Riverside Community College District (RCCD) Industrial and Non-Industrial Claim Recovery Michael W. Simmons, MAOM, CSRM Director, Risk Management

Transcription

1 Riverside Community College District (RCCD) Industrial and Non-Industrial Claim Recovery Michael W. Simmons, MAOM, CSRM Director, Risk Management Riverside Community College District

2 Presentation Agenda RCCD RISK Philosophy RCCD RISK Expertise Focus for RCCD RISK RCCD Strategies RCCD Results Questions and Answers RCCD S Commitment to its Staff, Faculty, and Students What RCCD Risk Management Believes About Its Service to the Institution RCCD Claims Management Team Experience and Expertise How Can RCCD Risk Management Provide the Service Levels Needed to Manage Claims Effectively? The Risk Management Process Risk Has Many Moving Parts. Risk Management Should be Approached Holistically Strategies Deployed by the RCCD RISK Team Risk Management Tactics and Strategies are the Key RCCD Risk Claims Management A Case Study Overview of the Results to Reduce Claims Liability Questions and Answers

3 RCCD Risk Department Claims Management Philosophy Every Injured Worker is a Human Being Every Injured Worker Will Be Treated with Dignity and Respect At the End of the Day, We are a Service Department We Perform (1) Early Investigations, (2) Early Evaluations, and (3) Early Resolutions Claims with Fraud Indicators are the Exception to the Previous Bullet For Industrial Injuries we Prefer to C&R All Issues. Stipulations are Rare Cases. Our Claims Management Process is Designed to Achieve the Previous Bullet Open Claims Represent a Primary Cost Driver and are Our Priority. We CLOSE Claims We Maintain a Rigid Procedural and Timeline Hold on ALL Industrial Injuries We Select Our Supporting Partners Based on Their Alignment with Our Philosophy We Demystify the Claims Process to Nullify the Employee s Need for an Advocate Creativity in ALL Settlement Scenarios is Welcome and Expected The Credit for the Results Goes to Our Team. There are No Individuals Here It is Our Goal to Hear Positive Feedback from Our Constituencies

4 RCCD Risk Management Team Expertise and Experience Question: What Qualifications Does the RCCD Risk Management Department Have? Answer: Over 200 Combined Years of Experience in Claims Management and an Extremely Diverse Claims Management Team with a Variety of Backgrounds. Team Member Michael W. Simmons, CSRM Monica Esqueda, CSRM Dr. Sherry Stone Rachel Shaw Dan Conley David Kargozar Medcor California Schools Risk Mgmt Wellcomp Various Career Focus Private and Public Sector Risk Management / Claims Management Private and Public Sector Claims Management Disaster Preparedness and Safety Management Widely Recognized as One of the Best Disability Experts Available York Risk Services Adjuster with Years of Public Sector Experience GL and Workers Compensation Attorney Private and Public Sectors Triage Nurse Services Middle Market Insurance JPA with Ample Support Resources Flexible Medical Provider Network Nurse Case Manager, Medical Specialists, and Private Investigations

5 The Risk Management Process What Can Does RCCD Set Out to Accomplish? PRE-LOSS STEPS ACCIDENT PREVENTION LOSS MANAGEMENT STEPS DAMAGE CONTROL POST-LOSS STEPS LEARN FROM OPPORTUNITIES Review of ALL Safety Processes with Focus on Effective Reduction of Frequency and Severity Redesign of Ineffective Safety Processes and Procedures Establish a Minimum Standard and Consequences for Failure to Comply / Perform Implement a Sense of Safety and Loss Control Continuity Develop Internal Claims Management, First-Aid, and Temporary Alternative Work Programs to Better Manage Claims Costs Focus Efforts on Timely Closure of ALL Claims Establish Goals for Claims Management, RTW, TPA Performance, Defense Counsel Effectiveness, etc. Develop Culture Specific Accident Investigation Procedures Based on Our Own Loss History Start Claims Cost Education Effort with Faculty, Staff, Managers, etc. Include Everyone in the Development of Safety and Claims Programs and Educate Them on Their Importance to the Successful Reduction of Losses

6 RCCD Risk Management Claims Liability Mitigation Plan Modify Current Claims Management Philosophy Revise the Claims Management Program Remove ALL Obstacles to the New Program Identify the Claims Management Team Members and Get Them Onboard Implement the New Strategies for Claims Management Apply Consistent Pressure to the Claims Management Flywheel Carve Out Older Claims and Target for Resolution Address our Actuarial Concerns and Identify a New Reserve Target Monitor Claim and Reserve Activity for Positive Trending Set an Aggressive Goal for Closed Files and Reserves and Achieve the Goals Acknowledge Positive Results and Support Team Efforts with Recognition Transition from Claims Management to Accident Frequency Controls Apply Claims Management Resistance Before and After Claims Occur Monitor for Applicant Attorney Adjustments and Modify Accordingly

7 RCCD Interactive Process Cooperative Effort Human Resources and Risk Management Work Collaboratively Risk Management Involved in Interactive Process for Industrial and Non-industrial Risk Evaluates all Non-industrial Scenarios for Industrial Exposures Interactive Process is an Opportunity to Facilitate Action to Mitigate Losses Consistency and Transparency are the Keys to an Effective Interactive Process The Disability Specialist is the Core Element to the Process Everything Risk Contributes is Designed to Support the Disability Specialist / HR Interactive Process Achieves Medical Separations Timely and Appropriately RCCD Aggressively Complies with the Laws Governing the Process Employees Rarely Claim a Lack of Understanding and Often Agree with the Outcome Bargaining Unit Representatives Have Complimented Our Process Not One Case Has Been Litigated in the Last 3 Years Helps us Manage Even the Toughest Cases and Most Difficult Personalities Should be Part of Every Claims Management Program

8 RCCD Risk Management Claims Liability Mitigation Plan Internal Claims Management Team Risk Manager Claims Coordinator District Safety & Emergency Planning Manager College Safety Coordinators (in hiring process) External Claims Management Team Dedicated TPA Adjuster GL Defense Attorney for Workers Compensation Defense Triage Nurse Services Disability Specialist Nurse Case Manager(s) JPA Resources Medical Specialists Private Investigations

9 Plan in Action A Case Study RCCD Case Analysis: Multi-College District with 4,500 Employees Workers Compensation Program Initiatives Created an Internal Claims Position Monica Esqueda Casualty Claims Coordinator Accessed JPA Claims and Safety Resources Implemented a Dignified and Respectful Claims Management Environment Modified TPA Accountability from Active Claim Handling to Directed Claim Handling Dedicated TPA Adjuster with Client Specific Instructions for Handling Our Claims Retrained a GL Defense Attorney to Mitigate / Defend Industrial Injury Claims Deployed a Triage Nurse Service for ALL Newly Reported Injuries Reinforced Use of the Medical Provider Network Drafted a Thorough Claims Reporting Process to Demystify Workers Compensation Partnered with Approved Specialists, Disability Expert, Nurse Case Managers, etc. Targeted ALL Future Med Claims for C&R Settlement to Reduce Future Liability Refined Conventional Claim Activity (RTW, Early Evaluations and C&R s, Treatment Approval, etc.) Proactive Employer Level Investigation (3 and 3 Rule)

10 Plan in Action A Case Study Open Workers Compensation Claims 95% of the Open Pending Actively Litigated Oldest Claim Date of Loss: 1997 High Rate of Litigation and Attorney Activity Claim Payment Reserves Underfunded (200%) Sought Relief Plan to Post $4M in Reserves Over $6M in Projected Claims Liability Lag Days Average at 60+ Days Average Time to Close: 475 Days Several Serious Injuries Into Excess Layer Average $182K Per Year in Defense Expenses Average Cost of Claims: $13,512 General Lack of Trust in Risk Management Open Workers Compensation Claims 30% of the Open Pending Actively Litigated Oldest Claim Date of Loss: 2000* 3 New Litigated Claims in the Last 37 Months Claim Payment Reserves Overfunded Returned $3M to the General Fund ( ) $2.1 in Projected Claims Liability Lag Days Average Reduced to 7+ Days Average Time to Close: 170 Days 0 New Excess Layer Claims in the Pending Average $70K Per Year in Defense Expenses Average Cost of Claim: $8,473 (-37%) Monica Receiving Thank You Notes * Only 2 of 23 Open Claims with Pre-2009 Dates of Loss

11 QUESTIONS