Chubb Claims Services WORKERS COMPENSATION CLAIMS ADMINISTRATIVE OVERVIEW

Transcription

1 Chubb Claims Services WORKERS COMPENSATION CLAIMS ADMINISTRATIVE OVERVIEW Chubb s commitment to providing world-class service has earned us a reputation for claim service excellence that is evident in the speed, empathy and integrity with which we handle claims. Superior claim handling is made possible by Chubb s experienced and knowledgeable staff who have access to expert resources throughout the claim process. Additionally, our Workers Compensation Managed Care Program allows injured employees to receive timely and appropriate medical care while mitigating expenses due to Chubb s associations with Preferred Provider Networks (PPNs) in many states.

2 Lost Time Claims that involve lost time or litigation are assigned to Chubb s Lost Time unit. An adjuster will make contact with all parties and utilize specialized resources, when warranted, to achieve a favorable outcome on each claim. Reporting a Claim Claims should be reported as soon as possible. Delays in reporting work-related injuries can cause workers compensation claim costs to increase by up to 51% 1. Claims with a delay of more than two weeks are more complex to settle, take longer to close and involve a longer period before the injured worker can return to work. As a rule of thumb, you should report a claim to Chubb within 24 hours of the notice/report of a potential workers compensation loss from the employee. Claims can be reported through several service channels: Online: Chubb s Website at (see Exhibit A for directions and Exhibit B for a worksheet that can be used as a guide when reporting claims). Phone: Fax: Claim Assignment Medical Only For minor injury Medical Only claims, our systems include sophisticated business rules that ensure timely claim resolution. In the event escalation information is identified or as questions arise during the claim, an adjuster will contact the insured. Minor Medical Only claims are handled out of our Chicago, New Haven and Atlanta core offices. Medical Only claims exceeding the minor injury threshold are assigned to Chubb s Medical Only unit. Once the critical case facts are assessed at claim intake, an adjuster may contact the insured to discuss if further investigation is necessary to determine the case exposure. Claimant contact will be considered if the investigation reveals complicating claim factors. Claim Handling Initial Contact The insured may receive an initial call right after the claim is reported to determine optimal claim assignment. For Lost Time claims, we make every effort to have an adjuster contact the insured and claimant within 24 business hours. Requests for Information During the initial investigation, an adjuster may request documents from the insured that could include the following: medical reports, job descriptions, completion of our Physical Demands Form, accident/investigation reports, the completion of a wage statement, or other documents. Chubb s Special Investigation Unit It is the mission of the Chubb Special Investigation Unit (SIU) to identify, investigate, and pursue claims which indicate the potential for fraud. Chubb s SIU conducts in-depth investigations on questionable claims, which may include onsite insured visits, in-person claimant statements and thorough claimant background checks. If you suspect fraud, notify your adjuster or report the activity by calling CHUBB. Recovery Unit If a third party is involved in the claim, an adjuster specializing in subrogation management is assigned in addition to the claim adjuster. Examples of third party cases are motor vehicle accidents, offpremises injuries and equipment malfunction. Medical and Disability Management Nurse Case Managers Nurse Consultants provide oversight of the case management process and assign Telephonic Nurse Case Managers (TCMs) or Field Nurse Case Managers (FCMs), as needed, to Medical Only and Lost Time cases. The case manager will work in collaboration with the assigned Claim Adjuster to assist with medical management and timely return to work.

3 Preferred Provider Networks Under Chubb s Workers Compensation Managed Care Program, employees receive medical care provided in accordance with approved techniques for specifying and monitoring treatment. Chubb has affiliations with Preferred Provider Networks in many states to help injured employees receive quality care at a reasonable cost. Providers within the PPO network can be located at: corvel.com/provider_lookup or by calling Corvel at Pharmacy Benefit Management Programs The Pharmacy Benefit Management Program (PBM) for Workers Compensation is administered by Express Scripts (ESI), except in Texas where Chubb uses Corvel s CorCareRX. Some of the key benefits of a PBM include: Reduction of out-of-pocket expenses when injured workers obtain prescription drugs for compensable injuries. First Fill program where ID cards can be provided to injured workers to present to a participating pharmacy, avoiding out of pocket expenditures from the start of a claim. ESI covers the cost of the first fill if the claim is not deemed compensable at no cost to the insured or to Chubb. Patient safety and injury-specific formulary, where only those drugs that are appropriate for the injury are dispensed to the injured worker. Appropriate utilization of generic drugs versus brand name drugs where allowed. Mail order capability for long-term use of prescription medications. Express Scripts can be reached at Narcotic Management Program Within our Pharmacy Benefit Program is the Narcotic Management Program which entails: Point of sale edits utilized to address opioids prior to dispensing. Combining advanced analytics and investigative outreach to detect and deter potentially fraudulent activity. Proactively identifying and managing excessive use of opioids early in the claim. Engaging the appropriate resources to find the right balance between pain relief and the risks of dependency, abuse and misuse. This will contribute to improved clinical outcomes, shorter disabilities, and reduced overall medical costs. Focus on patient safety and recommendations for alternative approaches to pain management and clinical screening for potential high-risk claims. Medical Bill Re-pricing Chubb s bill review service re-prices every medical bill in accordance to each state s fee schedule and Preferred Provider Network s discounts. Quarterly reports showing the medical savings and the fees for re-pricing can be provided. Return-to-Work Program One of the fundamental tenets of the workers compensation system is to treat injured employees and help them return to work in a timely and costefficient manner. In support of that, a return- to-work (RTW) program helps injured workers return to gainful employment by providing them with modified job responsibilities that take into consideration physical restrictions, skills and abilities. Chubb s Return-to- Work Program encourages a speedy recovery which can reduce workers compensation costs. To learn more, contact your local Chubb branch and see Exhibit C. Claim Reserving Chubb is committed to the timely and accurate setting of reserves. Reserves are evaluated based upon the complete loss profile, the merits of each claim and probable outcome of the case. Reserves are established as soon as practical but no later than 90 days from the date the loss is reported to and received by Chubb. Litigation When a claim is litigated, an assigned Chubb adjuster will engage one of Chubb s panel attorneys to represent your company. Our Litigation Management Guidelines also specify that defense counsel should send your company copies of all appropriate litigation correspondence, in accordance with state law.

4 At Chubb, we believe the best way to manage a claim is through a coordinated engagement with our customers, agents and brokers. Each claim is unique, and our claim handling approach is tailored to the situation with an unwavering commitment to provide world class claim service. Should you have any questions or need assistance, contact your local Chubb settling office. Chubb Group of Insurance Companies Warren, NJ NCCI, May 2015 Chubb refers to the insurers of the Chubb Group of Insurance Companies. Not all insurers do business in all jurisdictions. This literature is descriptive only. Actual coverage is subject to the language of the policies as issued. Chubb, Box 1615, Warren, NJ Form (Ed. 8/15)

5 Exhibit A ONLINE CLAIM REPORTING Simple, Online Reporting Instructions Designed with the user in mind. STEP 1: Click Report a Claim on Chubb s Homepage: Click Report a Claim STEP 2: Select Online from the list of claim reporting options Click Chubb s Online Claim Reporting application

6 Two Reporting Options STEP 3: Continue as a Registered or Unregistered User, both have the ability to reduce manual entry by retaining key information Unregistered Users: Everyone can submit a claim as an unregistered user. Business insurance customers should report claims as an unregistered user, unless you have an ID. For an improved experience as an unregistered user, check Remember my Information to save contact and policy detail for future claim reporting. Registered Users: Personal insurance customers who have registered their accounts online and agents or business insurance customers IDs will have the option to log-in. Logged in users, with valid policy numbers, will have the ability to populate the form with select policy level information. Questions related to log-in credentials: Personal Insurance Customers & Agents Business Insurance Customers & Agents STEP 4: Follow the onscreen instructions and complete the form Navigation Keys: Indicates a required field Indicates a field that while not required will speed up claim processing (Workers Compensation only) Indicates addditional information is available, click on the icon to reveal the detail

7 STEP 5: Review the claim summary click edit to make changes to a section Identify who should receive an confirmation and who should be contacted by the adjuster Upload documents Save information for future claim notices Submit the claim Click Submit Claim

8 STEP 6: The confirmation page Print a confirmation with claim number & summary Registered users can access Chubb s Property & Auto Vendors All Worker s Compensation Claims can access the Corvel Medical Network Chubb Group of Insurance Companies Warren, New Jersey Chubb refers to the insurers of the Chubb Group of Insurance Companies. Not all insurers do business in all jurisdictions. This literature is descriptive only. It is off ered as a resource to be used together with your professional insurance advisor in maintaining your insurance program. No liability is assumed by reason of the information this document contains. Form (Rev. 3/15)

9 Chubb Workers Compensation Report of Injury Worksheet Internet: Click on To Report a Loss. Phone: Exhibit B Things to remember when reporting a Workers Compensation Claim: Use this Report of Injury Worksheet as a reference for collecting details. It is not necessary to write in answers to questions you know when calling us. If you plan to fax us, you should fill in the 2 page worksheet. However, whether you are calling or faxing, do not delay in reporting the claim even if you do not have answers to every question. LOCATION/SITE CODE: STATE: DATE OF ACCIDENT: EMPLOYERS NAME: MAIL ADDRESS (STREET): PHONE # (AREA CODE FIRST): NATURE OF BUSINESS: PREPARER S NAME: PREPARER S TITLE: DAYS OPEN: POLICY NUMBER: EMPLOYEE NAME (LAST, FIRST): MAIL ADDRESS: CITY/COUNTY/PARISH: STATE: ZIP: PHONE # (AREA CODE FIRST): SOCIAL SECURITY # SEX AGE DATE OF BIRTH: MARITAL STATUS (S,M,D,W): OCCUPATION: REGULAR DEPT: HIRE DATE: LENGTH EMPLOYED: YRS. MOS. DYS. DATE IN JOB: LENGTH IN JOB: YRS. MOS. DYS. DATE INJURY REPORTED TO EMPLOYER: ESTIMATED/ACTUAL DAYS OFF: INJURY/ILLNESS DESCRIPTION: EMPLOYMENT STATUS: (F,P,S,V) IS THE EMPLOYEE OWNER/OFFICER, PARTNER? WAGE CLASS: PAID DAY INJ? (Y/N/U) PIECE/TIME: HRS/DAY: DAYS/WK: HRS/WK: WAGES/HR: WAGES/DAYS: AVG. WAGE/WK: SALARY/MOS. REG DAYS OFF: PER (W/M/Y): Page 1 of 2

10 Chubb Workers Compensation Report of Injury Worksheet ACCIDENT LOC (STREET ADDRESS): CITY: STATE: COUNTY: STATE: ZIP: ON PREMISE (Y/N): INJURY/DISEASE (I/D): TIME OF INJURY: TIME SHIFT BEGINS: A/P: ENDS: A/P: SUPERVISOR TIME REPORTED: A/P: LAST WORKED: TIME LEFT: A/P: LOST TIME (Y/N): FIRST OFF: # OF EMPLOYEES INJURED: FATAL (Y/N): DATE OF DEATH: WHAT WAS THE EMPLOYEE DOING? NATURE OF INJURY/BODY PART: OBJECT/SUBSTANCE INVOLVED: HOW COULD EMPLOYER PREVENT? HOW COULD EMPLOYEE PREVENT? WHO CAUSED THE ACCIDENT IF NOT THE EMPLOYEE? ADDRESS OF THE PERSON WHO CAUSED THE ACCIDENT: RETURNED (Y/N): DATE: TIME: AP REG ( ) LIGHT ( ) DUTY (X) RETURN WAGE: RETURN OCCUPATION: PAID WHILE INJURED? (Y/N): REASON TO DOUBT VALIDITY OF CLAIM? WITNESS NAME(S): ADDRESS CITY STATE ZIP DOCTOR S NAME: ADDRESS CITY STATE ZIP DOCTOR S PHONE #: HOSPITALIZED (Y/N)? HOSPITAL NAME: ADDRESS CITY STATE ZIP HOSPITAL PHONE #: TOTAL DEPEND. #: MINOR DEPEND. #: DEATH IF YES, NEXT OF KIN NAME & ADDRESS: PREPARER S PHONE NUMBER: MAILING INSTRUCTIONS: THE ADDRESS THE EMPLOYER WOULD LIKE THE FIRST REPORT OF INJURY MAILED TO: ADDITIONAL ADDRESS EMPLOYER WOULD LIKE THE FIRST REPORT OF INJURY MAILED TO: YOUR CLAIM # Phone: Internet: Fax: Page 2 of 2 Form (Rev. 8/15)

11 Exhibit C Return-to-Work Program: A SMART STRATEGY FOR EMPLOYERS AND EMPLOYEES FACT: The average American business pays approximately 25 cents of every dollar of pretax corporate profi ts for work-related injuries. 1 FACT: In terms of payroll, 1.23 cents of every payroll dollar goes toward workers compensation insurance. 2 FACT: According to the U.S. Department of Labor, in 2013 about 1.2 million workplace injuries and illnesses resulted in time away from work. 3 Work-related injuries are hurting both employers and employees. An employee who misses work due to an on-the-job injury suffers emotionally and financially. Businesses suffer, too. Medical costs, lost productivity and overtime wages add up. You know that keeping valuable employees safe and working is critical to your organization s financial success. But, what can you do to help reduce the effects of work-related injuries on the corporate bottom line? Chubb s Return-to-Work Program can help. YOUR RETURN ON INVESTMENT One of the fundamental tenets of the workers compensation system is to treat injured employees and help them return to work in a timely and cost-effi cient manner. In support of that, a return-to-work (RTW) program helps injured workers return to gainful employment by providing them with modifi ed jobs that take into consideration physical restriction, skills and capabilities. Chubb s Return-to-Work Program combines best industry practices to develop a plan that encourages a speedy recovery and reduces workers compensation costs. EMPLOYERS AND EMPLOYEES BENEFIT FROM AN RTW PROGRAM Employer Benefits Reduces the total cost of workplace injuries Maintains productivity Allows management to actively participate in the employee s recovery Improves the morale of the workforce by knowing there is a process in place Retains good employees and the benefi ts of their labor Reduces loss costs and improves experience modifi cation

12 Employee Benefits Returns the injured employee to full wages instead of workers compensation indemnity payments, which are typically two-thirds of full wage Depending upon the state, permits the injured employee to continue participation in employee benefits and retirement benefits programs Provides a sense of security and stability for employees Facilitates communication between the employee and employer, promoting a positive attitude upon return to work READY TO TAKE THE NEXT STEP Chubb takes an integrated team approach to assisting you with your RTW program. Through the combined resources of our nurse consultants and our loss control, claims and underwriting professionals, our RTW team has the expertise necessary to help you further improve and promote utilization of your current RTW program or implement a program tailored specifically to your organization. We can help you in several ways. If your organization is interested in developing an RTW program, you can use Chubb s Return-to-Work Guidebook to lead you through the process. Or, if you have an existing program, you can utilize the Guidebook s programassessment tool to further improve your program s effectiveness. Chubb s Return-to-Work Guidebook provides you with the following: Roles and responsibilities for RTW program success An assessment worksheet for existing programs Implementation guidance and flowchart Injury management practices Additional useful forms and resources to assist you in implementing or assessing an RTW program A Chubb team of RTW consultants can provide additional assistance based on your program needs and funding for resources. FOR MORE INFORMATION Remember, a successful RTW program doesn t just help reduce workers compensation costs. Ultimately, it will create a safer workplace and significantly reduce employee injuries. To find out more about Chubb s Return-to-Work Program, as well as our other tools to help better manage workers compensation issues in your organization, contact your local Chubb underwriter. 1 American Society of Safety Engineers Government and Professional Affairs, John Burton s Workers Compensation Resources, Research Report, Issue 5, December 2012 Chubb Group of Insurance Companies Warren, NJ Bureau of Labor Statistics, 2013 Whether or not or to what extent a loss is covered depends on the facts and circumstances of the loss and the terms and conditions of the policy issued. Chubb refers to the insurers of the Chubb Group of Insurance Companies. Not all insurers do business in all jurisdictions. This literature is descriptive only. Actual coverage is subject to the language of the policies as issued. Form (Rev. 5/15)