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John D'Alusio

John D’Alusio has more than 30 years of experience in insurance and claims. He can be reached at riskletters@lrp.com.

Column: Workers' Comp Dispensation

Handling Claims Right, From the Start

By: | May 12, 2014 • 5 min read
John D’Alusio has more than 30 years of experience in insurance and claims. He can be reached at riskletters@lrp.com.

One of the most important aspects of handling workers’ comp claims correctly is immediately determining the nature of the loss based on the employer’s first report of injury (FROI), and a phone call or two. Does the claim involve no compensable lost time, thus making it a medical only (MO) claim, or is there lost time in excess of the state waiting period, which would render it an indemnity claim?

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At times, the FROI indicates there is no lost time. The case is then assigned to a medical only adjuster for cursory investigation, if any, and adjudication. However, even though the FROI may state there was no lost time involved, it is far from uncommon to find out the report was incorrect about the employee’s loss of compensable time from work. Conversely, the opposite also applies where a FROI might indicate lost time, assigned to a lost time adjuster, but the employee does wind up losing authorized time from work as a result of the injury or condition.

Clearly the level of investigation differs with each type of loss. Medical only claims normally have one or two point contact (the employer or the employer and the doctor), while lost time cases usually require three point contact (employer, employee, and medical provider) and involves more detailed fact finding. Or at least that is the way it supposed to work.

The proper determination of the claim type has financial consequences with third party administrator handling. TPAs charge more for handling lost time claims than they do for medical only cases. However, there is a double edged sword here. The overarching objective should be that a case is properly investigated regardless of type.

A typical scenario is that a claim is reported with no compensable lost time but involves an aberrant set of circumstances. This can be anything from occupation exposure, to an accident that takes place off-premises with the employee allegedly conducting the employer’s business. Should the case be classified as an MO and simply given to the medical only adjuster as if the exceptional circumstances of the alleged injury did not matter, or should it be assigned to a lost time adjuster for a full investigation?

The answer should depend on the claim particulars rather than a simple rote procedure strictly predicated on whether lost time is involved. For example, let us postulate that a FROI is received by a TPA. It states there is no compensable lost time involved, but the cause of the injury is inhalation of deleterious fumes. Is this a claim that should be simply assigned to an MO adjuster for one or two point contact and to confirm no lost time before simply processing the medical bills, or to a lost time adjuster for a full investigation on compensability and causal relationship?

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The client may complain about being overcharged if an MO case is handled as a lost time claim, It is probably also a good wager that they would complain even more if the claim wasn’t initially properly investigated and then became more serious, eventually involving litigation, and significant exposure.

The obvious answer is to have the claim properly screened with a telephone call to the employer prior to assignment. If the employer believes there is something suspicious about the claim, they will usually impart this belief verbally. This will be the telltale that should influence how the claim will initially be assigned for handling.

Even if the claim is improperly assigned to an MO adjuster, there is still a chance of redemption as long as the MO adjuster performs some type of investigation that will yield information that strongly suggests the claim should be reassigned to a lost time adjuster. The salient point here is that the MO adjuster has to do something with the claim in fairly expeditious fashion. Based on the nature of the position, many MO adjusters are processing oriented and may miss a key issue, or simply not act on a piece of information as they should. The more seasoned individuals will make a few calls and ascertain if the nature of the loss should remain in their futurity, or reassigned by the supervisor to a lost time adjuster. I have even witnessed MO adjusters calling the claimant to find out the nature of the injury and if lost time is involved before making their investigative findings and recommendations, including reserve commentary. These individuals deserve the accolades for their initiative as well as analysis, but regrettably this does not constitute the norm.

Obviously, there is far more exposure if an MO adjuster does not properly alert management that a claim should be reassigned to a lost time adjuster than the opposite if a lost time adjuster doesn’t timely suggest that a case be “stepped down” from a lost time to an MO.  Therefore the MO adjusters are the gatekeepers to some extent, and it is incumbent upon the supervisor to make sure expectations are established in the unit relative to investigative findings that commend a change of the type of claim from MO to lost time or vice versa. This involves training and active communication, both of which appear in short supply these days in many claims facilities.

At first blush, this topic may seem rather bland, but if the a claim is improperly assigned as an MO, and then contact is not made timely to determine the true nature of the issues, and simply placed on diary to await medical bills (that may not even be related to a compensable injury) being received and processed, there is trouble in the offing.  That trouble will often come home to roost at the most inconvenient times.

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It is far easier to make the correct assignment determination at the time the case is received. But that often takes work, as well as insight as to proper investigative needs. However, that is what claim professionals are paid to do. Clearly, the employer expectation is that it is done with accuracy and altered based on unique circumstances extant in each claim.  Ultimately, if the MO adjusters are not properly performing their contacts and documenting analysis of their findings, there will be breakdowns of a more frequent nature than necessary. So be careful out there!

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Column: Workers' Comp Dispensation

The Many Aspects of Fraud

By: | April 11, 2014 • 5 min read
John D’Alusio has more than 30 years of experience in insurance and claims. He can be reached at riskletters@lrp.com.

I was recently reading an industry column on the ubiquitous subject of workers’ comp insurance fraud. The author of that piece postulated that there were essentially two types of fraud: premium fraud and claimant fraud.

Of course, claimant fraud is the usually the first thing people think about when they think at all about fraud. Most likely a far distant second thought to claimant fraud is premium fraud. That is usually the province of unscrupulous employers attempting to save on workers’ comp premiums by intentionally under reporting the amount of employees they have working, or misreporting the class code exposures of those workers.

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If only life was so simple. Regrettably, there are various other strains of fraud that have plagued our existence at various times, for example, the California situation in the early ’90s. Anyone who was around and connected with workers’ comp insurance in California could not overlook that bane of existence for insurance carriers and employers during that time.

The impetus for this massive viral strain of workers’ comp fraud in California was that the workers’ comp law required employers/carriers to pay for medical exams for workers on contested cases such as continuous trauma and occupational exposure claims. With this incentive, clinics actually began to start law firms, which the clinics surreptitiously owned, with the overriding intention of feeding the clinics “patients” to examine. Applications to the Workers’ Comp Appeals Board were then filed by the law firms alleging various and sundry disabilities that required myriad medical exams to quantify the permanent impairment rating as well as future regimen of treatment recommendations.

A battery of medical examinations often yielded charges exceeding $10,000 in total. The applicants’ attorneys were more often than not willing to settle the claims on compromise and releases for a minimal amount of money to the claimants, because that was not the point of the entire endeavor. Once the case was concluded with the claimant, the medical liens had to be addressed. This resulted in a windfall revenue stream for the clinics that viewed the law as a license to steal, and did so with a frightening degree of efficiency and regularity.

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Where did the clinic owned attorney firms obtain their workers’ comp “clients”? That was another innovation. It was basically the workers’ comp version of ambulance chasing. They would go down to the unemployment offices and “cap” them off the lines of people there to collect their unemployment check, or to make a claim. This one can be filed under doctor and attorney fraud. However, one must admit to the simple elegance of this system, which added incredible cost burdens to an already overwhelmed workers’ comp system in the state with the largest population base in the country.

There have also been cases of claims adjuster fraud in the industry. These involve “enterprising” claims professionals who typically devise methods to embezzle funds out of their employer in the form of fraudulent claim payments made to bogus medical providers. This scheme usually entails setting up a medical provider in the payment system that the adjuster has “founded.” Durable medical equipment is a favorite choice in this realm. The key is to spread the payments to the provider (whose address is invariably a post office box) over a group of files so as not to attract any undue attention of claim and/or financial auditors. Over the course of a year or two, these adjusters can accumulate tens of thousands of dollars. The ones that have been caught either were too greedy, and streamed a surfeit of payments over a short period of time to the “vendor,” or else were simply the victim of a serendipitous audit that discovered the fraud.

Another not entirely unknown adjuster-perpetrated fraud involves seeking willing accomplices to initiate false claims that the adjuster would most likely handle. The adjuster makes payments to the claimants, who then split the claim payment “proceeds” with the adjuster. Although this is more likely in a liability claim scenario than a workers’ comp case, there have been incidents of this nature in the workers’ compensation landscape.

Let us not overlook possible producer fraud. There have been a number of situations over the last several decades involving premium being collected by an agent for coverage, and then not being forwarded to the insurance carrier. This is an audacious form of fraud as the corrupt producer is gambling that there will be little or no claims turned in on the supposed in-force policy. Of course, in the workers’ comp arena, at least seven out of every 10 claims involves no compensable lost time (“Medical Only” in the vernacular), and these claims are usually minimal in cost. Moreover, in many instances, the accident reports are sent directly to the agent, who can then pay for the medical treatment out of the embezzled premium funds. One must have nerves of steel to engage in this type of fraud, but it has been done.

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The medical community is also not entirely pristine in this area. I have seen several instances in my own career where bills for medical appointments that never took place have been submitted for payment. These are often most difficult to discover, especially if the modalities are many over an extended period of time. But it has happened.

As is evident, there are many more types of fraud than simply claimant and employer generated. As the aphorism goes, where there is a will, there is a way. Vigilance is always necessary.

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Column: Workers' Comp Dispensation

The Urge to Merge

By: | March 6, 2014 • 4 min read
John D’Alusio has more than 30 years of experience in insurance and claims. He can be reached at riskletters@lrp.com.

If history teaches us anything, it is that trends are cyclical. This is true whether the trends are social, political or economic in nature. One trend that is immediately recognizable to denizens of the property/casualty industry is the perpetual pendulum of mergers and conglomeration versus that of divestiture or spin-offs.

In the former, companies acquire other organizations to augment their perceived value and revenue. In the latter situation, they conclude that the organization will be more successful focusing their expertise upon the niche that originally brought them riches, and shed subsidiary companies.

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At the present time, the property/casualty industry seems to be enthralled with acquiring and combining organizations. The combination of Progressive and PMSI, OneCall and Align Networks, and Examworks and Gould & Lamb, are but a few recent examples of this example in the workers’ comp arena. The perpetual question (of private investment firms, as well as the rest of the market) is whether the “best in breed” model trumps “one-stop shopping” or vice versa. Presently, the smart money appears to be betting on the “one-stop shop” paradigm.

This recent trend is much more than simply an academic issue. Private equity organizations are betting significant assets that the combination of providers of services such as physical therapy, pharmacy benefit management, diagnostic imaging, nurse case management, durable medical equipment sales, Medicare set-asides, etc. will attract much greater revenue opportunities among payers. The overarching theory that presently holds sway is that adjusters would rather deal with an “all-in-one” vendor than separate “best-in-breed” companies that specialize in one particular area.

Although the theory of “bigger and more diverse” is presently holding sway in the minds of investors, it is not necessarily the case in the perception of the payers. There are several reasons for this that must be taken into consideration.

The adjusters who refer cases generally do not have the luxury of choosing the subcontractors they use on claims. This approved subcontractor list usually is vetted and assembled by the inhabitants of the payer’s “C” suite, which controls everything from the list of defense attorneys to utilize to PBM use, as well as vocational rehabilitation vendors, physical therapy network use, and nurse case managers. Once a vendor is on the list of any particular payer, that organization must prove itself to the adjusters in multiple ways.

Quality of service and responsiveness is critical. However, ease of assignment is also crucial. The ability to effect Internet assignment via computer looms larger with each passing year. The prior model of vendors placing “feet on the street” to encourage assignments is less important in these days of strict ethical and moral business behavior mandates placed on the adjusters by the majority of employers, which proscribe even the acceptance of business lunches from vendors.

Just because an organization excels in one area, it doesn’t immediately translate to other areas. Acquisitions of other “ne plus ultra” quality providers can minimize such concerns, but acquisitions and consolidations often have the impact of attempting to amalgamate and then dissipate individuals in the acquired companies to cut expenses and “streamline” the organization. More often than not, this disrupts many of the pre-existing client relationships of the acquired company.

Increasingly, the growth of revenue in the property/casualty area is a zero sum game. Revenue growth often does not take place unless it is obtained from other vendors already in the space.

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It is speculative to assume that a combination of organizations will yield an increase in market share that exceeds the pre-merger combination of both vendors. Adjusters routinely are told that mergers and acquisitions will have no impact on quality of service and existing relationships. In many cases, this is pure chimera. Corporate mergers always have an impact of some sort, and often this is not of a positive nature. Mergers can actually result in a drop-off in clients and revenue so that the combined revenue of the companies is less than it was when measured against the pre-merger amount of the separate organizations. However, this is not what the equity companies sponsoring the buyouts want to consider. But it should be noted as a consideration in any business.

The competition in any market these days is fierce. That goes double for the dollars in the lucrative property/casualty/workers’ comp marketplace. Margins of successful organizations in this vendor space are often truly impressive. This acts like a magnet for private equity organization investment. These organizations have many times made millions on many investments. But there have also been tremendous failures. The salient issue is not only to invest in the correct opportunities, but to insure that acquisitions are led by the most effective leadership team who know how to parlay a merged organization to realize growth in excess of what any part of the company could have earned prior to the amalgamation.

Keep your eyes open and your ears up. The acquisition and merger trend is in full bloom in the property/casualty marketplace. It will play out on a public stage and everyone will ultimately know the winners and losers in this round.

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