Sedgwick manages injury claims from start to finish with proven strategies that produce better outcomes for clients and injured workers.

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1 CLAIMS AND CARE MANAGEMENT SOLUTIONS Sedgwick manages injury claims from start to finish with proven strategies that produce better outcomes for clients and injured workers. As the leader in customized claims and productivity management solutions, Sedgwick provides an expansive array of services unparalleled in the industry. Our endto-end solutions encompass workers compensation; disability, Family Medical Leave, and other employee absences; general, automobile, product, and professional liability; as well as specialty market services, such as affinity and first and third party fleet programs, healthcare risk management, and retail and consumer care services. Sedgwick provides employers with an integrated approach including comprehensive care management and claims services customized to meet their individual goals. From the first call to one of our nurses soon after an accident occurs to the moment our examiner closes the claim, each service we provide is truly connected every step of the way. And our clients are pleased they continue to renew and integrate their services with Sedgwick because we produce results. Early care is critical for positive outcomes Through Sedgwick s unique clinical consultation service, we help clients remove medical care coordination from supervisors and managers, and ensure a nurse becomes involved earlier in the claims process. Upon injury, our 24/7 nurse line is contacted, symptoms are reviewed, and if applicable, the appropriate level of care is arranged using our five-star provider benchmarking program. With the best providers engaged early in the process, we are able to improve outcomes. As with all our services, clinical consultation is fully integrated with the claim intake and management process. During this initial call, the nurse will determine if the injured worker needs treatment or if they can self-treat. They will ask several questions with topics related to existing conditions such as diabetes or obesity, types of medication they are taking, how the accident happened, etc. It benefits the injured worker because they can talk to a nurse right at the time the incident happens and they feel like their employer is taking care of them. The service benefits employers because it takes the liability of deciding whether they need to get treatment out of the supervisor s hands. When we manage the clinical consultation portion, we are getting up front information that is useful in the claims handling process and the initial call is recorded so it can be reviewed later if needed. If the injured worker needs care, our nurses will send them to an urgent care facility or occupational medical clinic within our preferred provider organization (PPO) network. Hospital emergency rooms are the most expensive option and only used when necessary. After the call, the nurse sends the information to the provider and when they see the injured worker, they already know where to send them for medication, imaging, or therapy, if needed. This is pivotal for the continuity of care as the claim progresses.

2 CLAIMS AND CARE MANAGEMENT SOLUTIONS / P. 2 An automated follow-up call occurs the next day and the injured worker will have the opportunity to speak with the nurse again if they would like to. With our clinical consultation service, we can show clients short-term, measureable results that can be tracked over time. We can set goals and objectives that lead to better outcomes. One of the advantages of having the integrated claims and care management data is the ability to evaluate incoming calls and look at claims metrics to see where care is occurring. Most in-network providers are less costly than out-of-network providers; and with our integrated system, we can show the added value. Throughout the whole treatment process, the claims examiner can see what is happening, and can place alerts or suggest peer-to-peer consultations if something is becoming excessive. The pharmacy is also looking at various aspects of the drug requests, such as the use of generic/brand name medications, or any switches made to mail order prescriptions. If issues arise, the nurse will work with the examiner to develop a plan. For older claims, we have a system that pulls adverse trend alerts for cases that include a significant amount of pharmacy spend. Our pharmacy nurses will determine if long-term usage is appropriate and explore possible options to mitigate costs, such as safely weaning the employee off the drug. From our experience working in a non-integrated environment where the clinical consultation is done by another vendor, it is not a seamless process for the examiners. They have to look for notes in the system from the initial call with the nurse, but sometimes the data that comes to us is not a clear match (ex. the name used is Jim instead of James). We must try to match it up using what we have or contact the supervisor for confirmation. When the information is integrated, the examiner can immediately see that they spoke to the clinical consultation nurse and review the details of the claim. Focusing on drug safety When medications must be prescribed, Sedgwick focuses first on the health and safety of our clients employees. Our injury-specific and acute to chronic formularies ensure that any drugs inappropriate for the injury type and the age of the claim are identified at the point-of sale. An alert goes to our team, so they can review it and see what caused the alert. They can call the provider or pharmacist and quickly determine an appropriate drug; or place restrictions on it, such as no refills. This is particularly useful in eliminating early narcotic use where it is not appropriate. Sedgwick s total pharmacy management process is unique in our industry. Our team educates injured employees to ensure they receive the maximum benefit from drug therapies and to foster drug safety awareness. We work diligently to educate providers and to ensure they are following best practices. If not contracted and managed, prescriptions dispensed from physicians offices can cost two to three times more than a network pharmacy; and often do not follow best practice protocols. Pharmacy expenses are among the highest claims costs for employers. The objectives of our pharmacy services are to ensure injured workers are getting the appropriate medication and to control costs for our clients. When pharmacy services are managed by outside vendors, Sedgwick does not have the opportunity to monitor prescriptions that are not filled appropriately or to make sure the employee received a prescription card from their employer. It is also difficult to manage the early medical aspects of the claim, such as diagnostics and physical

3 CLAIMS AND CARE MANAGEMENT SOLUTIONS / P. 3 therapy, when providers are outside the network. The examiner becomes the stopping point for managing each of these. In an integrated environment, the examiner can easily find the specialty services and doctors in the network, and it is a seamless process. Keeping specialty networks in check Sedgwick completes a due diligence process to make sure our partners for services, such as radiology, diagnostics, durable medical equipment, and physical therapy, are workers compensation specific; and that the protocols and service expectations are in-sync with our total program. We ensure our specialty vendors understand our process and we have integrated them into our system so examiners can easily make referrals. And when bills come in, they are processed a certain way and according to state guidelines. From a service expectation, they understand our programs and what we are trying to achieve. They have also agreed to best in class pricing and we have leveraged this for our clients. To control costs, it is beneficial that the injured workers go to these providers and that the service levels are what we expect. This is also pivotal to the continuity of care. Providing top-notch bill review services Sedgwick s best in class bill review program is more than just state fee schedules, PPO discounts, and network negotiations. It is the way the information is processed within our program that offers key benefits. The main question when Sedgwick built its bill review program was how can we save our clients the most money and do this in the most efficient way possible? We needed to access the bills to be able to quantify what was going on with the medical portion of a claim. The first step we take to lower costs in the bill review process is through fee schedule reductions. Two-thirds of the fee schedule savings are straightforward and we generate the other one-third based on rules that are embedded in the system. For example, if you have an assistant surgeon treating a patient, they are paid at a reduced rate; and we maximize the value of those types of reductions by making sure we have the right people looking at the bills so that they are paid appropriately. Our goal is to ensure accurate coding, and once we have the right code, we want to be sure it reflects the lowest possible allowance for that code and that provider. Our primary objective is to make sure we are accessing the value-added fee schedule reductions on every bill to get the proper price for our clients. We ensure that all reductions are included to produce the lowest possible fee schedule allowance. All additional savings after that point are typically charged as a percentage of savings, so the more discounts obtained here, the lower the service fee is going to be. The major benefit in our program is that we are going to pursue all reductions before we move on to nurse negotiations, network negotiations, and other discounts to make sure we reduce administrative costs as much as possible. With our integrated bill review system, we are only processing bills for the services that should be paid for the injured worker. We process about four million bills a year and half a million claims a year, and we have the largest data set in the workers compensation industry. With our size, we can better measure performance and we can identify more providers. The data set is extremely valuable and can be used to identify trends (adverse or positive), and then leveraged to create strategies to improve outcomes at the desk level and through care management. It also provides key information for network and provider negotiations. All of those things are much stronger with more data; and there are gaps in the data when services are not integrated.

4 CLAIMS AND CARE MANAGEMENT SOLUTIONS / P. 4 In a non-integrated program, Sedgwick must also act as the intermediary between the bill review vendor and the clinical consultation vendor. We rely on these two vendors to exchange the client s preferred doctors to ensure the list is up to date. When we receive the claim, the examiner does not have access to information, such as the details of the initial conversation with the injured worker, what portion of the body was hurt, and which doctor they were referred to, unless the clinical consultation nurse puts these details in the notes. When an outside vendor manages the bill review services, examiners generally have to go into a different system to review the bills. If the client switches bill review vendors, it creates challenges for the third party administrator as well as the insurance carrier; and there are additional hurdles with claims that include Medicare set-asides. Benchmarking ensuring the best providers for our clients Sedgwick was one of the first in the industry to create a quantitative methodology to measure the quality of care provided to injured workers and use that knowledge to build superior networks. Sedgwick has a five-star provider benchmarking program that includes an online search tool enabling our customers and colleagues to direct injured workers to providers who achieve the most successful claims outcomes. Our program is based on scientific methodology and meaningful measurements. Providers are scored on a scale of one to five, and these scores are used to identify top providers who deliver high value, and have proven that they understand the needs of employers and will work with all parties to achieve desired results. We believe the best healthcare comes from the best physicians and not necessarily the ones offering the lowest PPO fees. In addition to being highly recognized, the providers become advocates for injured workers. This approach ultimately lowers costs by ensuring quality care designed to foster prompt, appropriate return to work while minimizing the risk of litigation. Clients participating in our provider benchmarking program consistently realize a 20% reduction in their total cost of risk. One of the major benefits of Sedgwick s integrated program is that our team can quickly access all of the information needed to assist an injured worker. Integrated services in action In November 2008, a large retailer of specialty pet services and supplies selected Sedgwick to manage their workers compensation and general liability claims. With thousands of associates involved in sales, customer service, training, grooming, boarding, and medical care, they needed a solution to streamline their program and control costs. The client was previously under a fully insured program and dealing with a large number of calls being made to their clinical consultation vendor from associates with injuries that were not work-related. Sedgwick s business development and managed care teams worked together to develop a customized clinical consultation service for them. Through our program design, work-related injuries are reported by the location manager and then the injured worker is transferred to the Sedgwick clinical nurse. This is a more efficient process for both the client and the injured worker. As a result, the costs for misdirected calls to the nurse were eliminated. Our program facilitates getting the right care at the right time to the associate and it provides them with comfort. In many cases, it also alleviates the need for them to leave the store to go to the doctor, saving the client additional medical costs. If medical guidelines reviewed by the nurse reveal that the associate can treat their injury, they will receive specific care instructions and a description of the signs to look for that would require medical attention. If they

5 CLAIMS AND CARE MANAGEMENT SOLUTIONS / P. 5 need medical treatment, they will be directed to a doctor within the employer s preferred provider network based on state guidelines. Sedgwick has developed physician panels within a five-mile radius of each of the client s locations, as well as networks for specialty services, such as diagnostics and rehabilitation. Once the nurse completes the consultation, the examiner can access the report in our claims management system. As an added benefit, the clinical consultation calls are recorded, giving the examiner the ability to cross check between what the associate tells the nurse and what they tell their manager. In addition to clinical consultation, Sedgwick coordinates home health care, pharmacy benefits, and bill review; and supports post injury drug testing for the client. There are triggers set up in the system for integrated services, such as utilization review, and telephonic and field case management. Through the coordination of bill review services, our team provided information showing how many tetanus shots were administered off site, which has prompted the client to introduce a new program requiring associates to be current on their tetanus shots. As a value-added service, we also provide the client with SMART auto claim acknowledgements, which have been a real benefit for consistency. Once a claim is assigned, the client automatically receives an initial from the examiner with their contact information. As a part of this push technology, the claim intake system is set up to notify key stakeholders of any incidents, such as fires, storms, acts of violence, and other major accidents. A message is sent to each individual s smart phone allowing them to quickly deploy resources where they are needed. The client appreciates the benefits of Sedgwick s tailored clinical consultation solution, which produces significant savings while enhancing all of the other integrated services in their program. Doing the right thing for the injured worker The integration of the data offers several advantages for the employer and the injured worker. In an integrated program, we can quickly see details such as what types of injuries are occurring more often and where; and then look for the best doctors in that field. For example, if a client is seeing an increase in rotator cuff injuries in a particular state or city, we can use our provider benchmarking tool to find the best orthopedic doctors in that region who also specialize in shoulder surgeries and add them to the network. We focus on what is medically the best option for the injured worker and what is going to produce the best overall result. It is all about doing the right thing for the injured worker there is a good chance that by getting them to the best doctor, they are going to get better faster and return to work sooner. Sedgwick s team provides a carefully crafted strategy designed to ensure clients are getting the most value for their dollar at the claim level and the most efficient process at the examiner s desk. You cannot do that as well in a non-integrated program because the services are managed as separate entities. With our integrated care and claims management solutions, we can provide clients with every service they need under one roof and each one is delivered with the highest customer service levels in the industry. Contact Sedgwick today to learn more about how our integrated approach can help your business

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