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Risk Insider: Susan LaBar

The High Cost of Fraud

By: | August 21, 2014 • 2 min read
Susan LaBar is the risk manager at Coach USA/Megabus. She has more than 20 years experience in handling nationwide liability and workers’ compensation claims. She can be reached at susan.labar@coachusa.com.

Workers’ compensation fraud is prevalent and is costing employers and insurance carriers significant dollars each year.

There are many degrees of fraud. There are blatantly false claims, such as someone faking a fall or accident, to more subtle examples, such as complaining of false or lingering pain to get more time off of work.

All forms of fraud cost money.  Recognizing fraudulent claims and controlling them can be difficult.  Below are two of the many ways that workers’ compensation fraud can be controlled.

Get the Facts

The initial investigation is the first step, and one of the most important in preventing and controlling fraud.  When an employee reports an injury, ensure that an accurate report is received.

Investigate every claim in detail.  No matter how minor the injury, it is important to complete a thorough investigation.

How many times has that “minor” claim turned into a large exposure?  An effective way to investigate is by interviewing the employee.  Question the employee about how exactly the incident happened, who witnessed it and what could be done to avoid it in the future.

Specifically ask them to name all body parts that were injured. One form of fraud is an attempt to add non-related injuries to the claim by expanding reported injuries to different body parts as time goes on.

Ask them questions about their life.  What are their hobbies, do they have other employment, and do they have a spouse and children?

These questions help document the accident and provide great information if there is a need to investigate the validity of the claim.  Having their version of the accident in writing makes it less likely that the facts will change.

Nurse Case Management

Nurse case management is useful in many ways to help ensure proper treatment, mitigate costs and return the worker to full duty. It is also a way to help manage situations where there is suspected claims fraud.

The nurse can observe and establish a relationship with the claimant.  The nurse should attend medical appointments with the injured worker and ensure the worker is being forthright with the doctor about their injury and job duties.

He/she should have a detailed job description so there is no question what restrictions the doctor should or shouldn’t place on the injured worker.  The nurse can present information to the doctor about the worker’s hobbies and lifestyle.

If investigation reveals that an employee is performing activities that he/she states they cannot do, the nurse can present this to the doctor in the hope of getting a full duty release.

There are numerous ways to reduce or prevent claims fraud.  Initial investigation and nurse case management are valuable tools.

While some fraudulent claims are prosecuted, most are not.  The evidence of fraud can be used to limit exposure of the claim.

Use the information to bring the worker back to full duty as soon as possible.  These tools can help shorten the length of a claim and save the company money.

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Risk Insider: Jason Beans

Hospitals Are Not Getting Safer

By: | August 19, 2014 • 2 min read
Jason Beans is the Founder and Chief Executive Officer of Rising Medical Solutions, a medical cost management firm. He has over 20 years of industry experience. He can be reached at Jason.Beans@risingms.com.

Nearly 15 years ago, the Institute of Medicine report “To Err is Human” drew attention to the disturbing number of preventable deaths in hospitals.

According to recent testimony by a panel of patient safety leaders to the Senate Subcommittee on Primary Health and Aging, there has been little progress in addressing this issue in the 15 years since, despite all of the increased regulations.​​ In fact, preventable medical errors in hospitals are now the third leading cause of death in the US, only after heart disease and cancer.

“The problem of patients dying or being harmed because of preventable medical errors in U.S. hospitals remains [a] grave consequence that is not getting enough attention,” according to the Senate subcommittee chairman.

There are five main types of preventable medical errors. The question is, who in our industry is watching out for these errors, and where does responsibility for oversight end and begin?

  • Errors of omission: Provider fails to perform an obvious, necessary action, like prescribing a certain medication.
  • Errors of commission: A mistaken action harms a patient, like surgery on the wrong body part.
  • Errors of communication: Miscommunication or failed communication between providers, or between a provider(s) and patient, such as a failure to warn a patient about the risks of certain activities.
  • Errors of context:  Provider does not account for the unique constraints in a patient’s life, like not having reasonable access to follow-up care.
  • Diagnostic errors: Harm to the patient resulting from delayed, wrong, ineffective, or no treatment.

A recent study by Patient Safety America estimated that the 98,000 preventable error deaths cited in the Institute of Medicine’s original 2000 report may have been severely understated, and the real number could be closer to 440,000 deaths annually.

That is roughly equivalent to 148 September 11th attacks every year.

In fact, preventable medical errors in hospitals are now the third leading cause of death in the US, only after heart disease and cancer.

This is only preventable deaths.  It doesn’t include infections and sickness that did not result in death.

Even without human error, the potential for hospital-acquired infections is immense. There are thousands of patients coughing and touching furnishings and other items, which are then touched by relatives and staff. It is almost impossible to prevent the spread of disease and infection in this environment.

And this doesn’t even factor in issues of inappropriate treatment, over-treatment, over-medication, or unnecessary surgeries, which can result in a poor prognosis for individuals who may already be in fragile health.

I am not a big fan of politicizing an issue, but this transcends politics. Hospitals attract the sickest of the sick people.  That is what they are there for, but we as an industry need to focus on reducing the potential for preventable deaths in hospitals.

We need to focus on directing people to healthier options — whether non-surgical alternatives, the best providers, or non-hospital based surgeries and treatment.

We may never know when our actions prevent a health complication, or even death, but any time we can lower a patient’s risk, everyone is better off.

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Sponsored: Aspen Insurance

A Modern Claims Philosophy: Proactive and Integrated

Aspen Insurance views the expertise and data of their claims professionals as a valuable asset.
By: | August 3, 2014 • 4 min read
SponsoredContent_Aspen

According to some experts, “The best claim is the one that never happens.”

But is that even remotely realistic?

Experienced risk professionals know that in the real world, claims and losses are inevitable. After all, it’s called Risk Management, not Risk Avoidance.

And while no one likes losses, there are rich lessons to be gleaned from the claims management process. Through careful tracking and analysis of losses, risk professionals spot gaps in their risk control programs and identify new or emerging risks.

Aspen Insurance embraces this philosophy by viewing the data and expertise of their claims operation as a valuable asset. Unlike more traditional carriers, Aspen Insurance integrates their claims professionals into all of their client work – from the initial risk assessment and underwriting process through ongoing risk management consulting and loss control.

This proactive and integrated approach results in meaningful reductions to the frequency and severity of client losses. But when the inevitable does happen, Aspen Insurance claims professionals utilize their established understanding of client risks and operations to produce some truly amazing solutions.

“I worked at several of the most well known and respected insurance companies in my many years as a claims executive. But few of them utilize an approach that is as innovative as Aspen Insurance,” said Stephen Perrella, senior vice president, casualty claims, at Aspen Insurance.

SponsoredContent_Aspen“We do a lot of trending and data analysis to provide as much information as possible to our clients. Our analytics can help clients improve upon their own risk management procedures.”
– Stephen Perrella, Senior Vice President, Casualty Claims, Aspen Insurance

Utilizing claims expertise to improve underwriting

Acting as adviser and advocate, Aspen integrates the entire process under a coverage coordinator who ensures that the underwriters, claims and insureds agree on consistent, clear definitions and protocols. With claims professionals involved in the initial account review and the development of form language, Aspen’s underwriters have a full sense of risks so they can provide more specific and meaningful coverage, and identify risks and exclusions that the underwriter might not consider during a routine underwriting process.

“Most insurers don’t ever want to talk about claims and underwriting in the same sentence,” said Perrella. “That archaic view can potentially hurt the insurance company as well as their business partners.”
SponsoredContent_AspenSponsoredContent_AspenAspen Insurance considered a company working on a large bridge refurbishment project on the West Coast as a potential insured, posing the array of generally anticipated construction-related risks. During underwriting, its claims managers discovered there was a large oil storage facility underneath the bridge. If a worker didn’t properly tether his or her tools, or a piece of steel fell onto a tank and fractured it, the consequences would be severe. Shutting down a widely used waterway channel for an oil cleanup would be devastating. The business interruption claims alone would be astronomical.

“We narrowed the opportunity for possible claims that the underwriter was unaware existed at the outset,” said Perrella.

SponsoredContent_Aspen
Risk management improved

Claims professionals help Aspen Insurance’s clients with their risk management programs. When data analysis reveals high numbers of claims in a particular area, Aspen readily shares that information with the client. The Aspen team then works with the client to determine if there are better ways to handle certain processes.

“We do a lot of trending and data analysis to provide as much information as possible to our clients,” said Perrella. “Our analytics can help clients improve upon their own risk management procedures.”
SponsoredContent_Aspen
SponsoredContent_AspenFor a large restaurant-and-entertainment group with locations in New York and Las Vegas, Aspen’s consultative approach has been critical. After meeting with risk managers and using analytics to study trends in the client’s portfolio, Aspen learned that the sheer size and volume of customers at each location led to disparate profiles of patron injuries.

Specifically, the organization had a high number of glass-related incidents across its multiple venues. So Aspen’s claims and underwriting professionals helped the organization implement new reporting protocols and risk-prevention strategies that led to a significant drop in glass-related claims over the following two years. Where one location would experience a disproportionate level of security assault or slip & fall claims, the possible genesis for those claims was discussed with the insured and corrective steps explored in response. Aspen’s proactive management of the account and working relationship with its principals led the organization to make changes that not only lowered the company’s exposures, but also kept patrons safer.

SponsoredContent_Aspen

World-class claims management

Despite expert planning and careful prevention, losses and claims are inevitable. With Aspen’s claims department involved from the earliest stages of risk assessment, the department has developed world-class claims-processing capability.

“When a claim does arrive, everyone knows exactly how to operate,” said Perrella. “By understanding the perspectives of both the underwriters and the actuaries, our claims folks have grown to be better business people.

“We have dramatically reduced the potential for any problematic communication breakdown between our claims team, broker and the client,” said Perrella.
SponsoredContent_AspenSponsoredContent_AspenA fire ripped through an office building rendering it unusable by its seven tenants. An investigation revealed that an employee of the client intentionally set the fire. The client had not purchased business interruption insurance, and instead only had coverage for the physical damage to the building.

The Aspen claims team researched a way to assist the client in filing a third-party claim through secondary insurance that covered the business interruption portion of the loss. The attention, knowledge and creativity of the claims team saved the client from possible insurmountable losses.

SponsoredContent_Aspen

Modernize your carrier relationship

Aspen Insurance’s claims philosophy is a great example of how this carrier’s innovative perspective is redefining the underwriter-client relationship. Learn more about how Aspen Insurance can benefit your risk management program at http://www.aspen.co/insurance/.

Stephen Perrella, Senior Vice President, Casualty, can be reached at Stephen.perrella@aspen-insurance.com.

This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Aspen Insurance. The editorial staff of Risk & Insurance had no role in its preparation.
This article is provided for news and information purposes only and does not necessarily represent Aspen’s views and does constitute legal advice. This article reflects the opinion of the author at the time it was written taking into account market, regulatory and other conditions at the time of writing which may change over time. Aspen does not undertake a duty to update the article.


Aspen Insurance is a business segment of Aspen Insurance Holdings Limited. It provides insurance for property, casualty, marine, energy and transportation, financial and professional lines, and programs business.
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