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Early Identification of High Risk Cases in Workers Compensation Sheila K. Bennion RN, BSN, CCM Manager of Medical and Disability Services Liberty Mutual.

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Presentation on theme: "Early Identification of High Risk Cases in Workers Compensation Sheila K. Bennion RN, BSN, CCM Manager of Medical and Disability Services Liberty Mutual."— Presentation transcript:

1 Early Identification of High Risk Cases in Workers Compensation Sheila K. Bennion RN, BSN, CCM Manager of Medical and Disability Services Liberty Mutual Insurance Group December 2, 2005

2 Learning objectives Enhance knowledge of statistical data related to cost of high risk cases Enhance knowledge of statistical data related to cost of high risk cases Recognize predictors of high risk cases Recognize predictors of high risk cases Understand strategies for early identification of high risk cases to optimize the case outcome Understand strategies for early identification of high risk cases to optimize the case outcome

3 Statistical Data

4 Cost of Workers’ Compensation absences In 1999, total direct costs including medical and indemnity payments were $40.1 billion In 1999, total direct costs including medical and indemnity payments were $40.1 billion Indirect costs for lost productivity and overtime ranged from $80 to $200 billion Indirect costs for lost productivity and overtime ranged from $80 to $200 billion - A 2-5 fold factor to direct costs General industry estimates indirect costs at 2-15 times the direct cost of WC General industry estimates indirect costs at 2-15 times the direct cost of WC Source: Liberty Mutual’s 2002 Workplace Safety Index

5 2003 Cost of Workers’ Compensation absences Total direct costs including medical and indemnity payments were $50.8 billion Total direct costs including medical and indemnity payments were $50.8 billion Impact of workplace injuries costs grew $1 billion per year from 1998 to 2003 Impact of workplace injuries costs grew $1 billion per year from 1998 to 2003 Number of serious work-related injuries fell Number of serious work-related injuries fell Source: Despite Drop in Workplace Injuries, Financial Impact Remains Significant. Insurance Journal. September 20, 2005.

6 Direct Costs Medical expenses Medical expenses Payment for lost wages Payment for lost wages Claims expenses Claims expenses Insurance premiums or self-funding increases Insurance premiums or self-funding increases Source:

7 Indirect Costs Temporary labor or overtime Temporary labor or overtime Diminished productivity Diminished productivity Supervisor time loss Supervisor time loss Property or equipment damage Property or equipment damage Source:

8 Drivers of Cost Increased use of medical benefits Increased use of medical benefits Duration of disability Duration of disability Source:

9 Return to Work Statistics If someone is out of work for 6 months If someone is out of work for 6 months - 50% chance of achieving return to work Is someone is out of work for 1 year Is someone is out of work for 1 year - 25% chance of achieving return to work If someone is out of work for 2 years If someone is out of work for 2 years -Virtually no chance of achieving return to work Source: Bureau of Labor Statistics

10 Return to work statistics – A carrier perspective According to a major carrier: If someone is out of work for 1 month If someone is out of work for 1 month - 50% chance of achieving return to work Is someone is out of work 6 months Is someone is out of work 6 months - 25% chance of achieving return to work If someone is out of work for 1 year If someone is out of work for 1 year - Only a 2% chance of achieving return to work Source: DiBenedetto, Continuing Care, 2003, p.12

11 Predictors of High Risk Cases

12 Do you have a Crystal Ball?

13 Injured Worker Risk Factors Age Age Place of residence Place of residence Education Education Opinion on degree of disability Opinion on degree of disability History of drug or alcohol use History of drug or alcohol use Financial problems Financial problems Family problems Family problems Source:

14 Injured Worker Risk Factors Continued Language Language Lack of Mobility Lack of Mobility Unable to reach injured worker Unable to reach injured worker Reliance on third party Reliance on third party Prior claims Prior claims Attorney involvement Attorney involvement Source:

15 Employment Risk Factors Employment history Employment history Nature of employment Nature of employment History of poor performance History of poor performance Excuses for not returning to work Excuses for not returning to work Little or no contact with employer Little or no contact with employer Rate of compensation Rate of compensation Job dissatisfaction Job dissatisfaction Lack of job opportunities Lack of job opportunities Source:

16 Medical Risk Factors Extended disability Extended disability Other medical conditions Other medical conditions Lack of physical findings Lack of physical findings Frequent MD changes Frequent MD changes Past related problems Past related problems Expansion or change in location of symptoms Expansion or change in location of symptoms Noncompliance with treatment Noncompliance with treatment Source:

17 Red Flags Injury reported on Monday morning Injury reported on Monday morning Injury not reported timely Injury not reported timely First report from an attorney First report from an attorney Injury reported after job action Injury reported after job action Description of injury is vague or doesn’t match symptoms Description of injury is vague or doesn’t match symptoms Discrepancies in injury account or exam findings Discrepancies in injury account or exam findings Plays sports outside of work Plays sports outside of work

18 Strategies

19 The initial period is critical in handling workers’ compensation claims.

20 Employer- Pre-injury Strategies Prevention- First and foremost Prevention- First and foremost - Develop a safety improvement program - Identify leading causes of workplace injuries - Create a culture of safety - Implement a safety audit program Source: Liberty Mutual’s 2003 Workplace Safety Index

21 Employer- Post-Injury Strategies Report injury timely and investigate thoroughly Report injury timely and investigate thoroughly Communicate all necessary information Communicate all necessary information Utilize preferred providers Utilize preferred providers Communicate openly and frequently Communicate openly and frequently Distribute job descriptions Distribute job descriptions Match functional capabilities to alternate job opportunities Match functional capabilities to alternate job opportunities Partner with claims adjuster to control claim costs Partner with claims adjuster to control claim costs

22 Claims Strategies Thorough investigation of accident and injury Thorough investigation of accident and injury - First report of injury - Initial medical report - Injured workers description of injury and past history - Assess for risk factors and red flags Utilize medical case managers immediately if red flags or risk factors present Utilize medical case managers immediately if red flags or risk factors present Utilize expected recovery timetables Utilize expected recovery timetables Review medical records for each visit Review medical records for each visit

23 Injured Worker’s Description Who was there? Who was there? What happened? What happened? When? When? Where? Where? Why? Why?

24 Other Elements of Interview Description of job and any recent changes Description of job and any recent changes Hobbies Hobbies Participation in sports Participation in sports General health General health Prior work related injuries Prior work related injuries Description of problem Description of problem Symptoms Symptoms Treating provider Treating provider

25 Initial Medical Report Subjective Subjective Objective Objective Assessment Assessment Plan Plan

26 Medical Case Manager Strategies Interview injured worker Interview injured worker Review medical records Review medical records Utilize expected recovery timetable Utilize expected recovery timetable Identify RTW opportunities Identify RTW opportunities Utilize provider network Utilize provider network Proactive management of risk factors Proactive management of risk factors

27 Provider- Strategies Thorough evaluation and treatment plan Thorough evaluation and treatment plan Utilization of screening questionnaires Utilization of screening questionnaires Utilize SOAP notes Utilize SOAP notes Recognize risk factors and barriers Recognize risk factors and barriers Develop plan to address/eliminate barriers Develop plan to address/eliminate barriers Clear expectations with injured worker Clear expectations with injured worker Communicate with all parties Communicate with all parties RTW focus RTW focus Request job descriptions Request job descriptions

28 “In this world nothing is certain but death and taxes” Benjamin Franklin

29 Session Wrap Up Review session objectives Review session objectives - Enhance knowledge of statistical data related to cost of high risk cases - Recognize predictors of high risk cases - Understand strategies for early identification of high risk cases to optimize the case outcome Questions Questions


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