorVel Claim Adjuster. Settlement authority: $25,000 to $75,000 Decision makers that must approve settlement: HRD, Employee Health Medical Director, CorVel, local Occ Health Professional and Exec. Director Prior to final settlement, the following individuals must be consulted : Risk Management, Legal counsel (inside and outside), Executive Director, Employee Health Medical Director, Regional Executive Director (ED), Regional Finance Director (FD), Regional HRD and Claims Committee Settlement authority: $75,001 to $250,000 Decision makers that must approve settlement: Employee Health Medical Director, Regional ED and Regional HRD Prior to final settlement, the following individuals must be consulted: ALL those in the previous cell, Chief Operating Officer, and Senior VP of HR Settlement authority: $250,001 and Above Decision makers that must approve settlement: Chief Operating Officer and Cindy Youlton, Arch Insurance Prior to final settlement, the following individuals must be consulted: Chief Operating Officer and Chief Executive Officer Settlement authority for Florida Claims Devonshire WC claims have a guaranteed cost Work Comp Program policy does not have a deductible. For claim settlement amounts under $50,000, no settlement discussion needed per WC policy Page 5 Copy of Injury Management SOP EHWC Updated July 2017

6 21) Corvel semi annual audits by Altus Investigation: 3 point contact/24 hours Notice of loss/14 days CIB filing Reserves Plan of Action/30 days Subrogation RTW Status Reports: Every 90 days Reviewed by Supervisor Litigation: Initial status report and budget within 30 days; Updated every 90 days If required by state workers compensation authority Corvel assigns a Voc Case Manager Formal plan established by Corvel including parameters (such as total duration) and shared with NP/PA and Senior OH Nurse Progress reviewed with NP/OHN/HRD during monthly calls (including costs to date, compliance, etc) Continuation beyond 6 months must be approved by EL Senior Occupational Health Nurse 22) Vocational rehabilitation Not required but recommended by Corvel Must always be approved by EL Senior Occupational Health Nurse Formal plan established by Corvel including parameters (such as total duration) and shared with NP/PA Progress reviewed with NP/OHN/HRD during monthly calls (including costs to date, compliance, etc) Continuation beyond 6 months must be approved by EL Senior Occupational Health Nurse *Settlement request format: 1. Injured employee's name 6. Date of termination (if applicable) 11. Proposed Settlement amount. Full and final? 2. Age/date of birth 7. Date of injury/brief description of injury 12. Opposing party's requested amount 3. Case adjuster name and contact info 8. Vocational rehab/assessment requested? 13. Justification for proposed amount (similar cases, etc) 4. Job Title 9. IME, if applicable (MMI, workability, rating) 14. For settlement recommendations >$25,000 must always include attorney's recommendation 5. Date of Hire 10. Video surveillance, if applicable 15. Projected worse case scenario if lost at trial (including medical and indemnity over time) Page 6 Copy of Injury Management SOP EHWC Updated July 2017