By ZACK CRAFT, vice president, rehabilitation technology and complex care, for Total Medical Solutions, a firm specializing in complex care products and services for injured employees
Workplace accidents resulting in permanent disabilities are the most expensive workers' comp claims. Fortunately, only about 1.1 percent of workers' comp indemnity claims involve permanent disability.
However, these cases represent 11.4 percent of the costs of claims, according to a 2005 study by the National Council of Compensation Insurers titled "Demographic Factors to Consider: Calculating Lifetime Awards on Workers' Compensation Claims," by John Robertson and Dan Corro.)
The high medical cost of permanent disability claims comes as no surprise. Most insurance companies provide for a lifetime award to compensate injured workers for lost wages but continue to pay medical costs for the life of the claimant. The injuries are usually complex--defined as involving more than one body system and separate diagnoses, physicians and treatments for each system. Permanent disability claims usually require home healthcare services and products, including big-ticket items, like power chairs, home modifications and vehicle modifications.
The relative scarcity of these claims combined with their high costs set them apart for special treatment. This means thinking about things that people don't usually think about, like the height limitations of a van.
A recent claim illustrates the point. "John," a 45-year old male paraplegic, requested a new vehicle that could accommodate him when he was entering the van while seated in his wheelchair. The workers' comp carrier had recently replaced his old power chair with one John had personally selected.
Since he lived in a rural area and had buddies who hunted, John chose an extreme outdoor power chair with wide tires that could maneuver off road and in snow. However, when the chair arrived, John found out both he and his extreme power chair couldn't fit into the van. Vehicles can be modified with special electronics to accommodate a claimant who drives the van from the power chair. Other claimants drive the chairs into the van and then transfer themselves into a customized six-way adjustable seat and drive. Still others, like John, don't drive at all. They ride in power chairs that are secured in place in the van while another person drives. John and his old power chair fit into his van fine, but seated in the new one, he was too tall to clear the van's roof.
The carrier then looked at lowering the van's floor or raising its roof and installing taller doors but the costs of renovating the 1991 vehicle were too high. It made more sense to the carrier to purchase another vehicle, adding another $60,000 to $85,000 in expenses to the claim.
Could this extra expense have been avoided by checking the height clearance before buying the power chair? Of course, but sometimes carriers and other insurance professionals don't consider this sort of issue unless they deal with these injuries and equipment regularly.
A rehabilitation technician specializing in complex comp cases could visit John in his home to assess his physical capabilities, mobility needs and environment, then research types of power chairs to select the model that best fit his lifestyle and needs. In this case, a power seating feature called "tilt" would have solved the height problem and saved the carrier the cost of a newer vehicle.
Another option would have been to provide the claimant with two power chairs. Extreme outdoor chairs like the one John selected are like giant all-terrain vehicles (ATVs) or dirt motorcycles, able to navigate mud puddles and snow. It's not a good idea to equip them with high-end electronics that are susceptible to water damage and they aren't suitable for all indoor uses. Doctors' offices, stores, restaurants and malls do not look kindly upon big, wide tires dripping with snow and muddying their carpets. A second "indoor" power chair could be purchased for between $11,000 and $18,000, significantly less than the $75,000 the carrier ended up paying for a van and six months worth of case management to resolve the claim.
In another case, a claimant had selected his own van and then discovered that it did not fit in the garage. The van was just six inches too tall, but it meant raising the garage ceiling by 16 inches.This would involve removing trusses, lifting the ceiling and replacing the garage door with a special-order oversized door.
The insurance company, which had just paid $78,000 for a new van, now faced another $40,000 in home modifications. This extra expense could have been prevented by determining the van's height clearance and measuring the garage doors. This is another example of where a specialist's attention could have prevented additional costs.
The claim was ultimately referred to a company specializing in home modifications for comp claimants, which sent a rehabilitation specialist to the home to assess the situation. The rehab specialist saw that the claimant lived in a mobile home attached to a concrete block garage. Did it make sense to pour $40,000 into the garage? Were there other options?
Instead of modifying the existing, permanent garage, the complex-care specialty firm recommended a solid-roof carport that protected the claimant from the rain. The change immediately saved $20,000 on the claim. The solution provided future savings since the carport could be moved with the claimant or removed and stored for the insurance carrier for use in another claim.
Problems occur when carriers use general contractors or even customized van dealers without asking all the right questions. Since most adjusters do not deal with long-term disability claims, home or vehicle modifications or specialized equipment every day, they aren't likely to ask the right questions.
For complex claims, it pays to work with a company that has experience working with the equipment and home modification needs of workers' comp patients who have suffered serious injuries and need customized care.
Carriers should expect a lot of questions from the complex care specialist. Is the patient a man or a woman? How old is the claimant? What are the current living conditions? What kind of support system does the person have? What are the claimant's expectations? How long has the claim been active? What is medically necessary? Is there a compromise?
The complex care products and services provider should send a rehab specialist to the home to talk to the injured employee and assess the physical and emotional environment. If the injured employee does not have people who will drive him to appointments, for example, a van that locks the patient and chair in the back is useless. Conferring with physicians, case managers, and adjusters, as well as the injured employee, the rehab specialist will recommend the best equipment, assistive technologies or modifications for that situation.
Measuring doors and hallways, photographing the grounds and interiors and determining where changes can be made should be standard operating procedure. The complex care products and services provider should be up to date on the newest technologies and equipment options and needs to be able to explain how specific features will benefit that claimant. In addition, when the injured employee receives a new power chair or other assistive device, a rehab technician should return to fit the equipment and train people on its proper use.
In-home visits help educate the injured employee and caretakers and just as importantly, go a long way to mollifying a frustrated claimant. Just listening to a person's story helps ease claimant relations. How many case manager hours are eaten up by angry claimants? How much adjuster time is spent listening to complaints? People respond favorably when they feel that someone cares and is working in their best interest.
Complex injuries need the comprehensive services that only companies specializing in complex workers' comp injures can deliver. Many insurance companies refer all claims to large brokers, known as durable medical equipment (DME) firms that outsource to small, local home health and durable medical goods companies that mainly care for Medicaid and Medicare patients.
DMEs are familiar with the products and services of that market but not necessarily proficient in the variety of equipment and services that complex workers' comp injuries require. For these claims, payers are best served by a company that specializes in rehabilitation and home healthcare products and services for seriously injured employees.
The costs of long-term disability claims are on the rise and part of the cost occurs when carriers and suppliers do not take the time to verify what the claimant really needs. Asking all the right questions, visiting the claimant, conducting on-site evaluations, taking the proper measurements and researching the equipment and technologies take more time and money up front but ultimately saves considerable money on the back-end.
May 1, 2010
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