Employer Best Practices in Controlling NY WC Claim Costs As presented at the 2017 NYSBCA Annual Convention

Transcription

1 Employer Best Practices in Controlling NY WC Claim Costs 2017

2 Lisa Sauro, WC Supervisor Joined National Interstate in 2015 Supervises staff of WC adjusters throughout the U.S. 25 years of Worker s Compensation experience Including 10+ years as WC Senior Hearing Representative BS degree from Syracuse University Associates in Risk Management Currently resides in Syracuse

3 VOLUNTARY REMOVAL FROM THE LABOR MARKET ACCIDENT FRAUD DEFENSES OPIODS VENUE FUTURE CARE AWW LOST WAGES MEDICAL TREATMENT GUIDELINES DEFENSES CAMERAS INDEMNITY PRESUMPTION OCCUPATIONAL DISEASE LOSS OF USE RESPONSIBLE THIRD PARTY MECHANISM OF INJURY IMES CAUSALITY VOCATIONAL REHAB TEMPORARY PARTIAL LOST WAGES FROI/SROI AVERAGE WEEKLY WAGE LOSS TRANSFER STATUTE PERMANENCY DIAGNOSIS SAFETY POLICY FUNCTIONAL CAPACITY EXAMS LAW JUDGES WORK CAPABILITIES PRE-EXISTING CONDITION LOSS OF WAGE EARNING CAPACITY MEDICAL FEE SCHEDULE MRI HEARINGS IMPAIRMENT LIGHT DUTY REFORM PROGNOSIS MMI RTW WITNESSES SUBROGATION BACK INJURY DATE OF LOSS REBUTTAL OPPOSING COUNSEL PERMANENT PARTIAL DISABILITY DRIVING HISTORY DRUG AND ALCOHOL TEST NURSE CASE MANAGERS EXACERBATION NEGLIGENCE SCHEDULE LOSS OF USE WITNESS STATEMENTS MEDICARE LIENS GENERAL DAMAGES

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5 How Can We Reduce WC Claim Costs?

6 Good Management Practices Create clear job descriptions detailing the essential functions Provide written safety protocols Conduct consistent, ongoing safety meetings Properly maintain equipment Avoid overworking employees leading to exhaustion/injuries

7 Pre-Claim & Post-Claim Planning Pre-Claim Process in place for reporting claims Job descriptions for every job and identify modified duty work Medical providers selected for locations/areas of service Cameras in every vehicle Training drivers Post-Claim Injured employee to medical provider Timely reporting Investigate the accident; witnesses?

8 Preventative Costs vs. Claim Costs Preventative Background check PAT / POET exams Maintenance of equipment Management s time for safety meetings Claim Costs Medical expenses Wage loss Permanent impairment benefits Vocational retraining Defense attorney fees Loss of productivity Negative impact on coworkers

9 What NIIC Does To Reduce Claim Costs Aggressive cost containment Two onsite nurses (RN) on staff Multiple Return to Work Vendors (on-site vs. T2W/Re-employability) Bill Review/Reduction and Bill Negotiations Physical Therapy, DME and Home Health Networks National Prescription Benefits Program (PBO) Medical Management Challenging appropriateness of care: Utilization of NY Workers Compensation Treatment Guidelines Independent Medical Exams Use of Telephonic and Field Nurse Case Managers

10 How You Can Reduce Claim Costs Training supervisors on empathy and how to maintain communication with an injured employee Good communication between the carrier and employer Utilizing light duty and return to work programs Provide workers with materials that explain the claims process and expectations for RTW, medical networks and other cost containment requirements prior to any claim occurring Paying attention to demographic factors can make a difference. Extra sensitivity and encouragement following an injury

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12 NY WC 2017 Reform

13 2007 Reform 2007 Reform Increased Average Weekly Wage maximum to 2/3 NY State AWW $400 prior to 7/1/07 vs. $ eff 7/1/17 Result Exorbitant Schedule Loss of Use awards (permanency to extremities) Example: 20% SLU of hand Pre 2007 = $19,520 Post 2007 = $42,486

14 New SLU Guidelines Workers Comp Board was directed to adopt new permanent impairment guidelines for schedule awards by 1/1/18 effective 1/2/18 due to new medical advances and the concern over the increase in the size of schedule awards The WCB required to confer with stakeholders including NY AFL-CIO, NYS Business Council, NYS Insurance Fund, Medical Society of NY, NYS Osteopathic Medical Society, NY Self- Insurance Association, Zurich on behalf of insurance carriers and NYC Law Dept Published 9/1/17 for Public Comment Period thru 10/23/17

15 New Guidelines for SLU Awards Compensation for permanent loss of earning power due to a permanent residual deficit Does not consider pain and suffering WCB will determine the SLU based on medical evidence and the impact on a claimant s earning power New guidelines use a base percentage per body site adding in range of motion, strength and WCB s discretionary value (no greater than 15%) to reach the SLU value Any schedule loss of use awards that have not been determined by 1/1/18 will utilize these new guidelines

16 2007 Reform and PPDs 2007 Reform Capped benefits for classifiable conditions vs. lifetime benefits by enacting Loss of Wage Earning Capacity Extreme hardship Safety Net If > 80% LWEC claimant s can pursue additional benefits once their cap is exhausted Result Delayed permanency classifications from 4.8 years prior to 2007 reform to 6.4 years post 2007 reform Private carriers avoiding Aggregate Trust Fund deposits Claimant s avoiding implementation of capped benefits Settlements prior to ATF

17 2017 Reform and PPDs For dates of loss after 4/10/17 any temporary disability for periods > 2.5 yrs (130 wks) will be credited off the cap Amended definition of max medical improvement (MMI) Generally MMI is reached by 2 years If not, provider must document specific treatment required, improvements expected and the timeframe Question of future surgery is not a bar to MMI Assertion of consequential injuries does not preclude MMI Safety valve extends temp disability beyond 2.5 yrs if claimant has not reached MMI and that is not subject to credit Extreme hardship redetermination reduced to > 75% LWEC

18 Post PPD Labor Market Attachment A claimant who is found to be attached to the labor market at the time of classification is not required to demonstrate ongoing labor market attachment Absent a specific ruling at the time of classification the claimant will be presumed to be attached to the labor market An employer can combat this finding by offering light duty as soon as an employee has a partial disability Carriers should also raise the issue early, prior to classification

19 Additional Reform WCB will conduct a study on IMEs in 2018 and provide recommendations by 12/31/19 to address compliance, quality and produce data on fraud; may potentially suggest panels, rotating providers or state networks WCB to adopt a drug formulary by 12/31/17 and non-preferred drugs would require a variance request by the provider Where there is evidence of a work-related disability and claimant is not working and not receiving lost wage benefits the WCB will schedule a hearing within 45 days receiving a request for hearing WCB can assess penalties against carriers without a hearing to more effectively regulate carrier behavior regarding timely filing, payment and controversy

20 What We Don t Know Does the credit against the caps include temporary total awards or temporary partial awards or both? Does the 130 week period toll from the date of injury or the number of weeks of lost time? Will the Safety Valve result in increased litigation when claimant s attempt to stave off MMI? SLU guidelines are currently open to public comment until 10/23/17 so we may see modifications prior to 1/1/18 WCB is yet to issue guidelines addressing applications for extreme hardship redeterminations What changes will be implemented in the IME process

21 Thank you! Lisa Sauro Worker s Compensation Claims Supervisor National Interstate Insurance x5593 Lisa.sauro@natl.com