CLAIM ADVOCACY FACT OR FICTION?? Harper vs. The All American University

Transcription

1 CLAIM ADVOCACY FACT OR FICTION?? Harper vs. The All American University

2 Characters: Terry Hurt Injured Employee Harper Hurt Spouse of injured employee Kelly Vendetta Director of Maintenance Dylan Denial Adjuster Dr. Scalpel Treating Physician Max Hammer Plaintiff Attorney Francesca Justice Defense Attorney Dr. James Hood, Claim Advocacy Expert Witness

3 Facts: Date and Time of Injury: Tuesday, January 3 at 6:00 a.m. Standard work hours are 8a-5p, M-F Job Setting, Construction Site Description of Injury: Employee walked into a backhoe on an unsecured construction site coming into the office.

4 THE WOODSHED

5 Upcoming Vignette: Dylan Denial First Adjuster Francesca Justice Defense Attorney This video captures defense attorney, Ms. Justice, gathering facts from the adjuster, Dylan Denial, in preparation for the upcoming trial.

6 The Woodshed Justice & Denial

7 New Facts: (adjuster) Brand New Adjuster Late Initial Contact Investigation only 5 mins / not recorded Rights not explained prior to denial No working knowledge of best practices

8 Thoughts & Questions: Time of Accident? Course & Scope with HR issue? Unsecure Job Site? Training (Adjuster / Employer / Client) Morale What impact does the adjuster have on a claim and what could have been done differently?

9 V IS FOR VENDETTA

10 Upcoming Vignette Kelly Vendetta Director of Maintenance Francesca Justice Defense Attorney This video captures defense attorney, Ms. Justice, conducting a direct examination of the injured employee s supervisor, Ms. Kelly Vendetta, as it relates to the reporting of injury during trial.

11 Justice & Vendetta

12 Upcoming Vignette Kelly Vendetta Director of Maintenance Max Hammer Plaintiff Attorney This video captures plaintiff attorney, Mr. Hammer, cross examining the injured employee s supervisor, Ms. Kelly Vendetta, during the trial.

13 Hammer & Vendetta

14 New Facts: (employer) In position 7 years with training Short staffed Policies and procedures not followed Late reporting (2 weeks late & evidence not secured) Refused to offer RTW Facebook opinions expressed

15 Thought & Questions : Timely Reporting Employee report of injury Employer report to carrier Staffing shortage is not an excuse Employer Role in the Investigation Gathering video Securing subrogation evidence Safety investigation of job site Take report of ALL claims, don t adjust the claim Social Media

16 WHY ME?

17 Upcoming Vignette Harper Hurt Injured Employee s Spouse Max Hammer Plaintiff Attorney This video captures plaintiff attorney, Mr. Hammer, direct examining the injured employee s surviving spouse during trial.

18 Harper & Hammer

19 New Facts: (widow) Claimant died 18 years of marriage, 2 biological children, 4 adopted Tone and approach during communication Multiple narcotic drug use Continued denied treatment Feeling of helplessness / Mental health factor

20 Open Discussion: Communication Preferred methods ( vs. phone) Adjuster availability and promptness Explain claims process Poor communication prolongs claims Impact on claim costs in its entirety (backend) URA Denials -> Overturned -> increased claim costs due to litigation Claims handling driving to poor quality of care and attorney representation

21 THE BUSINESS OF MEDICINE

22 Upcoming Vignette: Without Advocacy Dr. Scalpel Injured Employee s Doctor Max Hammer Plaintiff Attorney This video captures plaintiff attorney, Mr. Hammer s direct examination of the injured employee s doctor, Dr. Scalpel, during trial.

23 Hammer & Dr. Scalpel

24 New Facts: (Treating Doctor) Died of Overdose Dr. Scalpel doesn t follow ODG URA continued to deny treatment Alternative medicine prescribed

25 ONCE UPON A TIME IN A PERFECT WORLD

26 Upcoming Vignette: Dr. Hood Insurance Carrier Expert Witness Francesca Justice Defense Attorney with Advocacy This video captures defense attorney s, direct examination of expert witness, Dr. Hood, who models medical treatment planning in a claim advocacy culture.

27 Dr. Hood & Justice

28 Open Discussion: UR Denials Communication with injured employee Explain the claim process Manage injured employee expectations Educate providers Listen to and address employee s concerns, even if not work-related Use treatment guidelines Scientific evidence to support decision Promoting RTW

29 IS THIS A REAL LIFE OR IS THIS JUST FANTASY?

30 Shift from the Traditional Model Culture (change your language) In-house to hybrid model Working with employee and employer focus Eliminate the injured employee vs. carrier atmosphere Prompt Investigation & Assistance Empathy, even if denied Focus on recovery from compensable injuries (RTW & Healing) TCM URA

31 UT System s Claim Advocacy Strategies : Program focus on injured employee and employer Performance Metrics Good Will Fund Outplacement Services FCM even on denied claims Use available resources (EAP) to assist employee through recovery Subro Expert Total expenditures decreasing Lower total incurred costs Melissa-isms

32 FISCAL YEAR PROGRAM EXPENDITURES The University of Texas System $12 Millions $10 $8 $6 $4 $2 $10.63 $8.58 $6.35 $6.07 $6.32 $5.87 $6.45 $6.81 $7.77 $7.71 $6.75 $5.61 $5.32 $5.23 $4.61 $4.62 $4.89 $4.80 $4.27 $5.18 $5.05 $4.06 $3.60 $3.19 $4.22 $3.87 $

33 AVERAGE PREMIUMS The University of Texas System

34 Takeaways Communication is the common thread Maintain transparency with dignity and respect Empathy between supervisor and injured employee Keep in touch and manage expectations Accommodate restrictions to support early RTW Subrogation (Videos and Info)

35 Questions