USING EFFECTIVE MEDICAL MANAGEMENT TO CONTROL WORKERS COMP COSTS

Transcription

1 USING EFFECTIVE MEDICAL MANAGEMENT TO CONTROL WORKERS COMP COSTS

2 Effective Medical Management Significance of medical management in workers compensation cost control For many employers, medical costs are only category of costs impacting workers comp experience o More than 3 out of every 4 new claims filed are medical only o 2 out of 3 open claims are medical only Even in Lost Time claims, medical costs are significant portion of total costs in claim 37% of total workers comp benefits paid during FY2017 were for medical costs (BWC Annual Report)

3 Effective Medical Management Significance of medical management in workers compensation cost control (continued) Bottom line medical management must be part of overall cost-control strategy! Examples of Medical Costs o Physician consultation & evaluation o Surgery o Diagnostic tests o Physical therapy o Other professional medical services (psych, chiropractic, dental, etc.)

4 Role of CareWorks (MCO) Key Functions of the MCO Education, Training & Communication Client Service! o o o Injury reporting process Relationships with Initial treating providers & occupational health clinics Ongoing communication with employer, injured employee and provider throughout life of claim Claims Management (Non-Clinical) o o Processing First Report of Injury (FROI) Process medical bills and make provider payments

5 Role of CareWorks (MCO) Key Functions of the MCO (continued) Clinical/Medical Case Management o Review medical treatment requests for appropriateness o Alternative Dispute Resolution (ADR) o Return-to-Work Strategies

6 Employer/TPA/MCO Responsibilities

7 Role of CareWorks (MCO) Responsibilities of the MCO Claim intake and reporting to BWC. Ensure injured workers receive appropriate medical care. Authorize or deny medical treatments requested by physicians. Assist employers and injured workers with successful return to work. Payment of medical bills (excluding prescriptions).

8 Role of CareWorks (continued) Responsibilities of the MCO Ensure injured workers and employers are aware of the latest progress in a claim. Assist employer with the development of programs to enhance their workers compensation program (Transitional Work, Injury Reporting Packets). Assist employer with identifying local initial treating providers. Ensure medical documentation is transmitted to BWC.

9 Role of CareWorks (continued) Best Practices of Medical & Claim Management Report Refer Remain In Contact Return to Work

10 COST CONTROL PANEL DISCUSSION

11 Panel Participants Program Manager. Safety Consultant TPA Account Executive. MCO Account Executive. Claims Examiner. Hearings Representative. VocWorks Manager. Unemployment Manager.

12 CareWorksComp Third Party Administrator (TPA) CareWorksComp utilizes proven cost-control strategies to effectively assist employers in minimizing claim costs and helps employers understand the effect claims have on their BWC premiums. CareWorksComp forms, files and administers group rating and group retrospective rating programs. CareWorksComp educates employers on what their options are with cost-control measures, rating programs and BWC deadlines. CareWorksComp advocates on claims and rate issues before BWC, Industrial Commission and the MCO.

13 RiskControl360 RiskControl360 helps employers implement safety programs that help reduce the frequency and severity of workers compensation claims. RiskControl360 offers risk and safety management consultations, regulatory compliance audits, safety training and accident investigations. RiskControl360 helps employers create a safety plan that helps reduce the occurrence of workers compensation claims.

14 CareWorksComp Panel Discussion Account Executive The Account Executives educate their clients on how the Ohio workers compensation system functions, how rates are calculated and how claims can affect their bottom line. They evaluate each client for the different cost-savings programs available through BWC. The Account Executives consult with clients on which ratings or savings programs would be most beneficial. They assist their clients on all BWC issues and changes and anticipate the affect to their clients.

15 CareWorks Panel Discussion Managed Care Organization (MCO) CareWorks provides high-quality medical management services, helping injured workers recover from workplace injuries and return to healthy, productive lifestyles as quickly and safely as possible. The MCO role is to be a neutral party funded by the BWC. The MCO maintains continuous contact with employers, while providing consultation, training and current case information.

16 CareWorksComp Panel Discussion Claims Management Claims examiners manage claims from a financial standpoint and assist employers with the claim investigation and help determine the next steps. Claims examiners educate the employer on the cost benefit of paying salary continuation. They gather evidence to prepare for hearings. They collaborate with the MCO and BWC on return to work and treatment strategies. They also work with the cost containment team on handicap and lump sum settlement referrals.

17 CareWorksComp Panel Discussion Hearings All Ohio Workers Compensation hearings are adjudicated by the Ohio Industrial Commission (IC) in one of their 12 administrative offices located throughout the state. CareWorksComp has 17 full-time Hearing Representatives located strategically throughout the state attending hearings at each of the IC offices. The role of the Hearing Representative is to work closely with the employer and your assigned claims examiner to organize a comprehensive hearing presentation based on available claim information. The Hearing Representative s objective is to secure a favorable hearing outcome.

18 VocWorks Panel Discussion Return-to-Work (vocational rehabilitation) VocWorks assists injured workers who require specialized services in order to continue working, or if they are experiencing difficulties due to an injury after returning to work. Vocational rehabilitation is a voluntary, closely monitored and individualized program for the injured worker, and is evaluated on a case-by-case basis. Vocational rehabilitation services are charged to the BWC s surplus fund in most cases and not against the employer.

19 CareWorksComp Panel Discussion Unemployment Compensation The unemployment compensation team averages over 20 years of unemployment claims and tax management experience. There are two program levels, consulting services and full-service representation. Their expertise includes working on the employer s behalf: protesting claims, detecting erroneous charges, preparing witnesses for hearings and appealing tax rates. A single unemployment claim may impact an employer s tax rate/account for multiple years.

20 Cost Control Scenario #1 Claim Background Employee was working on equipment, got up to get tools from cart, slipped on water and fell. BWC allowed claim for lumbar and cervical sprain.

21 Cost Control Scenario #1 (continued) Take the Right Steps FROI. Take pictures. Get witness statements. Get accident reports. Contact MCO and TPA. Confirm return to work (Medco-14).

22 Cost Control Scenario #1 (continued) TPA and MCO Cost Control Focus Salary continuation. Impact study will be completed for lost time claims, which will show you the premium savings. Return to work modified duty. Letters to the medical providers. Transitional work program. Modified duty off site (MDOS).

23 Cost Control Scenario #1 (continued) TPA and MCO Cost Control Focus Return-to-Work statistics: Time Off Percent Return 1 Month 90% 2 Months 60% 6 Months 30% > 6 Months < 10% Paying salary continuation can keep an injured worker from feeling that he or she needs to retain legal counsel.

24 Cost Control Scenario #1 (continued) Salary Continuation vs. Temporary Total Impacts Employer is in Group Rating at 29% group discount. Premium: $44,000. Impact of 12 weeks of SC vs. TT being paid with estimated $7,000 in medical: Wages for 12 weeks: $7,920. Estimated premium increase (for four years): $7,950 If BWC paid TT, the premium increase (for four years) would be $22,446. By paying SC for 12 weeks instead of TT, the employer can remain in group rating.

25 Cost Control Scenario #1 (continued) Salary Continuation vs. Temporary Total Impacts Employer is in Group Retrospective Rating. Premium: $44,000. Impact of 12 weeks of SC vs. TT being paid with estimated $10,000 in medical: Wages for 12 weeks: $7,900. Estimated premium increase (for four years): $6,000. Group Retrospective Rating savings to the group: $42,517. If BWC paid TT the premium increase (for four years) would be $32,064. By the BWC paying TT it would add $56,423 to the group with the Loss Development Factor (LDF).

26 Cost Control Scenario #1 (continued) TPA and MCO Cost Control Focus Managing claims through: Treatment following Ohio Disability Guidelines (ODG) and treatment authorized only for allowed conditions. Independent medical exams or reviews. C-11 treatment appeals. Vocational rehabilitation. Red Flags. Medical Release. Unemployment.

27 Cost Control Scenario #1 (continued) Unemployment Final incident is a primary factor used by the Ohio Department of Jobs and Family Services (ODJFS) to make their claim ruling. Consider length of unemployment when making termination/claim protest decisions. Voluntary quit - is it truly voluntary? Tax options - common rating.

28 Cost Control Scenario #1 (continued) TPA Cost Control Focus Cost containment team: Handicap reimbursement. Settlements. Subrogation.

29 Cost Control Scenario #1 (continued) Cost Impact of Handicap Award (CHP) Employer is in Group Retrospective Rating. Premium: $44,000. Claim total with medical, compensation and reserve is $62,000. By filing a handicap the savings (just for one year) is: 10% - Move EM 4 points and savings of $1, % - Move EM 7 points and savings of $2, % - Move EM 11 points and savings of $3, % - Move EM 14 points and savings of $4, % - Move EM 17 points and savings of $4,914.

30 Cost Control Scenario #1 (continued) Cost Impact of Settlements (LSS) Employer is in Group Rating at a 29% group discount. Premium: $44,000. Claims current cost with medical = $ 7,000 Compensation = $ 9,800 Reserve = $ 12,000 Total Cost = $28,800 Settlement in lieu of 3% PPD award. If settled for $2,000: Savings for one year are $3,914.

31 Cost Control Scenario #1 (continued) Cost Impact of Settlements (LSS) Employer is in Group Retrospective Rating. Premium: $44,000. Claims current cost with medical = $10,000 Compensation = $ 0 Reserve = $ 17,858 Total Cost = $ 27,858 Settlement in lieu of 3% PPD award. If settled for $5,000: Savings for one year are $6,936. Savings to the group for one year are $25,316.

32 Cost Control Scenario #2 Claim Background Per IW: truck went through stop sign and hit me on the right side of the car that I was traveling in for work. BWC allowed claim for concussion.

33 Cost Control Scenario #2 (continued) Take the Right Steps Complete AC-28 form. Citation. Police report. Proof the third party had valid insurance.

34 Cost Control Scenario #2 (continued) Take the Right Steps When the AC-28 decision is received, communicate the results with your CareWorksComp claims examiner. If granted, we check to ensure the credit was given to your policy. If denied, we have only 10 days to withdraw the application. If application is denied, then refer for subrogation.

35 BWC Updates Motor Vehicle Accident. Subrogation. Safety grants. BWC audits. Manual Codes. House Bill 27. Better You, Better Ohio.