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A Tale of Two Physicians

Understanding work environments and practice structures can encourage collaboration and enhance outcomes.
By: | May 1, 2014 • 5 min read

There are many factors that influence the outcome of a workers’ compensation claim. Some, such as the body part and nature of injury, come as no surprise. Similarly, the state of jurisdiction and associated regulatory requirements are long-recognized as having an impact. One might not consider however, the role of the prescribing physician and how their demographics and behaviors influence outcomes.

To illustrate this, here is a tale of two physicians, Physician A and Physician B. Both are committed to caring for their patients but have markedly different work environments and practice structures that influence their prescribing behaviors.

Physician A

SponsoredContent_ProMed-PMSIPhysician A treats workers’ compensation patients in a big city. She is well-known and well-respected in the community and has a thriving practice. Physician A is employed by the local hospital and she supplements her salary by performing some in-office, minor procedures, such as skin biopsies and steroid injections for achy shoulders. She belongs to an accountable care organization (ACO) that has quality metrics in place to help its providers follow evidence-based medicine and best practice treatment models. These quality metrics, if met, result in some shared savings that are passed on to physicians as a financial reward for better outcomes.

Physician B

SponsoredContent_ProMed-PMSIPhysician B sees patients in a rural setting in his own, private practice. For him, the efficiency at which he can see patients determines whether or not he will meet his overhead each month. His nurse fields as many patient questions as possible in advance, and he does a quick exam and writes a prescription. Physician B feels constantly inundated with the increasing changes in healthcare and technology. He has tried to incorporate evidence-based guidelines into his practice but, with everything else on his plate, he is frustrated at the mere thought of keeping up with the constantly expanding medical research. To supplement his income, he works with a physician dispensing company and speaks on behalf of pharmaceutical companies.

Two Patients

A claims professional, in the process of working her caseload, discovers that Physician A’s patient is taking large doses of opioid medications yet has never had any urine drug screens or other documented opioid monitoring. Physician B’s patient was identified by the PBM’s early intervention program as requiring further review. Physician B’s patient is seeing multiple physicians, filling prescriptions at multiple pharmacies, and has a high-risk of long-term opioid use and a high likelihood of prolonged claim duration.

PBM Intervention

Both physicians receive correspondence from the PBM requesting a Peer-to-Peer medication review. In addition to including all requisite patient information, the letter is courteous and professional, relaying the objective of speaking directly with the prescribing physician in order to discuss the findings and recommendations.

Two Very Different Reactions

Upon receiving the reviewing physician’s phone call, Physician A was appreciative and freely commented that she had missed opportunities to apply opioid monitoring strategies provided by the PBM. She also agreed to convert the claimant’s antacid to an over-the-counter version. The reviewing physician completed a report detailing his conversation with Physician A and submitted copies to her, the claimant’s insurer, the PBM, and the claims specialist. The agreed-upon changes took effect on the next refill.


In contrast, it took several calls from the reviewing physician to convince Physician B’s receptionist to let him speak with Physician B. At first, Physician B was quiet and did not offer much feedback to the recommendations provided by the reviewing physician. He was irritated by the request to switch the claimant’s brand medications to generic, interpreting this request and the entire call to be solely focused on cost savings. Once discussion about the claimant’s opioids began, Physician B couldn’t contain his anger, declaring, “This is my patient! You have never even seen this patient before, so who are you to tell me how to manage his pain?”

Having anticipated such a possible reaction, the reviewing physician calmly deescalated the conversation with careful and sensitive language to reassure Physician B that the recommendations are entirely rooted on evidence-based guidelines and that the control of the patient’s pain remains a priority. The reviewing physician was able to refer to alternative dosing schedules and non-opioid treatment options to address the patient’s neuropathic pain. He also pointed out that the medications being prescribed for insomnia could interact with the claimant’s pain medications, possibly resulting in over sedation and death.

By the end of the call, Physician B realized that he had indeed overlooked some of the medication interactions and opportunities to more effectively manage the claimant’s pain without the use of opioid analgesics. He did not verbalize this realization, but agreed to make some changes to the medication regimen. He was still reluctant to change the claimant’s antacid to an over-the-counter version, citing his experience that they are not as effective as those dispensed by pharmacies. A few months later, the PBM performed a retrospective review; the medication therapy had changed – except for the antacid.

The Result

While traveling different paths, both physicians responded favorably to the Peer-to-Peer intervention.

By understanding the challenges some physicians are facing and the impact they can have on prescribing behaviors, payers can be better equipped to engage physicians in cooperative care management. A collaborative approach emphasizing the patient’s safety can enhance the physician’s willingness to compromise with medication therapy recommendations. In the end, the result is a better outcome for the payer, physician, and injured worker.

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

Healthcare Solutions, Helios and their subsidiaries, as Optum companies, collaborate with our clients to deliver value beyond transactional savings while helping ensure injured workers receive safe and effective clinical care. Our innovative and comprehensive medical cost management programs include pharmacy benefit management, ancillary benefit management, managed care services, and settlement solutions.
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Workers' Comp Fraud

State Law Exacerbates Fraud Among Peace Officers

Workers' comp fraud has been on the rise in California ever since probation officers were included under the state's vexing labor law.
By: | May 29, 2014 • 3 min read

For several years now, California police officers, sheriffs’ deputies and firefighters have been entitled to a full salary with no tax deductions for a year when they’re injured on the job.

Apparently, benefits afforded through California Labor Code Section 4850 [LC 4850] have been tempting enough to result in instances of workers’ compensation as well as long-term disability insurance fraud.


Since select probation department employees became eligible to receive LC 4850 benefits in 2000, increases in salary-continuation workers’ compensation benefits to individuals claiming they were injured on the job have increased fourfold, according to Alex Rossi, chief program specialist with the LA County Chief Executive office.

That’s led the Los Angeles County probation department to beef up its investigations and begin to make new arrests. These included the arrest of former probation officer Robyn Palmer on May 16.

David Grkinich, bureau chief of professional standards for the LA County probation department, emphasized that he and his colleagues are now more determined than ever to investigate alleged on-the-job injury cases more closely and to prosecute fraud and employee misconduct.

His advice to other law-enforcement officials dealing with similar problems:

“Never lose track of your employees; make sure someone is engaging with them,” he said. “Learn how they’re doing and when they’re going to come back to work.” That can prevent them from “falling between the cracks,” Grkinich said.

Apparently, California’s new labor laws have had a profound impact on benefits payments. County payroll records indicate that in [calendar year] 1999, the probation department paid out approximately $1.7 million in salary continuation benefits due to workers’ compensation claims, Rossi told Risk and Insurance®. By 2001, the payout of salary continuation — in part due to probation’s inclusion under LC 4850 — was approximately $6.8 million, he said.

Besides that, total reported injuries per fiscal year — expressed as a percentage of the total number of employees — was just 11.22 percent in 1999 versus 15.24 percent by 2002, said the County CEO Risk Management Branch.

Snuffing Out Fraud

When dealing with insurance fraud, it’s easier to detect when there is a paper trail, Grkinich explained. In Palmer’s case, for instance, “Our return-to-work staff noticed a discrepancy on some of the paperwork she is alleged to have forged,” he explained.

Palmer had filed for and received disability benefits for an alleged back and shoulder injury she claimed occurred in July 2013 while restraining a minor. Probation records showed that on the alleged injury date, Palmer was not at work and there were no employee records documenting any work-related injury involving Palmer, the probation department stated.

A probation department complex case committee worked closely with the California Insurance Department and Allstate’s the American Heritage Life Insurance Co. unit. “As a result of this collaboration, Allstate submitted the allegation that Robyn Palmer filed numerous fraudulent insurance claims and received disability insurance benefits she was not entitled to for a total amount of more than $29,122,” the department said in a statement.

Palmer was arrested on 14 felony counts for insurance fraud, forgery, wire fraud, and grand theft. She was arrested and transported to the Century Regional Detention Facility in Lynwood, California, where she was booked into custody awaiting arraignment. If convicted, Palmer could be sentenced to state prison or county jail, and was being held without bail as of late May.


Much harder to detect, said Grkinich, are cases where someone is “fully able to do what they say they can’t do,” and there’s no documentation to prove it. Here, he noted, surveillance and other sorts of deep digging are required.

Within the past year, the county probation department added a special projects team comprised of four supervisory level investigators to get things moving. So far, he said, “Our staff has assisted with the prosecution only two cases,” of insurance fraud, but is investigating several more.

Legal reforms could certainly help, he added. “The biggest problem I see out here is the way our law is written and that it makes it more profitable for some employees to stay home,” rather than do their jobs.

Janet Aschkenasy is a freelance financial writer based in New York. She can be reached at [email protected]
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Sponsored: Lexington Insurance

Sparking Innovation and Motivating Millennials

What started off as a one-off project for Lexington Insurance evolved into an annual program that sparks innovative solutions and helps develop millennial talent.
By: | October 3, 2016 • 5 min read

Two trends in the insurance industry, if they continue, could compromise its vitality in today’s fast-paced, technology-driven business world: slow innovation and a scarcity of millennial talent.

The quests to develop innovative solutions and services and to recruit young people to the field have raised concerns in the industry for several years, causing some insurers to think about how they will stay viable in the future when senior-level managers begin to retire.

But Lexington Insurance Company, a member of AIG, may have found a way to spark innovation that also engages millennial minds.

Innovation Boot Camp started three years ago as a one-off project meant to identify young, high-potential employees, give them exposure to senior management and evaluate their teamwork and leadership capabilities.

“The original concept was fairly straightforward. We would bring together a group of about 30 high potential employees for some semblance of team project work and it would allow management to gauge and assess talent,” said Matt Power, Executive Vice President, Head of Strategic Development, Lexington Insurance.

Little did he know how well the program would not only generate a plethora of innovative ideas that would drive the company forward, but also reinvigorate younger employees.

Lexington_SponsoredContent“The boot camps would be focused on innovation, with the idea that if we ended up with a concept or product that we could commercialize, then the boot camp would have been effectively self-funded. When they came back at the end of the 12 weeks, we were absolutely shocked because they produced about half a dozen products that have since been commercialized and are in some phase of being rolled out.”
— Matt Power, Executive Vice President, Head of Strategic Development, Lexington Insurance

New Ideas Emerge

The inaugural Innovation Boot Camp began with a two-day kick off meeting for participants— consisting of six teams with five or six participants. Each team was tasked with developing a business plan, and began to connect virtually over the next 12 weeks. The plan would culminate in a presentation to a senior management judging panel at the program’s conclusion.

“The boot camps would be focused on innovation, with the idea that if we ended up with a concept or product that we could commercialize, then the boot camp would have been effectively self-funded,” Power said. “When they came back at the end of the 12 weeks, we were absolutely shocked because they produced about half a dozen products that have since been commercialized and are in some phase of being rolled out.”

Power credits the program’s success in part to the participants’ youth. They were tuned in to different trends and issues than their more experienced counterparts.

Cyberbullying, for example, was a problem that didn’t exist for Power and his contemporaries as they grew up, but was salient for millennials. Based on the presentation of one group, Lexington developed coverage on their personalized portfolio for exposures associated with cyberbullying.

Likewise, “they educated us on the emergence of the craft brewing industry and how rapidly it was growing in the U.S.,” Power said. “That led to us launching a whole suite of products for craft brewers.”

Another team brought forth the concept of how rapid sequencing laser photography could be used to create a three-dimensional picture of a construction work site. That would allow contractors or claims managers to virtually walk through the site at a given point in the construction process to identify deviations from the original blueprint plans.

The images could memorialize the building process down to the millimeter, to every screw and wire. If a loss emerges later on due to a construction defect, the 3D map would be a valuable investigation tool.

Innovation Boot Camp proved so successful that Lexington expanded it to other arms of AIG all over the world.

“Suddenly we started getting calls from London, Copenhagen, Brazil,” Power said. “We were doing these programs for our global casualty team, for our lead attorneys in New York, for our financial lines group, and so on. We recently embarked on the 16th iteration of this program in London, with additional programs in the works.

“It’s a journey that has evolved from trying different things and not being afraid to fail, not being afraid to try new ways of thinking about the business.”


Engaging Millennial Minds

In addition to generating new product ideas, Innovation Boot Camp also engages younger employees more fully by offering the opportunity to make meaningful contributions to the company through independent work that requires some creative thinking.

Past participants are often great crusaders for the program.

“A program like IBC is something rarely seen at a large corporate conglomerate, and really a concept for new age startup companies,” said Alyson R. Jacobs, Vice President, Broker and Client Engagement Leader in AIG’s Energy & Construction Industry Segment. “But we were given a chance to work with people of all different professional backgrounds, and that environment unearthed concepts and solutions that have made a significant impact in the lives of our insureds and their employees.”

The chance to do work that makes a difference, both for the success of their company as well as the clients its serves, is what attracts millennial employees to the program and motivates them to devote their best effort to the project.

“Millennials want to be able to share their ideas and make meaningful contributions at work,” Power said. “Innovation Boot Camp has evolved into the perfect forum for that.”

David Kennedy, Esq., Product Development Manager for Lexington Insurance and former Coach for two Innovation Boot Camps, said the program engenders an “entrepreneurial spirit of developing something new, of applying analytical rigor to emerging risks to create unique and timely solutions for our clients and the marketplace.”

Exposure to senior executives doesn’t hurt either.

“It provided a platform for me to not just interact with our Senior Executive leadership but present a concept that could potentially be adopted by our company in the future,” said Ryan Pitterson, Assistant Vice President, AIG. “It helps to build your internal network, elevate your profile in the company and connects you with our client base as well.”

At a time when recent college graduates choose employers based on how much opportunity they’ll be given to have meaningful input — as well as opportunities for advancement — projects like Innovation Boot Camp could be the answer to the insurance industry’s struggle to pull in millennials.

“We give them the time, space and resources to create something new,” Power said. “When employee engagement is done right, it inspires passion and creativity.”

As multiple arms of AIG adopt Innovation Boot Camp around the globe, both the quantity and quality of new ideas are bound to flourish.

“The bottom line is, many heads are greater than one, and AIG has figured out how to leverage this. AIG hears their employees’ voices and enables those ideas to take our company into the future,” Jacobs said.

To learn more about Lexington Insurance, visit http://www.lexingtoninsurance.com/home.


This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Lexington Insurance. The editorial staff of Risk & Insurance had no role in its preparation.

Lexington Insurance Company, an AIG Company, is the leading U.S.-based surplus lines insurer.
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