WORKERS COMPENSATION COST CONTAINMENT INITIATIVE

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Kelley Darleen Leonard
8 years ago
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1 WORKERS COMPENSATION COST CONTAINMENT INITIATIVE 1

2 Managing Workers Compensation Timely Triage and Reporting Key Items for Reporting Claims Medical Management Return-to-Work Program Managing the TPA Managing Fraud Preventing Litigation Roles and Responsibilities HR and ADA Matters Jurisdictional Benefits 2

Program Managing the TPA Managing Fraud Preventing Litigation

3 Injury Triage: Medical Management Process Chart- Manu Kai Injury Report claim to ESIS/HEMIC NCM/TCM Referral Contact Medical Provider/Manu Kai/Injured Worker 3

4 Reporting to ESIS Via phone (866) Via fax (866) Via Via internet 4

5 Reporting to Hemic Via phone (888) Via fax (888) Via 5

6 Reporting to LMS Via phone (888) Via fax (310) Via Via internet 6

7 WC-1: (available from 7

8 Reporting Claims/Important Reminders Report Claims within 24 hours of notification. Advise the carrier how you would like your claim set up and provide all the documents listed on slide 9 8

9 Reporting Claims/Important Reminders Record Only / First Aid Medical-Only Managed Medical (Enhanced Medical) Indemnity 9

10 Investigation Important Documents for TPA Job Analysis Wage Statement Internal Investigation Report All Information with Regard to Prior Injuries, Claims and Medical Conditions Summary of Your Discussion with the Employee Witnesses Subrogation Third Party Investigation/Preserving the scene Your Observation of Red Flags 10

Medical Conditions Summary of Your Discussion with the Employee Witnesses

11 Red Flags» Monday / Friday Accidents» No Witnesses» Prior History of Claims» Performance Issues» Reason to Retaliate» Post Termination Claims» Employee too versed in WC» Late Reporting of Accident» Not willing to return to work» Missing doctor appointments» Frequently not available at home during disability period» Inappropriate length of disability» First notice of injury received from an attorney» Frequent change in treating physicians» Objective findings not consistent with subjective complaints 11

appointments» Frequently not available at home during disability period» Inappropriate length of disability» First notice of

12 Medical Management Labor Management Services June 2011 Triage Nurse Case Management Clinic Physician Referrals/Independent Medical Evaluation Support 12

13 Medical Management Objectives Expedited Treatment Continuity of Care Return-to-Work Full Recovery 13

14 Medical Management Team Involvement Notify LMS: When an injury occurs If the injury/mechanism of injury is questionable If there are any extenuating circumstances If you are aware of any activities outside of work that employee engages in which may affect recovery (sports, etc.) 14

extenuating circumstances If you are aware of any activities outside

15 Return-to-Work What is modified duty? Accommodating modified duty/work restrictions Why is return-to-work so important? Consistency with modified work offers 15

16 Return-to-Work Programs Light duty: Return employees to useful employment Controls medical costs Controls WC cost Improves employee morale Reduces litigation Communicate with your health care provider: Job Description List of restricted-duty assignments Assurance that restrictions will be honored 16

litigation Communicate with your health care provider: Job Description

17 Managing the Third Party Administrator (TPA) ACI Database GRA GLOBAL RISK ADVANTAGE Understanding Roles and Responsibilities Teamwork Building Expectations Account Instructions Claim Reviews/Audits PGP- Performance Guarantee Program 17

Responsibilities Teamwork Building Expectations Account

18 Managing Fraud WC fraud costs insurers $5 billion a year Material evidence with intention Providing your TPA with new information Surveillance and activities checks Trace America Index Check 18

19 Preventing Litigation Forms, posters, and brochures Provide prompt emergency medical care Provide information as requested Document facts and events File the First Report in a timely fashion Address hazards promptly Train supervisors Follow policies consistently Make full and factual documentation of the reason for termination 19

First Report in a timely fashion Address hazards promptly Train supervisors Follow

20 Benefits- Hawaii 1. Temporary Disability: 66-2/3% of Average Weekly Wage (AWW) up to $ Permanent Disability 1. Partial: Based on AMA permanent disability rating. 2. Total: 66-2/3% of average weekly wage (up to $762.00) payable for claimant s lifetime + life pension 3. Medical Treatment: medical treatment which includes surgical and hospital services and supplies related to the injury. The injured employee is entitled to choose the treating physician. 4. Death Benefits: Funeral expenses (up to 10x AWW) + Burial expenses (up to 5x AWW), weekly benefit payments to dependent(s) depending on number of dependents and relation (Max 66-2/3% AWW up to $762.00) 20

Medical Treatment: medical treatment which includes surgical and hospital services and supplies related to the injury.

21 Benefits- Marine/Jones Act (Sea Crew) 1. Temporary Disability: 75% of Average Weekly Wage 2. Medical Treatment: Includes all medical, surgical, and hospital treatment and other medical supplies and services required by the employment related injury, as well as the cost of travel and mileage incidental to such treatment. 3. Negligence: a seaman can sue the employer in tort to recover damages, in addition to maintenance and cure, if the seaman s injury was caused by the negligence of the employer or his fellow employees. 21

22 Roles and Responsibilities Name Role Phone Kurt Urquhart Risk Manager- Exelis (703) exelisinc.com Lidia Peterson Haleh Khodayari Jamie McKinney Director, ESH- Exelis Information Systems Workers Compensation Consultant- ACI Workers Compensation Claims Adjuster- ESIS (719) exelisinc.com (310) acriskmgmt.com (510) esis.com Andrew Blauert Managed Care- LMS (310) lmscorp.net Myladel Aguillon Carla Paua-Nicasio Nurse Case Manager- Honolulu- LMS Nurse Case Manager- Kauai- LMS (888) lmscorp.net (888) lmscorp.net 22

23 HR and ADA Matters Pearlman, Borska & Wax Barry Pearlman, Esq. Phone: (818) Nicole Minkow, Esq. Phone: (818)

24 Q & A 24

Workers Compensation Claim Management and Reporting

Workers Compensation Claim Management and Reporting 1 Managing Workers Compensation Roles and Responsibilities Timely Triage and Reporting Key Items for reporting claims Medical Management Return-To-Work