South Texas ASSE San Antonio, TX

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Emory Webb
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1 Presentation To South Texas ASSE San Antonio, TX May 21, 2007

2 Presentation Summary Corporate Overview Essentials of Workers Compensation Law Red Flags of Questionable Comp Claims Influencing the Outcome of Your Claims Using Case Management to Save $$$$ Q & A

3 Corporate Overview

4 CasePro was founded August 1, 1996 Woman-owned Certified as WBE by the SCTRCA, and as SBE, DBE and WBE by NCTRCA Corporate Office San Antonio, Texas

5 Two Divisions Disability Management Division Federal Contracting Division Multi-State Operations Seven core states in Disability Management Division Capability for national coverage

6 Experienced Management Team Shirley Hill, RN, CRRN, CCM President 20 Years in Healthcare Management John Hill, CPA Executive Vice President 30 Years in Corporate Finance and Accounting Michael McCabe, BS Engineering, MBA Finance Senior Vice President, 15 Years Multi-National Corporate Experience

Years in Corporate Finance and Accounting Michael McCabe, BS Engineering,

7 Your Presenter Nancy Lewis, BS, MS Psychology, CRC Vice President, Disability Management 27 Years Providing Rehabilitation Services (210)

8 Other Members of the CasePro Team Registered Nurses Vocational Rehabilitation Consultants Life Care Planners

9 Overview of Texas Workers Comp Law

10 General History of Workers Comp Grew out of the Industrial Revolution Protects employer from being sued Provides wage replacement (indemnity) and medical care to eligible IW, i.e., claim must be compensable

sued Provides wage replacement (indemnity) and

11 Texas Law Employer Driven 1/2006 TWCC replaced by Division of Workers Compensation DWC oversees administration of comp rules and regulations Employers can now elect for injured worker to treat within a Physician Network

administration of comp rules and regulations Employers

12 Types of Comp Coverage Fully insured Large deductible Self-Insured Self-Funded Non-Subscriber

13 Types of Benefits Medical benefits Temporary Income Benefits (TIBs) Impairment Income Benefits (IIBs) Supplemental Income Benefits (SIBs) Lifetime Income Benefits (LIBs) Death benefits

14 Settling Disputes Benefit Review Conference (BRC) Contested Case Hearing (CCH) IW can request representation by DWC ombudsman or may be represented by plaintiff attorney Employer can be present at BRC and CCH and is represented by claims adjuster as well as defense attorney if they wish

represented by plaintiff attorney Employer can be present at BRC and

15 Red Flags

16 1. File Open More than Six Weeks Most back injuries resolve within six weeks, with or without care 2. Catastrophic or Multiple Injuries* Probability of prolonged time off work with considerable medical expense Need for highly skilled, specialty medical care * Catastrophic claims should always be referred for case management.

Catastrophic or Multiple Injuries* Probability of prolonged time off work with

17 3. Co-Morbid Conditions Smoking Diabetes Hypertension Overweight Drug abuse

18 4. Choice of Treating Physician Physician s specialty and strengths Physician s focus IW or employer? Physician s willingness to meet and work with case manager 5. Treatment Plan Appropriate? Conservative care vs premature diagnostic testing or more invasive treatment Treatment reasonable, necessary and related?

Physician s willingness to meet and work with case manager 5.

19 6. Lack of Objective Findings Objective testing should support subjective complaints Complaints without objective findings suggest symptom magnification and/or secondary gain 7. Positive Waddell s Signs Tests performed by MD revealing non-physiologic findings Suggest symptom magnification

symptom magnification and/or secondary gain 7.

20 8. Any Misrepresentation of Facts IW may represent condition as worse than it is IW may mislead physician regarding job demands* 9. Injured Shortly After Being Hired May indicate pre-existing condition for which IW is seeking treatment *A job analysis provides objective documentation of a job s physical demands.

Injured Shortly After Being Hired May indicate pre-existing condition for

21 10. History of Work Injuries Past injury may be cause of current complaints Or may be indicative of a professional claimant 11. Non-compliance With Medical Care Typically occurs with less serious injuries Suggests lack of commitment to recovery Secondary gain may be involved

22 12. Injury Occurring on Monday May indicate injury actually occurred over weekend 13. Injured Worker Has Personal Crisis Frequent correlation with more extensive disability 14. Excessive Use of Medications May be utilizing claim for drug seeking May correlate with history of substance abuse

23 15. History of Recent On-Job Discipline Claim may be retaliation 16. Injured Worker Adversarial Often has prior workers comp experience May be trying to drive up value of claim Usually a demanding and manipulative personality 17. Attorney Involvement Motivation to resolve claim and return to work questionable

24 18. Symptom Magnification Failure to respond to conservative care Complaints unsupported by objective findings Often prolonged chiropractic care or excessive physical therapy May be attempt to prolong time off work High percentage become permanently & totally disabled

25 19. Additional Diagnosis Secondary to Injury Such as back pain secondary to knee pain or Any kind of psychological (functional) overlay Multiple diagnoses typically complicate and prolong claim

26 20. Surgery Recommended Without Objective Findings Suggests physician may not be objective Suggests secondary gain or ignorance on part of IW 21. History of Psychological Problems Typically prolongs claim due to secondary gain issues Family dynamics Inability to withstand stress of being injured

27 22. Repetitive Trauma Treatment may be prolonged and include surgery Work station or job duties may require modification 23. Injured Worker Refuses Bonafide Job Offer Strongly suggests lack of motivation and secondary gain

28 Influencing the Outcome of Your Claims

29 Employer Must Take The Initiative Maintain contact with IW communication is key Hold claims handler and other team members accountable Create effective return-to-work program Recognize Red Flags Involve ancillary services (i.e., case management or private investigator) when appropriate

30 Communication is Key Positive contact with IW helps minimize time off Should be from supervisor or other manager Demonstrates genuine concern for and value of employee Helps offset negative influences Models expected work behaviors

31 Manage Your Team Members They work for you and: Should be responsive to you and IW Should be dedicated to your account whenever possible Should recognize and promote your values Should work and play well with other team members

32 Facilitate Modified Duty RTW Studies show IWs off work for more than 6 months are unlikely to return to any job ever DWC Reimbursement Account for small employers helps cover costs of job modification (see handout) Modified duty saves employer money Modified duty limits opportunity for secondary gain

33 Recognize Red Flags Red flags heads up for problem claims with potential for prolonged time off work and higher costs May require greater vigilance on your part May indicate need to mobilize ancillary services such as case management

34 Case Management

35 What is Case Management? Service provided by medical and vocational rehabilitation professionals who are: Representing your interests Assisting IW navigate medical and comp systems Facilitating rapid return to work Achieving cost savings for you

36 Two Types of Case Management Medical Case Management (MCM) Vocational Case Management (VCM) Either can be telephonic or field

37 MCM Should be Medical Pro Typically RN or with related degree Possesses years of medical and/or case management experience Expertise supported by national certifications such as CCM, CRRN, CRC or CDMS Participates in continuing education

38 Keys to Good Medical Case Management Sound medical knowledge Understanding of the law and its implications Excellent negotiating skills Ability to think like the account Knows when to close the file

39 Medical Case Management Should be involved early in life of claim With focus on resolving medical issues and limiting impairment And facilitating timely return to work

40 MCM Helps Resolve Claim By Assessing medical status Facilitating and coordinating appropriate medical care Holding medical providers and IW accountable Promoting communication between all parties Expediting return to work Resulting in cost savings for you

41 VCM Should be a Vocational Rehab Pro Typically has MS in rehab studies or related field Or may be a RN with appropriate on-the-job experience Expertise supported by national certification such as CRC, CCM, CRRN, CVE or CDMS Participates in continuing education

42 Vocational Case Management Assigned to IWs receiving 15% or greater impairment With focus on demonstrating access to the labor market and facilitating return to work To limit eligibility for SIBs Resulting in cost savings for you

43 VCM Helps Resolve Claim By Identifying IW s vocational interests and abilities, then Creating a Rehabilitation Plan and initiating job search While coaching IW in job seeking skills With goal of achieving return to work And limiting or preventing eligibility for SIBs Resulting in cost savings for you

44 Case Managers Represent Your Interests By Knowing your corporate values and goals Promoting those values and goals whenever possible Acting as your eyes and ears in the field All the while moving your files toward closure For the bottom line purpose of saving you $$$$

45 Good Case Management = Cost Saving

46 Glossary of Terms (see handout) Q & A

47 Thank you for your time! Please let us know how we can assist you with your claims.

Overview of the Income Benefit Structure in the Texas Workers Compensation System. Texas Department of Insurance, Division of Workers Compensation

Overview of the Income Benefit Structure in the Texas Workers Compensation System Texas Department of Insurance, Division of Workers Compensation 1 Workers' compensation will provide benefits if: The injury