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Roberto Ceniceros

Roberto Ceniceros is senior editor at Risk & Insurance and co-chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at rceniceros@lrp.com. Read more of his columns and features.

Vendor Relationships

Southwest Emphasizes Teamwork in Workers’ Comp Services

To discover and mitigate adverse claims trends, Southwest Airline’s workers’ comp program manager fosters cooperation.
By: | July 31, 2014 • 4 min read
Patti Colwell - Southwest (2)

Subject matter expertise alone is not enough when workers’ compensation service providers want Southwest Airlines’ business.

They also need to set aside any inclination to compete with other workers’ comp companies that also provide services to the airline — even when their product offerings overlap.

And they need to adopt Southwest’s customer service culture that follows from The Golden Rule’s mandate to treat others as one wishes to be treated.

“We work really hard to foster our Southwest Airlines corporate culture and spirit into the vendors that we work with because we want our claims team, and the nurses that we have in our [workers’ comp] program, and all the [other service providers] involved, to feel like they are an extension of Southwest Airlines,” said Patti Colwell, Southwest’s workers’ comp program manager responsible for on-the-job injury care of the company’s 45,000 employees.

“At Southwest we live by The Golden Rule,” she continued. “We expect our employees to treat our paying passengers with kindness and respect so why would we expect our vendor partners to treat our employees with any less kindness and respect?”

Like many other employers, the service providers Southwest partners with include third-party administrators, managed-care companies, pharmacy-benefit managers, and attorneys.

In addition to workers’ comp expertise, Colwell looks for service providers capable of working as a team with other companies servicing her program.

There can be a tendency to compete, for example, when a TPA and a managed-care company both offer managed-care services, but under an “unbundled” arrangement, the TPA provides claims-adjusting services while the other company provides the managed-care products.

“We make it very clear they are not competing with each other for our program and we expect our data and information to be shared completely among the parties because that is the only way we will know what is going on and can come to solutions,” Colwell said.

“We also look for partners willing to be accountable for results and we do that with performance guarantees.”

“We expect our employees to treat our paying passengers with kindness and respect so why would we expect our vendor partners to treat our employees with any less kindness and respect?”

After seven years, though, Southwest recently discontinued its unbundled approach, or separating managed care and bill review services from their TPA’s services. Those services are now bundled together and provided by Sedgwick Claims Management Services Inc., Colwell said.

Even when an employer obtains a bundled product from a single source, however, there may be competing interests among a single provider’s own managers who oversee different services, she added.

“Oftentimes, which has been my experience in the past, we found even within the same company they may have competing objectives, so we still foster this team approach even when they are internal to the same organization to make sure we all have the same goals,” Colwell said.

To do that, Southwest brings together a program manager from her TPA’s claims-administration side and a program manager from the managed-care side, for both quarterly partnership meetings and monthly claims-review meetings. Other service providers also join the meetings, such as pharmacy-benefit-manager representatives

In addition to reviewing specific case files, the claims-review meetings improve communications between all the service providers and Southwest, and they provide an opportunity to spot trends needing corrective action.

“We try to find solutions to wrap claims up, but we also try to find trends that we need to address because our whole goal is to get our employees early diagnostics, get them the treatment they need, and to get them back to good health as soon as possible,” Colwell said.

One adverse trend revealed in such a meeting, for example, involved second shoulder surgeries performed on employees treated by a specific doctor.

“We had all the players at the claims review and we kept hearing the same thing over and over about second shoulder surgeries,” Colwell said. “The same doctor’s name kept coming up and it was obvious there was an issue.”

Further analysis revealed the doctor referred patients to a particular physical therapist who frequently prescribed home physical therapy after just a couple of office visits. But post-shoulder surgery therapy can be painful and injured workers were not following through with their prescribed routine.

Consequently, they suffered frozen shoulder issues requiring the second operation, Colwell said.

That occurred in a state that allowed the airline to direct injured employees to medical providers known to produce better medical and return-to-work outcomes.

Spotting and correcting the trend resulted from the relationships built through the meetings, Colwell said.

“You have to have the relationships in place to be able to act quickly and mitigate circumstances,” Colwell said.

Patti Colwell will speak on Nov. 20 at the National Workers’ Compensation and Disability Conference® & Expo in Las Vegas. She will be joined by Tron Emptage, chief claims officer at Progressive Medical Inc., and Julie Fortune, senior VP and chief claims officer for Arrowpoint Capital, to discuss “Approaches to Managing Nontraditional Claims Including Unions, Legacy Claims and Co-Morbidities.”

Roberto Ceniceros is senior editor at Risk & Insurance and co-chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at rceniceros@lrp.com. Read more of his columns and features.
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Shoulder Injuries

Little Progress Reducing Shoulder Claims

Workplace shoulder injuries are challenging workers’ comp payers, especially as the nation’s workforce ages.
By: | July 23, 2014 • 4 min read
Shoulder injury

While the nationwide frequency of workplace injuries impacting other body parts, such as lower backs, continues on a downward trend, workers’ compensation experts say they have not seen a corresponding drop in workers suffering from shoulder problems.

Shoulder injuries can require longer recovery times than do other body parts, diminishing the likelihood of a quick return to work, several medical experts said.

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“Shoulder claims are huge now,” with the joints of an aging workforce wearing down, said Liz Thompson, CEO at Encore Unlimited LLC, a case management company in Stevens Point, Wisconsin. Treatment options are often expensive, particularly for older workers who are more likely to suffer accompanying comorbidities, she added.

Thompson recently analyzed the claims from one insurer client and found that 70 percent of those stemmed from extremity injuries, including many shoulder issues, she said.

Similarly, Judie Tsanopoulos, director of workers’ comp and loss control at St. Joseph Health System in Orange, Calif. said that beginning about three years ago she observed a rise in shoulder injuries and incidences of frozen shoulder.

“We see far more shoulders,” Tsanopoulos said.

When she drilled into her company claims data she found that women aged 40 to 60 years old accounted for many of those shoulder issues, she said.

Other workers’ compensation experts say they have not seen an overall increase in the frequency of shoulder-related injuries. Yet despite nationwide gains in reducing injuries to other body parts, shoulder injuries are not decreasing.

An NCCI Holdings Inc. report released on July 18 states, among other findings, that from 2008 to 2012 the frequency of lost-time claims for most body parts dropped an average of 13.9 percent.

Freq by Body Part

“One notable exception is that the frequency of injuries involving the arm and shoulder, which represent more than 15 percent of all injuries, remained flat over the period,” dropping only 1 percent, according to NCCI’s frequency report.

In contrast, lower back claims dropped 15 percent during the period while upper back claims dropped 7 percent. Upper back claims showed the least amount of claims decline next to the 1 percent drop in arm and shoulders among body parts.

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NCCI’s report stated that the flattening trend in arm and shoulder frequency “may be influenced by an older workforce, where rotator cuff injuries are not uncommon.”

Prior to the flattening in lost-time arm and shoulder claims seen from 2008 to 2012, injuries to those body parts had been declining. They decreased 13 percent from 2004 to 2008 while frequency for all lost-time injuries dropped 17 percent, said Jim Davis, an NCCI director and actuary.

In addition to an aging population more likely to suffer shoulder injuries, more treatments may be occurring today when workers complain about shoulder pain.

In contrast to 20 years ago, doctors are increasingly able to diagnose and address shoulder pain complaints that previously went untreated, said Ira Posner, an MD, orthopedic surgeon, and consultant to third party administrator Broadspire.

“So you are seeing a lot more people with a diagnosis now that we couldn’t make before,” Posner said. “People would present with shoulder pain and we didn’t know why they hurt — now we know why they hurt.”

The improved medical quality means doctors are able to help more workers while workers’ comp payers may now be feeling the increase in shoulder treatments.

“That is why you are seeing more pathology in the shoulder being treated, because we understand the shoulder better and we are able to do more for complaints of shoulder pain,” Posner said.

One cost mitigating factor, however, stems from a shift from conducting mostly open shoulder surgeries to performing more orthoscopic and outpatient treatments, added Jacob Lazarovic, senior VP and chief medical officer at Broadspire.

Still, shoulder injuries typically require more recovery time than do other body parts, experts said.

“Recovering from shoulder surgeries is a pretty prolonged process in the best of cases, but it would be even more prolonged for older workers,” Lazarovic said.

The complexity of shoulder joints adds to the problem, medical experts said.

In addition to a longer recovery time, shoulder injuries such as those requiring rotator cuff surgeries make it challenging for employers to return workers to certain jobs, such as those requiring overhead lifting, said Teresa Bartlett, senior VP and medical director at Sedgwick Claims Management Services Inc.

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“Shoulder injuries in general are problematic,” Bartlett said. “Regardless of age, it’s the mechanism of the shoulder that tends to be very difficult.”

In response, Thompson at Encore Unlimited is seeing employers increasingly interested in shoulder protection and corresponding loss control programs.

“Anytime you have an injury group that is driving your claims costs, as an employer you have to evaluate what can you do to eliminate some of that risk,” such as making sure the worker fits the job, she said.

Roberto Ceniceros is senior editor at Risk & Insurance and co-chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at rceniceros@lrp.com. Read more of his columns and features.
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Undocumented Workers

Workers’ Comp Laws Regarding Illegal Immigrants See Little Change

Will renewed calls to ban workers’ compensation benefits for illegal immigrants follow rising immigration worries?
By: | July 15, 2014 • 3 minutes min read
Immigration

With immigration grabbing headlines, some state legislators may decide to once again push bills to disqualify illegal immigrant workers injured on the job from receiving workers’ compensation benefits.

“Is it plausible that elected officials who feel strongly about the immigration issue might use the current instability to make a political point?” asked Bruce Wood, workers’ comp director for the American Insurance Association (AIA). “You can connect the dots. But from me sitting here today it would be speculation to say that is going to happen.”

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The immigration issue surged to the forefront recently with news stories of tens of thousands of Central American children flooding the U.S. border in recent months, an angry reaction by residents in one California town who blocked Homeland Security buses carrying illegal immigrants, and a political stalemate in Washington D.C. over immigration law reforms sought by business groups.

“There was definitely that wave [of legislation] four or five years ago and it has been pretty quiet on that front the last two or three [legislative] session cycles, but given the current news and political climate we are potentially expecting to see bills in 2015.” — Trey Gillespie, senior workers’ comp director for the Property Casualty Insurers Association of America

But with a history of businesses opposition to legislation denying workers’ comp benefits to illegal immigrant workers, any new bills could meet the same fate as those introduced in 2011 in Georgia, Montana, New Hampshire, and South Carolina.

Those legislative efforts failed to pass into law amid insurer opposition and concerns they would harm employers, including by allowing claimants to seek redress in civil courts rather than through workers’ comp systems where employer liability is limited.

“There was definitely that wave [of legislation] four or five years ago,” said Trey Gillespie, senior workers’ comp director for the Property Casualty Insurers Association of America (PCIAA), “and it has been pretty quiet on that front the last two or three [legislative] session cycles, but given the current news and political climate we are potentially expecting to see bills in 2015.”

That lull doesn’t apply to all state legislation regarding immigration-related issues, which rebounded in 2013 after falling off the prior year, according to the National Conference of State Legislators.

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Lawmakers in 45 states and the District of Columbia enacted 437 immigration-related laws and resolutions during 2013, affecting issues such as education, drivers’ licenses, and budget appropriations, according to NCSI. That compared to 267 in 2012, and included resolutions praising immigrant contributions.

AIA’s Wood recalled a 1999 Virginia’s Supreme Court finding that illegal immigrants in that state could not receive workers’ comp benefits when injured.

“The employer community took a victory lap after that and then AIA and others reminded them that this opened them up to tort exposure because there was nothing precluding an undocumented worker from filing a tort suit,” Wood said.

That new exposure pushed Virginia employers to support the successful adoption of a law requiring workers’ comp benefits, with the exception of vocational rehabilitation benefits, to be paid to undocumented workers.

Overall, despite legislative attempts over the years to prevent providing workers’ comp benefits to illegal immigrants, state laws on the matter have remained unchanged, Wood said.

“Notwithstanding all of the bills introduced there haven’t been a whole lot that actually got through and were signed into law,” he said.

But that has not stopped attempts, even recently.

In North Carolina, Sen. Thom Goolsby (R-Wilmington) amended House Bill 369 in late June to disallow workers’ comp benefits being paid to workers “not lawfully employable in the United States and [those who] knowingly made a false representation to the employer as to his or her legal work status.”

But on July 8, the bill was removed from the state Senate’s calendar and referred to a Senate Rules and Operations Committee, meaning it had stalled.

Insurers oppose such legislation because in addition to stripping employers of worker’s comp exclusive remedy protections, there is a public policy concern. Such laws could incentivize certain employers to hire illegal workers and ignore safety practices because they would not be obligated to purchase workers’ comp insurance.

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Those employers would gain an unfair advantage over other employers paying workers’ comp premiums.

“There is a concern,” said PCIAA’s Gillespie, “as to whether you are rewarding employers for knowingly hiring illegal aliens at the expense of employers who do their best to follow immigration and employment laws and pay benefits to their injured workers, as opposed to other employers who may get a benefit from hiring illegal aliens because they wouldn’t have to pay workers’ compensation claims arising out of injuries.”

Roberto Ceniceros is senior editor at Risk & Insurance and co-chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at rceniceros@lrp.com. Read more of his columns and features.
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