Early Identification of High Risk Cases in Workers Compensation

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 • Recognize predictors of high risk cases • 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 • 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 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 • Impact of workplace injuries costs grew $1 billion per year from 1998 to 2003 • 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 • Payment for lost wages • Claims expenses • Insurance premiums or self-funding increases Source: www.thefabricator.com

7. Indirect Costs • Temporary labor or overtime • Diminished productivity • Supervisor time loss • Property or equipment damage Source: www.thefabricator.com

8. Drivers of Cost • Increased use of medical benefits • Duration of disability Source: www.marshriskconsulting.com

9. Return to Work Statistics • 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 - 25% chance of achieving return to work • 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 - 50% chance of achieving return to work • Is someone is out of work 6 months - 25% chance of achieving return to work • 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 • Place of residence • Education • Opinion on degree of disability • History of drug or alcohol use • Financial problems • Family problems Source: www.wcbask.com

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

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

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

17. Red Flags • Injury reported on Monday morning • Injury not reported timely • First report from an attorney • Injury reported after job action • Description of injury is vague or doesn’t match symptoms • Discrepancies in injury account or exam findings • 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 - 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 • Communicate all necessary information • Utilize preferred providers • Communicate openly and frequently • Distribute job descriptions • Match functional capabilities to alternate job opportunities • Partner with claims adjuster to control claim costs

22. Claims Strategies • 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 expected recovery timetables • Review medical records for each visit

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

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

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

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

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

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

29. Session Wrap Up • 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