Understanding Workers Compensation Claims

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1 Understanding Workers Compensation Claims DESIREE TOLBERT, SEDGWICK CLAIMS MANAGEMENT SERVICES ROB VAN EPPS, FCAS, MAAA, FINANCIAL RISK ANALYSTS RAFAEL GONZALEZ, GOULD & LAMB, LLC

2 Understanding Worker's Compensation USA Risk Group 9 th Annual Executive Educational Conference Charlotte, North Carolina 2014 Sedgwick Claims Management Services, Inc Sedgwick Claims Management Services, Inc. Confidential Do not disclose or distribute. Confidential Do not disclose or distribute.

3 Workers Compensation Goals 1. Promote workplace safety 2. Provide reasonable and timely income and medical benefits to employees who suffer occupational disease or accidental injury arising out of and in the course of employment. 3. Reduce the need for costly litigation 2014 Sedgwick Claims Management Services, Inc. Confidential Do not disclose or distribute.

4 Importance of Timely Reporting The earlier the claim is reported, the lower the cost of the claim After 7 days, the average paid loss is 14.5% more and the average days of disability is 19.8% greater 2014 Sedgwick Claims Management Services, Inc. Confidential Do not disclose or distribute.

5 Best Practice Reserve Evaluation 2014 Sedgwick Claims Management Services, Inc. Confidential Do not disclose or distribute.

6 Jurisdictional Change Cycle Legislative Changes Regulatory Changes Appellate and Supreme Court Decisions 2014 Sedgwick Claims Management Services, Inc. Confidential Do not disclose or distribute.

7 WC Claims Actuarial Perspective Actuarial Roles Setting Reserves Higher level analysis Generally review claims on aggregate basis Will review individual cases upon need Esp. for smaller companies i.e. captives Developing Rates/Funding Estimates 7

8 WC Claims Actuarial Perspective Actuary must understand: Industry Differences in regions i.e. tort reform Overall trends i.e. medical inflation, impact of MSA Company Coverage What classes, retentions, treatment of ALAE, etc. Data Especially changes to reserving practice! 8

9 WC Claims Actuarial Perspective Data Typically provided by TPA Claim detail data preferred paid and case reserve medical and indemnity split loss and expense split Communication regarding any changes to reserving practice i.e. increasing average reserve to account for MSA 9

10 WC Claims Actuarial Perspective Cumulative Incurred Losses 12-mos 24-mos 36-mos 48-mos 60-mos 72-mos 80-mos 92-mos ,519 18,531 20,655 21,840 22,753 23,381 23,978 24, ,819 18,262 20,410 21,797 22,570 23,332 24, ,093 19,247 22,024 23,487 24,569 25, ,513 20,304 23,005 24,707 26, ,539 20,410 23,300 25, ,309 18,500 22, ,391 20, ,824 Interval Loss Development Factors Average Avg ex. Latest Latest

11 WC Claims Actuarial Perspective Quantifying Changes Discussions with TPA, legal team Analysis of loss metrics Average reserve per claim Change in reserve on individual claims Industry data on impact of law changes, trend, benefit level changes, etc. Actuary can adjust methods to reflect changes 11

12 Contact Rob Van Epps, FCAS, MAAA Managing Principal 706 Northeast Drive, Suite 4 Davidson, NC Phone: Fax:

13 Medicare Secondary Payer Compliance: Taking Medicare s Interests Into Account USA Risk Group Executive Educational Conference Charlotte, North Carolina May 20-22, 2014

14 Taking Medicare s Interests Into Account Mandatory Insurer Reporting Conditional Payment Resolution Medicare Set Asides Allocations, Approvals, and Administration 14

15 Mandatory Insurer Reporting

16 The Medicare, Medicaid, and SCHIP Extension Act of 2007 Self-Insured, No-fault, Work Comp, Liability Determine eligibility for Medicare Submit information to COB $1,000 per day per file penalty 16

17 Mandatory Insurer Reporting Implementation Time Line TPOC after 10/1/12 more than $5,000 are reportable beginning 1/1/13 TPOC after 10/1/13 more than $2,000 are reportable beginning 1/1/14 TPOC after 10/1/14 more than $1,000 are reportable beginning 1/1/15 ORM payment for medicals over $750 17

18 Conditional Payment Resolution

19 Conditional Payment Resolution Lien from DOA to DOS Primary Payer Responsibility CP Requests/Final Demand 19

20 Conditional Payment Process Conditional Payment Letter Conditional Payment Negotiation Final Demand Payment 20

21 Medicare Set Asides

22 Medicare Set Asides Current Medicare Beneficiaries Eligible Within 30 Months of DOS No Reasonable Anticipation 22

23 MSA Process Allocation Approval Administration 23

24 G&L Services Mandatory Insurer Compliance Services Conditional Payment Resolution Services Medicare Set Aside Allocation Services Future Medical Costs Projection Services Post Settlement Account Administration Life Care Planning Services Medical Case Management Services Prescription Drug Services 24

25 G&L Tools GL-Medicare Risk Assessment GL-Search GL-Code GL-Professional Administration Quote GL-Resources & Forms GL-Industry News Bulletin 25

26 Thank You! Rafael Gonzalez Director of Medicare & Medicaid Compliance and Post-Settlement Administration Gould & Lamb, LLC 101 Riverfront Blvd., Suite 100 Bradenton, Florida X

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