Bringing Everyone Together in Workers Compensation

Transcription

1 Bringing Everyone Together in Workers Compensation

2 Weird: Unusual or strange Together: With each other; in or into one group, mixture, piece, etc.; in a close relationship

3 Why does working together matter? Choosing the right partners?

4 Building Communication and Trust Consistent Communication Know everyone s roles Follow through The adjuster s role Adjudicate the claim Process payments

5 Understanding the Network What does the network provide? Bells and Whistles

6 Understanding the Network 504 Not regulated by the State Owned by Public Entity Can move all legacy claims into the network No 504 s are the same Open to political influence Non-Network Claimant s may use any DWC approved Dr. Cannot prevent claimant from treating at bad Dr Regulated by the State Claims occurring prior to 9/1/05 can be moved into the network for treatment (legacy Claims) Cannot cover claims that occurred after 09/01/05 and before the network was put into effect (legacy claims) Designed for Statewide Insurance Carriers and not Self-Funded Entities.

7 The Network s Role Contracting with Medical Providers Hold Medical Providers accountable to the contract and outcomes Provide a Medical Director

8 The doctor/employer relationship Return to Work Program DWC 73 s, 69 s

9 The Medical Provider s Role Provide Medical Care Follow Official Disability Guidelines

10 Consultant Fee based. Insurance Consultant is an expert or experienced professional in the insurance industry. The insurance consultant identifies risk and works in the best interest of their client. Agent Commission based. Agents sell a variety of insurance products and represent a number of insurance carriers and in most cases work in the best interest of the insurance carrier.

11 Return to Work Programs Modified Duty Temporary Job Assignments Benefits

12 The Employers Role General Manager/Coach Quarterly Claims Review

13 Has an Inter-local Agreement with another entity s 504 WC Network Every claimant provided with a Telephonic Case Manager (must be a certified nurse) TCM contact claimants to assist with care and act as liaison between medical provider and adjuster/employer Adjuster may assign a Field Case Manager when a claim needs more detailed attention

14 Grand Prairie ISD Workers' Comp 3 Year Loss Averages 42.6% Drop in Workers' Comp Losses over ther period shown. $900,000 $837,427 $800,000 $768,931 $700,000 $600,000 $644,577 $624,341 $500,000 $400,000 $300,000 $200,000 $100,000 $

15 Grand Prairie ISD Workers' Comp Lost Time Claims 3 Year Averages Period Shown reflects a 50% drop in Lost Time cases

16 $4,500,000 $4,239,051 $4,000,000 $3,614,635 $3,500,000 $3,000,000 50% drop in Claims Liability $2,500,000 $2,503,199 $2,000,000 $1,500,000 $1,246,793 $1,000,000 $500,000 $

17 Grand Prairie ISD Workers' Comp Cost Per Student 64% Drop in Cost Per Student 30,000 $ ,000 $ ,912 26,476 27,593 $ ,614 $30.86 $ ,000 $24.35 $22.62 $ ,000 $20.00 $ ,000 $ ,000 $ $- Student Count Cost Per Student

18 Claimant #1 Date of Injury: 08/27/2015 Medical 10, Expense Indemnity 1, Total 12, Claimant states her and two co-workers were pushing a teacher s desk up a ramp and onto a flatbed to put on a stage. The desk kept falling. The claimant was in the front, pulling the desk, and the desk fell and hit her L big toe. She sought treatment with clinic, diagnosed with a broken toe, and referred to an Ortho. She was initially placed on light duty, taken off work by the Ortho (Dr. #1) on 9/10/15, and returned back to work on 10/01/15 l/d. Her treatment plan consisted of medication and physical therapy. Dr. #1 then transferred case to peer (Dr. #2) in the same firm on 04/26/16. File was assigned to Field Case Manager as the claimant continued on l/d.

19 Claimant #1 Date of Injury: 08/27/2015 Medical 10, Expense Indemnity 1, Total 12, On 05/24/2016 claimant was seen by Dr. #2 and diagnosed with Complex Regional Pain Syndrome and notified that the fracture was healed a long time ago. This diagnosis was questioned, therefore the FCM set the claimant up with Dr. #3. She was seen by Dr. #3 on 7/6/16 and was advised that she does not meet the criteria for Complex Regional Pain Syndrome. Claimant had a CT scan on 7/15/16 which showed that her fracture had healed. She had been wearing a hard soled shoe and on 8/3/16 was advised to stop using it immediately. Claimant continued l/d until 8/31/16, in which Dr. #2 placed her at MMI with 1% IR, which is paid in full. Claim was closed on 10/11/16.

20 Claimant #2 Date of Injury: 10/21/2015 Medical 5, Expense Total 5, Claimant states she was on a ladder, and fell from ladder when she was pushed by a student. She sought treatment with Clinic #1 for the Left hand, shoulder, wrist, and hip and placed on l/d. X-rays were taken and were normal. On 11/20, Clinic #1 added neck sprain to the diagnosis. Her treatment consisted of PT and medication. She continued l/d. She was scheduled for an MRI in January but was a no show. At this point she was seen almost weekly with new prescriptions for pain given. On 3/2/16, the Medical Director advised that they will no longer see the claimant under worker s comp nor personal insurance as she became verbally aggressive when the doctors refused to continue prescribing meds. TCM was able to get the claimant into Clinic #2 to be seen on 4/18/16. She could have been seen earlier, however she was not returning calls.

21 Claimant #2 Date of Injury: 10/21/2015 Medical 5, Expense Total 5, We received the MRI report showing we attended on 2/1/16 which showed some disc bulges, protrusions, and degenerative disc disease. We obtained an index which showed previous injuries claimed to the neck. We obtained a Peer Review which showed the MRI findings were not part of this injury. We filed an extent of injury on 5/19/16. Clinic #2 also started having the same problems with the claimant regarding the prescriptions. She was given a prescription by one doctor on 4/18 and the same prescription by another doctor on 4/27. When she was told they would no longer give her any meds, she became irate as well. She was advised that she could not return to that specific location. She was initially being referred to an Ortho but it was stopped once the extent of injury was filed.

22 Claimant #2 Date of Injury: 10/21/2015 Medical 5, Expense Total 5, The claimant then filed another injury advising that her neck has been hurt in that injury as well. TCM found another Clinic #2 location for the claimant to attend, however when she attended the appointment, she advised she only wanted to be seen for the new injury. There was no further treatment on this injury so the file was closed. Once the claimant was placed at MMI on the new file, she went back and sought treatment under this claim, therefore the claim was reopened. She is f/d at this time. We are trying to get her scheduled for IR for this claim. During this time her social media pages were discovered where she was shown working out, riding bikes, going hiking, etc. during the time period that she was telling the Dr. that she had a 7-9 out of 10 on the pain scale.

23 Jason Hardy Scott Irot Yvonne Moorad Patricia Piper