Best Practices in Catastrophic Claims Management
This panel at the 2015 California Workers’ Compensation & Risk Conference discussed the best practices in managing catastrophic claims to achieve the best possible outcome while proactively managing costs.
- Denise Evans, Director of Workers’ Compensation Claims at Staffmark
- Sherri Hickey, Director of Medical Management at Safety National
- Karen M. Derrico, RN, BSN, CCM, CDMS, VP Workers’ Compensation and Critical Care Division at Best Doctors, Inc.
- Stanley E. Smith, SVP/Managing Partner at Adva-PAC
Catastrophic injury claims such as brain injuries, spinal cord injuries, severe burns or major amputations are life-changing events for injured workers. If these claims are not managed properly, the injured worker will not achieve the best possible outcome and the costs will be significantly increased.
What to understand up front:
- The definition is expanding. There are creeping catastrophic cases like individuals with complicated fractures or organ failure.
- The necessity of early intervention with the proper medical experts is critical to managing your catastrophic cases for the best possible outcomes.
- Know your policy language. You have reporting obligations to your carrier and reporting these claims in a timely manner is critically important. You can be in violation of your policy if you do not.
What do you do first?
- Set up a detailed investigation with safety department involvement and OSHA.
- Get involved with employee’s family.
- Nurse case management involvement is very important. Involve them immediately and make them part of your team.
- Prepare upper management. Keep in mind that they are going to want answers and costs that you likely won’t have immediately.
- Make sure the TPA is well aware of the claim.
- Notify your insurance carrier and realize the importance of partnering with your carrier to properly utilize their resources
When costs begin to add up, don’t settle. Do your research. There are many resources and you need to begin this immediately. Build a network of resources and be very involved.
Be aware of medical cost drivers:
- Costs of medical care is greater in workers’ compensation than in group health.
- Increased severity – The quantity of claims is decreasing, but severity is increasing.
- New technology – Microprocessor limbs for amputees, for instance, can help the employee with their quality of life, but technologically-advanced items are going to be very costly.
- New medications – There is always new pharma, but this can get costly as well.
Look for red flags that can drive costs or complicate the claim:
- Type of injury – What will this claim consist of?
- Length of time since the injury – Acting quickly is critical.
- Clinical findings – What is the extent of injury and outlook?
- Comorbidities – Obesity, smoking, etc., will impact recovery and cost.
- Multiple diagnosis – Catastrophic claims often come with multiple injuries.
- Treating providers – What is their skill set? Is your worker with the experts at the right facility?
The Expert Physician Model
The more expertise you can bring to catastrophic claims is going to play a major part in managing a solid plan of care. Then entire team benefits from expert physician oversight.
- The injured employee benefits from being treated by an expert. Also, don’t be afraid to let the injured worker’s family know the resources that you are bringing to their family member’s care and helps to prevent litigation.
- The employer also benefits. There are cost savings through appropriate and early intervention, they can plan and predict expectations related to return to work.
- The claims professional benefits by maintaining better control of the claim and keeping abreast of changes as they occur.
Anticipate long-term needs like acute or post acute rehab, home or vehicle modifications and attendant care. Network with other employers and see what networks they use and who the trusted resources are for different areas of the claim.
Remember: No one knows everything, but everyone knows something. Use the entire team and each of their strengths to feed information to you and best manage these unique and difficult claims.