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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
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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.

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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
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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.

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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.

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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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Your Workers’ Safety May Be at Risk, But Can You See the Threat?

Violence at work is a more common threat than many businesses realize.
By: | September 14, 2016 • 5 min read
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Deadly violence at work is covered extensively by the media. We all know the stories.

Last year, ex-reporter Bryce Williams shot and killed two former colleagues while they conducted a live interview at a mall in Virginia. In February of this year, Cedric Larry Ford opened fire, killing three and injuring 12 at a Kansas lawn mower manufacturing company where he worked. Also in 2015, 14 people died and 22 were wounded by Syed Farook, a San Bernardino, California county health worker, and his wife, who had terroristic motives.

Active shooter scenarios, however, are just the tip of the iceberg when it comes to violence at work.

“Workplace violence is much broader and more pervasive than that. There are smaller acts of violence happening every day that directly impact organizations and their employees,” said Bertrand Spunberg, Executive Risks Practice Leader, Hiscox USA. “We just don’t hear about them.”

According to statistics compiled by the FBI, the chance that any business will experience an active shooter scenario is about 1 in 457,000, and the chance of death or injury by an active shooter at work is about 1 in 1.6 million.

The fact that deadly attacks — which are relatively rare — get the most media attention may lead employers to underestimate the risk and dismiss the issue of workplace violence as media hype. But any act that threatens the physical or psychological safety of an employee or that causes damage to business property or operations is serious and should not be taken lightly.

“One of the core responsibilities that any organization must fulfill is keeping employees safe, and honoring that duty is becoming more challenging than ever,” Spunberg said.

Hiscox_SponsoredContent“Workplace violence is much broader and more pervasive than that. There are smaller acts of violence happening every day that directly impact organizations and their employees. We just don’t hear about them.”
— Bertrand Spunberg, Executive Risks Practice Leader, Hiscox USA

Desk Rage and Bullying: The Many Forms of Workplace Violence

Hiscox_SponsoredContentBullying, intimidation, and verbal abuse all have the potential to escalate into confrontations and a physical assault or damage to personal property. These violent acts don’t necessarily have to be perpetrated by a fellow employee; they could come from a friend, family member or even a complete stranger who wants to target a business or any of its workers.

Take for example the man who killed three workers at a Colorado Spring Planned Parenthood in April. He had no affiliation with the organization or any of its employees, but targeted the clinic out of his own sense of religious duty.

Companies are not required to report incidents of violence and many employees shy away from reporting warning signs or suspicious behavior because they don’t want to worsen a situation by inviting retaliation.  It’s easy, after all, to attribute the occasional surly attitude to typical work-related stress, or an office argument to simple personality differences that are bound to emerge occasionally.

Sometimes, however, these are symptoms of “desk rage.”

According to a study by the Yale School of Management, nearly one quarter of the population feels at least somewhat angry at work most of the time; a condition they termed “chronic anger syndrome.”  That anger can result from clashes with fellow coworkers, from the stress of heavy workloads, or it can overflow from family or financial problems at home.

Failure to recognize this anger as a harbinger of violence is one key reason organizations fail to prevent its escalation into full-blown attacks. Bryce Williams, for example, had a well-documented track record of volatile and aggressive behavior and had already been terminated for making coworkers uncomfortable. As he was escorted from the news station from which he was terminated, he reportedly threatened the station with retaliation.

Solving Inertia, Spurring Action

Hiscox_SponsoredContentMany organizations lack the comprehensive training to teach employees and supervisors to recognize these warning signs and act on them.

“The most critical gap in any kind of workplace violence preparedness program is supervisory inertia, when people in positions of authority fail to act because they are scared of being wrong, don’t want to invade someone’s privacy, or fear for their own safety,” Spunberg said.

Failing to act can have serious consequences. Loss of life, injury, psychological harm, property damage, loss of productivity and business interruption can all result from acts of violence. The financial consequences can be significant. In the case of the San Bernardino shootings, for example, at least two claims were made against the county that employed the shooter seeking $58 million and $200 million.

Although all business owners have a workplace violence exposure, 70 percent of organizations have no plans in place to avoid or mitigate workplace violence incidents and no insurance coverage, according to the National Institute for Occupational Safety & Health.

“Most companies are vastly underprepared,” Spunberg said. “They don’t know what to do about it.”

Small- to medium-sized organizations in particular lack the resources to develop risk mitigation plans.

“They typically lack a risk management department or a security department,” Spunberg said. “They don’t have the internal structure that dictates who supervisors should report a problem to.”

With its workplace violence insurance solution, Hiscox aims to educate companies about the risk and provide a solution to help bridge the gap.

“The goal of this insurance product is not so much to make the organization whole again after an incident — which is the usual function of insurance — but to prevent the incident in the first place,” Spunberg said.

Hiscox’s partnership with Control Risks – a global leader in security risk management – provides clients with a 24/7 resource. The consultants can provide advice, come on-site to do their own assessment, and assist in defusing a situation before it escalates. Spunberg said that any carrier providing a workplace violence policy should be able to help mitigate the risk, not just provide coverage in response to the resultant damage.

“We urge our clients to call them at any time to report anything that seems out of ordinary, no matter how small. If they don’t know how to handle a situation, expertise is only a phone call away,” Spunberg said.

The Hiscox Workplace Violence coverage pays for the services of Control Risks and includes some indemnity for bodily injury as well as some supplemental coverage for business interruption, medical assistance and counseling.  Subvention funds are also available to assist organizations in the proactive management of their workplace violence prevention program.

“Coverage matters, but more importantly we need employees and supervisors to act,” Spunberg said. “The consequences of doing nothing are too severe.”

To learn more about Hiscox’s coverage for small-to-medium sized businesses, visit http://www.hiscoxbroker.com/.

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




Hiscox is a leading specialist insurer with roots dating back to 1901. Our diverse portfolio includes admitted and surplus products for professional liability, management liability, property, and specialty products like terrorism and kidnap and ransom.
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