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Risk Insider: Allen Melton

Top 10 Tips for Submitting a Claim

By: | August 26, 2014 • 2 min read
Allen Melton is a partner and the leader of EY's Insurance & Federal Claims Services Practice. He has 20+ years of experience working for both policyholders and insurers in the claims process. He can be reached at allen.melton@ey.com.

Napa residents and businesses were awakened early Sunday morning to the ground swells of a strong 6.0 earthquake. Buildings crumbled, glass shattered, gas and water lines ruptured, and other destruction ensued.

Now begins the unfortunate task of completing the repairs and, in many situations, preparing an insurance claim.

Below is a top 10 list of items to consider when faced with an impending claim:

1. Read your insurance policy.

Understand what types of losses are covered (earthquake damage, fire damage, water damage), what is insured (building, equipment, stock and supplies, business interruption, extra expenses), what deductibles apply, and whether there are any coverage limits that might apply?

2. Assemble a claims team.

All areas of your business may be affected and you should get the details from all facets of your operations. Impact to building and equipment, operations, sales, finance, and logistics should all be considered when trying to understand how your business has been affected.

3. Establish procedures to capture expenses.

Develop charge codes, purchase orders, or accounts to capture all claim-related expenses.

4. Designate a single point of contact.

Information about a loss has a tendency to change as more facts are known. Having a single point of contact providing information to insurers can avoid confusion about the details of your loss.

5. Manage expectations.

Keep management apprised about the details of the loss such as claim estimates, and timeframe to rebuild/restore operations as well as details regarding the claims process including the amount of time and effort that is required to adequately document and support a claim.

Be cautious of loss estimates and recovery timeframes that are too low or overly optimistic, which can result in a false sense of security and mismanage expectations internally and externally.

6. Prepare for meetings.

Coordinate your claim team in advance of insurer meetings to set the agenda, assemble supporting documentation, and ensure that the right people are present to answer questions that might arise.

7. Explain your business model.

Don’t assume that others have a thorough understanding of your business. Explain your business model so that the adjuster and his/her team will have better context around the measurement of the loss.

8. Help the insurance adjuster set the loss reserve.

Explain the areas of loss and provide sufficient information to allow the adjuster to set an appropriate loss reserve. Setting a reserve that is too low or too high can cause issues down the road.

9. Document substantive discussions with insurers.

Confirm discussions or verbal agreements in writing to maintain a record of the loss.

10. Request a cash advance.

Once the magnitude of the loss is determined, request an advance from the insurance company to offset expenditures you already incurred. Obtain additional cash advances as claim items are agreed to. This will limit the amount of open claim items at the end of the process.

Read all of Allen Melton’s Risk Insider contributions.

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Risk Insider: David Theron Smith

Evaluating Risk Management’s Corporate Synergies

By: | August 25, 2014 • 3 min read
David Theron Smith is divisional VP, risk management for Charlotte, N.C.-based Family Dollar Stores, and President of Family Dollar Insurance, Inc. Smith was a 2010 Risk & Insurance Risk Innovator of the Year as well as a Liberty Mutual Responsibility Leader. He can be reached at DSmith2@FAMILYDOLLAR.com

The decision as to which department takes ownership of risk management in the corporate organizational hierarchy is potentially flawed.

Risk management departments identify, prioritize risks, drive risk reduction, mitigate losses, conduct root cause analytics, and transfer risks, making a significant impact on corporate liabilities and financial reporting. For these reasons, risk management is often considered a financial discipline, reporting to the finance department and CFO.

Risk management is also involved in legal and regulatory activity (OSHA, environmental, employment practices, etc.). Therefore risk management is often assigned to the corporate legal department, reporting to the general counsel.

Casualty claims dollars managed by risk management and driven by workers’ compensation, general liability and auto claims costs, are of significant interest to the CFO and general counsel.

As a result, a corporation may decide that the legal department has the greatest ability to control the claims dollars, while finance has the greatest interest in the timeliness and accuracy of the dollars. Not wrong, but are these perhaps reasons that a risk management department should not report to the CFO or general counsel.

The fundamental element of a successful risk management program rests in the human behavior of the enterprise and its employees.

In a recent Aon market survey, 83 percent of the companies in this study view risk management as a financial or a legal function, with 51 percent reporting to finance.

While the majority of corporations view risk management as a finance or legal function under the CFO or general counsel; risk managers should examine the wisdom of this approach. Is this an inefficient or potentially dangerous strategy?

The fundamental element of a successful risk management program rests in the human behavior of the enterprise and its employees. I suggest that although only 2 percent of all organizations agree, human resources departments offer more successful synergies and firewalls against undue financial pressures.

A legal or finance department exercising authority over risk management may be tempted to pressure financial outcomes. Organizations are constantly under pressure to “make their numbers”. A finance or legal department may pressure risk managers to deviate from claims reserving best practices; delay timely reserving or understate claim reserves. The result, inconsistent loss trending or understatement of liabilities.

The synergies of the human resources and risk management functions offer a foundation of complementary strategic, knowledge and skill. Admittedly, many organizations lack a robust human resources department. In these cases, consideration should be given to the realignment of the health care, LTD, STD functions to risk management while remaining cognizant of the challenges of upward reporting relationships.

Human resource’s focus on personnel, culture and performance complements risk management’s safety, workers compensation and customer service focus.

Any potential financial and legal departmental influence, is removed, alleviating pressure on liability reserving bias.

Human resource’s oversight of risk management sets the scene for future strategic initiatives. Creating efficiencies relative to people and health care management expertise, with the added benefits of potential health and disability benefits integration with workers compensation management.

Although it may buck the trend, the synergistic opportunities of the risk management and human resources functions should be weighed against the traditional CFO or general counsel alliance which may not only be inefficient but offer conflicting strategies.

Read all of David Theron Smith’s Risk Insider contributions.

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Sponsored Content by Helios

Medication Monitoring Achieves Better Outcomes

Having the right patient medication monitoring tools is increasingly beneficial.
By: | September 2, 2014 • 5 min read
SponsoredContent_Helios

There are approximately three million workplace injuries in any given year. Many, if not the majority, involve the use of prescription medications and a significant portion of these medications is for pain. In fact, prescription medications are so prevalent in workers’ compensation that they account for 70% of total medical spend, with roughly one third being Schedule II opioids (Helios; NCCI; WCRI; et al.). According to the U.S. Drug Enforcement Administration (DEA), between the years of 1997 and 2007, the daily milligram per person use of prescription opioids in the United States rose 402%, increasing from an average of 74 mg to 369 mg. The Centers for Disease Control and Prevention (CDC) reports that, in 2012, health care providers wrote 259 million prescriptions—enough for every American adult to have a bottle of pills—and 46 people die every day from an overdose of prescription painkillers in the US. Suffice to say, the appropriate use of opioid analgesics continues to be a serious issue in the United States.

Stakeholders throughout the workers’ compensation industry are seeking solutions to bend the curve away from misuse and abuse and these concerning statistics. Change is happening: The American College of Occupational and Environmental Medicine (ACOEM) and the Work Loss Data Institute have published updated guidelines to promote more clinically appropriate use of opioids in the treatment of occupational injuries. State legislatures are implementing and enhancing prescription drug monitoring programs (PDMPs). The Food and Drug Association (FDA) is rescheduling medications. Pharmaceutical manufacturers are creating abuse-deterrent formulations. Meanwhile payers, generally in concert with their pharmacy benefit manager (PBM), are expending considerable effort to build global medication management programs that emphasize proactive utilization management to ensure injured workers are receiving the right medication at the right time.

SponsoredContent_Helios

A variety of factors can still influence the outcome of a workers’ compensation claim. Some are long-recognized for their affect on a claim; for example, body part, nature of injury, state of jurisdiction, and regulatory policy. In contrast, prescribing practices and physician demographics are perhaps a bit unexpected given the more contemporary data analysis showing their influence on outcomes. Such is the case for medication monitoring. Medication monitoring tools promote patient safety, confirm adherence, and identify potential high-risk, high-cost claims. Three of the more common medication monitoring tools include:

  • Urine Drug Testing (UDT) is an analysis of the injured worker’s urine that detects the presence or absence of a specified drug. Although it is not a diagnosis, UDT results are generally a reliable indicator of what is present (and what is not) in the injured body worker’s system. The knowledge gained through the testing helps to minimize risks for undesired consequences including misuse, abuse, and diversion of opioids. With this information in hand, adjustments to the medication therapy regimen or other intervention activities can occur. UDT can also be an agent of positive change, as monitoring often leads to behavior modification, whether in direct response to an unexpected testing result or from the sentinel effect of knowing that medication use is being monitored.
  • Medication Agreements or “Pain Contracts” signed by the injured worker and their prescribing doctor serve as a detailed and well-documented informed consent describing the risks and benefits associated with the use of prescription pain medications. Medication agreements help the prescribing doctor set expectations regarding the patient’s adherence to the prescribed medication therapy regimen. They serve as a means to facilitate care and provide for a way to document mutual understanding by clearly delineating the roles, responsibilities, and expectations of each party. Research also suggests that medication agreements promote safety and education as injured workers learn more about their therapy regimen, its risks, and benefits.
  • Pill Counts quantify adherence by comparing the number of doses remaining in a pill bottle with the number of doses that should remain based on prescription instructions. Most often, physicians request pill counts at random intervals or the physician may ask the injured worker to bring their medication to all appointments. As a monitoring tool, pill counts can be useful in confirming proper use, or conversely, diversion activities.

On a stand-alone basis, these tools rank high on individual merit. When used together as part of a consolidated medication management approach, their impact escalates quite favorably. The collective use of UDT, Medication Agreements, and pill counts enhance decision-making, eliminating gaps in understanding. Their use raises awareness of potential high-risk, high-cost situations. Moreover, when used in concert with a collaborative effort on the part of the payer, PBM, physician, and injured worker, they can improve communication and align objectives to mitigate misuse or abuse situations throughout the life of a claim.

SponsoredContent_Helios

Medication monitoring can achieve better outcomes

The vast majority of injured workers use medications as directed. Unfortunately, situations of misuse and abuse are far too common. Studies show a growing trend of discrepancies between the medication prescription and actual medication-regimen adherence when it comes to claimants on opioid therapy (Health Trends: Prescription Drug Monitoring Report, 2012). In response, payers, working alongside with their PBM and other stakeholders, are deploying medication monitoring tools with greater frequency to verify the injured worker is appropriately using their medications, particularly opioid analgesics. The good news is these efforts are working. Forty-five percent of patients with previously demonstrated aberrant drug-related behaviors were able to adhere to their medication regimens after management with drug testing or in combination with signed treatment agreements and multispecialty care (Laffer Associates and Millennium Research Institute, October 2011).

In our own studies, we have similarly found that clinical interventions performed in conjunction with medication monitoring tools such as UDT reduces utilization of high-risk medications in injured workers on chronic opioid therapy. Results showed there was a decrease in all measures of utilization, driven primarily by opioids (32% decrease) and benzodiazepines (51% decrease), as well as a 26% reduction in total utilization of all medications, regardless of drug class. This is proof positive that medication monitoring can be useful in achieving better outcomes.

This article was produced by Helios and not the Risk & Insurance® editorial team.


Helios, the new name for the powerful combination of Progressive Medical and PMSI, is bringing the focus of workers’ compensation and auto-no fault pharmacy benefit management, ancillary services, and settlement solutions back to where it belongs—the injured party.
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