By MARK SIDNEY, who heads claims for the area of Liberty Mutual that services the commercial insurance needs of large companies, most of which retain a portion of their workers' comp risk
This case highlights six best practices for managing workers' comp claims that result in injured workers receiving high quality medical care while controlling overall costs and producing outstanding outcomes.
Those best practices--gained from Liberty Mutual's years of experience as one of the leading providers of workers compensation insurance--are:
-- Promptly reporting claims
-- Quickly assembling the right claims management and clinical resources
-- Establishing clear lines of communication between all parties
-- Providing quality care that is appropriate for the injured employee
-- Using the best specialty medical resources
-- Returning injured employees to work
By understanding each of these, insureds and their representatives can fine-tune workers compensation programs to provide the highest quality medical care while still controlling overall costs.
This is critical in today's tough economy, as companies strive to manage their workers' compensation costs within an environment where medical inflation continues to rise. It is also important because even though the number of workplace injuries has decreased over the past several years, soaring medical costs mean the resulting claims are more expensive.
The following story illustrates each of the best practices outlined above. In the interest of privacy, we have changed the names and several other details.
MEET STAN BAKER
Stan is 54 years old and lives in Florida with his wife of 29 years, Kate. He's a vice president of sales for a major U.S. manufacturer.
In early 2008, Stan was driving home from a sales meeting in Georgia when his car collided with a tractor-trailer.
An ambulance rushed Stan to a nearby hospital where doctors treated him for several injuries including fractures of the shoulder, jaw and leg, as well as a traumatic brain injury. The hospital contacted his wife, who notified Stan's employer of the accident. The employer informed its workers' comp insurer, Liberty Mutual.
Effectively managing a workers' comp claim starts with reporting. The sooner the insurer is aware of the claim, the greater impact the carrier can have on its outcome and cost.
Each employer should determine the best and most efficient reporting process given its operation, structure and culture, and the capabilities the carrier has for receiving a claim (telephone, internet, electronic data exchange, et cetera). Whichever method is chosen, serious claims--like Stan's--should always be reported immediately so that the carrier can quickly assign resources to manage it.
In addition, front-line supervisors, who receive most of the initial employee injury reports, should be trained to communicate openly and frequently with their injured employees, and respond with empathy and assistance.
Liberty Mutual Research Institute studies show that those employees whose supervisors communicated with them throughout their disability were away from work far less often and for much shorter periods than their peers who work for supervisors with less supportive communication styles.
Regardless of who reports the claim and how, the insurer must quickly focus the right resources on that claim.
Once Stan's employer reported the claim, Liberty Mutual assigned it to a claims management team that specializes in the handling of complex and potentially expensive claims. The claim handler assigned to Stan's case immediately dispatched a field investigator and a field nurse case manager.
The field investigator performed a comprehensive investigation of the accident and Stan's activities prior to it in order to determine compensability and potential subrogation opportunities.
The field nurse case manager immediately went to the hospital to talk with Stan's wife and his medical providers to assess his condition and review his treatment plan. The nurse quickly consulted with one of the regional medical directors--full-time Liberty Mutual employees who are board certified physicians and who consult with treating physicians to review proposed medical treatment plans. Together, they concluded that Stan was receiving appropriate short-term medical care.
The field nurse and claim handler then consulted with a certified rehabilitation specialist in Liberty Mutual's Catastrophic Case Management Unit, which provides long-term medical care, cost containment and return to work expertise for catastrophic injuries.
The Catastrophic Case Management Unit estimated the claim's future medical exposure so that the policyholder and Liberty Mutual could set proper reserves. The unit also reviewed the claim to start developing long-term medical care strategies and selecting appropriate facilities to provide this care.
With all the resources involved in this claim--case handler, field investigator, field nurse case manager and Catastrophic Case Management Unit--it's easy to see the vital role communication plays in managing claims effectively.
It is important to understand how insurers share information between all of the areas and resources involved in a claim. Does the insurer have a single claims management system that everyone uses? Posting all data and notes in a single system, and having an imaging system that allows access to medical records and reports lets the entire team work toward a single objective and follow best practices. Even greater efficiency is achieved when the carrier, rather than an outside vendor or sub-contractor, employs all resources.
Communication is vital among the resources the insurer draws upon to manage a claim, but is equally critical in keeping the claimant and his or her family, the policyholder and the broker informed of developments.
So in Stan's case, the field nurse case manager informed his family and employer about what they could expect in the weeks and months ahead. Stan's family could plan for a lengthy recovery and Stan's employer knew the company would be without Stan's talents for several months and could react accordingly.
Over the next several weeks, Stan underwent multiple medical procedures, including leg and hip surgery.
At each step, Liberty Mutual made sure the treatments were appropriate and medically necessary, the costs were within usual and customary levels, and the bills were accurate.
When doctors found that Stan had a new condition that required another surgery, they contacted Liberty Mutual. The Complex Case Unit, medical director and nurse case manager reviewed Stan's hospital records. The team agreed the surgery, while needed, was not related to the accident. They coordinated with Stan's employer, and the surgery was performed and covered through Stan's group health insurance.
While Stan was recovering from his surgeries, it became clear that his traumatic brain injury would require specialized rehabilitation expertise that his current hospital could not provide.
A joint decision was made by the various Liberty Mutual medical resources involved in the claim, Stan's medical providers and Stan's family to transfer him to one of the nation's leading brain trauma rehabilitation facilities.
Liberty Mutual applies advanced data analytics to help in the selection of appropriate specialty providers, such as the one to which Stan was referred.
RETURN TO WORK
Over the ensuing weeks in the rehabilitation facility, Stan's progress was truly remarkable.
Throughout his stay, Liberty Mutual worked with his medical team to track progress and decide at what point he could be released, preparing Stan, his family and his employer for his discharge home and eventual return to work.
After three months of rehabilitation, Stan was eager to get home and return to work. And Stan's company was anxious to have him back on the job. After reviewing Stan's condition and prognosis, the case handler partnered with the employer to create a return to work plan.
The case handler, the employer and Stan outlined his key work responsibilities. They looked at what Stan needed to do to be successful, any short-term modifications needed given his injury, and how Stan could return on temporary duty.
Because Stan had some residual effects from his traumatic brain injury, he returned to work in a light-duty capacity. He came back to his former responsibilities as a sales vice president, but worked for just a few hours each day.
Stan began spending more time at work and was eventually cleared to return full-time.
Stan's experience offers a map for strengthening workers' comp programs to better provide injured workers with the highest quality medical care while controlling overall costs and producing outstanding outcomes.
April 1, 2010
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