Solutions for Legacy Casualty Claims

Transcription

1 Solutions for Legacy Casualty Claims October 2008 Aon Global Risk Consulting Copyright 2008 Aon Corporation

2 Solutions for Legacy Casualty Claims Many casualty claims fail to receive proper attention and remain a burden to organizations. There is usually not one reason for the lack of attention, but typically a confluence of many adjusters caseloads, inadequate claims training, staff turnover and changing priorities within some claim service provider s organizations. More often than not, your firm ultimately pays for inadequate claims service. As casualty claims costs continue to increase, Aon s Accelerated Claim Closure Consulting Practice (ACC), provides client s with a method for managing and reducing its ultimate casualty claim loss portfolio. Generally the longer a Casualty Claim remains open, the more costly it is to your company. At the very least, it demands your time and review. In a week s time, how often are you approached by a Workers Compensation claimant indicating he or she has not received a check or a claims handler asking if a Workers Compensation claimant can return to work within the restrictions from the treating doctor? What s the company s policy when a location manager asks how long a job position must remain open? While a worker is out, or if he or she returned to modified duty, is the location able to provide the appropriate manpower? Do you then have to deal with union issues? More than likely you are called upon by management to provide quarterly, if not monthly, estimates on the open Casualty reserves and the anticipated payments of claims. Have you had situations where you have to explain why an auto loss reserve increased by 3-4 times due to new developments, (which usually translates to the auto adjusters finally securing Medical reports showing a great deal of treatment)? Are you faced with a situation where your Paid Loss retro program is about to convert after 60 months to an incurred loss program? If so, do you feel you that the reserves on the open files are appropriate and accurate? In a perfect world, given ample time and resources, we all like to think we handle our jobs progressively with appropriate plans and processes in place. However, more than likely we are reacting to open claims. The Cost of Unresolved Casualty Claims Claims resulting from workers compensation, general and auto liability can be a persistent and systematic burden on the financial well-being of an organization. Revenue that could be used to support vital company initiatives and innovation gets locked up in burdensome claims. Unchecked, these claims typically don t simply go away ; over time, only increase their drag on the organization. In today s chaotic market environment where investment firms are declaring bankruptcy and the housing market has yet to bottom out it s critical to ensure you re making wise financial decisions, and getting the most of your liquidity. The best investment may come from within. Freeing up revenue tied to burdensome claims may be the most cost-effective means of investing in your company s future. Aon White paper: Solutions for Legacy Casualty Claims Page 1

3 Factors that Lead to Unresolved Claims The following are arbitrary but common scenarios many organizations have experienced in effort to resolve claims TPA/Carrier claims administration You may notice that the prior TPA/Carrier has provided less than adequate claims service now that you are no longer a current account. You and/or your claim staff, (for those lucky enough to have staff) have seen too many recent cases where reserves are increased without your consultation, or worse, claims are settled with your money but without benefit of your input. You may have seen the severity of the Casualty claims worsen over the last few years. The cost of Medical continues to rise significantly which affects Workers Compensation and Liability BI losses. Entry level job requirements for claims staff is not rigorous now as in the past. Many believe that claim handlers don t have adequate training and their case loads are growing to levels that make effective claims handling a difficult exercise. Many years ago the nationally recognized carriers had Home Office examiners that followed the more significant losses with the higher exposures. The vast majority of TPAs/carriers have done away with that level of claims handling. Once you become a lost account, you may see that the TPA/Carrier changes the account executive. You may find you have limited access to the loss information system and, in many cases, you even have to now pay significantly more for the service. Further, your influence, resources and ultimate input on the claims process has since waned due to cost-cutting and the vagaries of dealing with staff change. At ACC, we recognize and appreciate that many risk managers have similar challenges. Most risk managers want to be proactive in identifying and solving unresolved claims but bottlenecks, inefficiencies and lack or resources limit just how much influence they can have over the process. Can you or your staff effectively conduct an audit of these older claim files on your own? Are you aware of the state changes in Workers Compensation? Do you know the applicable state auto laws? Do you have enough time and manpower to devote to overseeing the claim handling? Even if you do conduct a claims audit, what do you hope to accomplish? Do you have a systematic or standardized process for identifying and managing claims? What s more, does your organization have the resources both in staff and resources to confidently see claims processing to fruition? And, once an audit is completed, how will you get your suggestions and feedback back to the adjusters with the hope they will respond? Aon White paper: Solutions for Legacy Casualty Claims Page 2

4 Aon Accelerated Claims Closure: A Systematic Process Aon s Accelerated Claim Closure consultants use a systematic process, which includes extensive audits, action plans with closure dates and claim service provider administration. The primary objective of accelerated claim closure is to close the claim or mitigate the claim s ultimate cost. Aon s Accelerated Claims Closure offers a truly distinctive approach with a 12 year track record of delivering proven results. Over this period, we have engaged clients in more than 200 successful project engagements. Historically, our expert and dedicated claim staff has been able to achieve case closure rates in excess of 50% and savings off those closures in excess of 20% from the outstanding reserves at the onset of the engagement. Our Process: We bring in a focused and dedicated team of claim professionals to audit the open older claims (those claims at least 12 months old). Our team works for months with the TPA or carrier on the action plans to ensure that our recommendations are followed. We form an alliance with our client along with regular progress reports, which include measurable analytical results. Our goal is to bring the claims to closure within the engagement period. For those claims that remain open, we make certain that all parties agree to a specific and measurable plan of action and the reserves are appropriate. Time Proven Tactics: During the initial extensive audit and the ensuing engagement period, ACC will focus on the best practices that we believe, drive the ultimate cost and outcome of the claims. They are: Reserve Rationale Initial reserves should reflect probable exposure according to investigation and information received. The reserves should be placed on the claim in a timely manner and documentation to support the reserve dollars. Reserves should at all times reflect the probable exposure of the case. Stair stepping or suppressed reserves are not acceptable practices. Return to Work Return to work. Documentation should support an active pursuit to return injured workers to work (modified or full duty). Job description to doctor Coordination of restrictions to position Contact with claimant/representative, who is actively treating and/or disabled, every 30 days for update of condition. Aon White paper: Solutions for Legacy Casualty Claims Page 3

5 Investigation Initial investigation should be completed within 7 days or documentation to support delay and/or plan for completion. In no case should it exceed 30 days. This should include all statements, public records and medical information (if applicable). Documentation to summarize the results of the investigation, stating the facts, defenses and legal issues. Medical record and wage information should be reviewed and utilized in the initial investigation. Documentation should support that the medical records and wage information was reviewed and utilized in the evaluation of the claim. All files should be indexed at the time of set-up and every 6 months thereafter. Indexing should also be completed when red flags are revealed. Index results should be reviewed and appropriate action taken. Documentation should support that fraud indicators were recognized and appropriately handled. Contact should be verbal - written after several attempts. Insured/Client and claimant/representative should be contacted within one business day from date notice received. Physician - contact for disability verification and/or request medical records. Request for Medical/Wage authorization within 7 days. Coverage issues should be addressed in file documentation. Appropriate notices to all parties on any coverage issues in whole or in part. All exposures identified and documented. Medical Status Medical Records should be reviewed and action taken according to report (i.e. Reserve/evaluation adjusted, appropriate payments issued) Evaluate for Independent Medical Exam (IME), Utilization Review (UR), Medical Management/Vocational. Rehabilitation. Documentation should support the use of or determination not to use. Medical documentation should support efforts to obtain medical records and review of same File documentation should reflect aggressive action taken to move the claimant s medical status to Maximum Medical Improvement (MMI) with an Impairment Rating. Litigation Defense attorney selection should reflect the attorney s specialties/abilities are appropriate for the type of claim. File documentation/correspondence should contain the Attorney s evaluation and recommended strategy no later than 30 days after referral. A litigation plan should be in place and adjusted throughout the life of the case. It should also reflect communication/input from the adjuster, the client and the defense attorney. Aon White paper: Solutions for Legacy Casualty Claims Page 4

6 The claims adjuster should remain involved in the case and monitor legal expenses. Activities that can be completed by the adjuster, should be and not by the attorney. Legal bills are reviewed and evaluated for cost effectiveness. Action Plan Claim should be reviewed for settlement potential any time new or additional information is received. Settlement evaluation should be discussed with client according to the service agreement Settlement evaluation documentation should support the use of all facts, medical records, etc. to appropriately evaluate claim. Negotiations should begin in a timely manner after the evaluation process is complete. The file should reflect a plan of action was in place at all times, stating dates of projected completion and evidence that it was completed timely. The plan of action should be reviewed and adjusted accordingly. Recovery Documentation to support claim was reviewed for subrogation potential and/or SDTF. The file should reflect aggressive action for maximum recovery. We Get Results Case Study One A nationally recognized hardware retailer, which grew over 80 years to over 4,700 locations, had legacy Workers Compensation and Liability claims which accounted for $6 MM in outstanding reserves. Through claim closures, outstanding reserves were reduced by $1.7 million, which represented 28% immediate savings. A total of 152 claims were closed, representing 76% of the claims in the ACC engagement Aon White paper: Solutions for Legacy Casualty Claims Page 5

7 Case Study Two A nationwide provider of various business services with over 4,100 locations and 30,000 employees, had legacy Workers Compensation claims which resulted in outstanding reserves of over $13 million. Through claim closures, outstanding reserves were reduced by $2.1 million, which represented 16% immediate savings. A total of 168 claims were closed, representing 48% of the claims in the ACC engagement Case Study Three A nationally recognized State University had over 4,700 legacy Worker s Compensation claims with over $120 Million in outstanding reserves. Through claim closures, outstanding reserves were reduced by $28.1 million which represented 23% immediate savings. A total of 2,650 claims were closed, representing 56% of the claims within the ACC engagement. Additional Potential Benefits Elimination of loss development on the closed claims Reduction in accruals Reduced letters of credit/collateral Reduction in TPA claims handling fees Ability to redeploy headquarters claim staff to other strategic cost reduction initiatives or to apply a more concentrated effort on those claims outside of this project Reduction of internal administrative costs in managing these claims Improved reserving, forecasting practices on those claims that remain open Greater marketing appeal with carriers Reduced fixed/basic insurance charges with carriers Expanded capital for growth and/or reduced debt load More competitive pricing for products and services Return on Investment The return on investment is usually $3.00-$4.00. This means the client would realize a return of $3.00-$4.00 for every dollar invested in the ACC project. Compensation There may be an initial fee, usually $300-$350 per claim that covers our direct costs. This fee covers our project set up, the audit, including travel expense, analysis of the data and the development and presentation of the Initial Report of Findings. The majority of our compensation is performance based and is in the form of a 22%-24% gain share of the savings achieved through closings during the engagement. Under other specific circumstances we are willing to offer a straight gain share pricing approach, placing all of our compensation at risk. Aon White paper: Solutions for Legacy Casualty Claims Page 6

8 Conclusion While you may already have an excellent internal claim staff that has been working on these claims, we believe this added, focused resource will be able to result in additional savings. Also, while the project will require a small amount of time from your staff it also provides a second set of eyes and a strategic approach to the claim s management. Again, the process has the added advantage of containing and reducing any further loss development (IBNR) on the claims that close. Our actuaries indicate that there will eventually be an additional savings of 30% to 40% from the loss development on the claims that close. The Findings and Observations Section of our Initial Report of Findings will provide an excellent road map for training and ultimately improvement in the quality of work you are receiving from your claim service provider. We also believe that our final report of progress that we will provide you at the end of the engagement is a compelling argument to present to those holding letters of credit or bonds to achieve reductions in such collateral. For more information, please contact: Jerry Colvin National Director- Business Development Aon Global Risk Consulting Accelerated Claim Closure Consulting 1339 S. W. 18 th Street Boca Raton, FL Tel: [email protected] All materials contained in this document are protected by United States copyright law and may not be reproduced, distributed, transmitted, or published without the prior written consent of Aon Corporation. You may not alter or remove any trademark, service mark, copyright or other notice from copies of this document. Aon White paper: Solutions for Legacy Casualty Claims Page 7