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Controlling Costs Through Claims Management. Why Claims Management?. Web Sites. BWC ohiobwc.com IC www.ic.state.oh.us. Rate Making. The main question is … How does BWC determine what an employer pays in premium? BWC must collect enough money in premium to pay claims costs.

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Controlling Costs Through Claims Management


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    Presentation Transcript
    1. Controlling Costs Through Claims Management

    2. Why Claims Management?

    3. Web Sites • BWC ohiobwc.com • IC www.ic.state.oh.us

    4. Rate Making • The main question is … • How does BWC determine what an employer pays in premium? • BWC must collect enough money in premium to pay claims costs. • Costs must be equitably divided among all employers.

    5. Four-YearCalculation Private employers* • For policy year beginning July 1, 2009, BWC used data from calendar years 2004, 2005, 2006 and 2007 for rate-making purposes. • Each year, the oldest year drops off and a new year is added. • For policy year beginning July 1, 2010, BWC will use data from calendar years 2005, 2006, 2007 and 2008 for rate-making purposes. *Public employers’ rating year begins on Jan. 1

    6. BWC Rating Concept Compare actual claims cost and expected claims cost

    7. BWC Rate Making • Once actual claims costs and expected claims costs are obtained, BWC uses that information to determine the rate that the employer will pay. • Note that the BWC is “revenue neutral” when it comes to rate making.

    8. Claims Costs • Medical • Indemnity • Reserves

    9. Claims Costs Medical Money paid for doctor bills, diagnostic tests, drugs, etc.

    10. Claims Costs Indemnity (compensation) • Money paid to injured workers to compensate for lost wages • Money paid to injured workers to compensate for permanent damage

    11. Claims Costs Reserves A reserve is the anticipated future cost in a claim. • A reserve is set only on claims that are designated as lost-time claims.

    12. Result • A large reserve has a significant impact on the value of a claim. • Claims with large reserves can be the driving factor in an employer’s rates.

    13. Maximum Value Claim • Each employer is assigned a maximum value for each individual claim. • It’s based on employer size and determined by expected losses. • This prevents large claims from negatively impacting small employers. • Injured employee receives all benefits due. • Amounts over the maximum value are assigned to surplus fund (a shared liability).

    14. Experience Rating • Credit-rated • An employer has less claims cost than BWC would expect. The experience modifier (EM) is less than 1.00. • Debit (penalty)-rated • An employer has more claims cost than BWC would expect. The EM is greater than 1.00.

    15. Simply put … claims costs drive rates.

    16. Types Of Claims • Medical only – seven or fewer days of lost work • Lost time – eight or more days lost from work • Does not have to be consecutive

    17. Timely Reporting Of Claims • Company policy to report injuries on same work shift? • Immediate reporting of claim allows faster/more appropriate treatment. • Reporting more than seven days = increased costs.1 • 11 to 20 days = 29% increase • 21 to 30 days = 39% increase • Over 30 days = 50% increase • More than 31 days = 113% increase in litigation (i.e. attorney involvement).2 1Kemper Insurance – 1993 2International Assoc. of Ind. Accident Boards & Commissions

    18. Accident Analysis

    19. Why is accident analysis in a claims management class?

    20. Why Analyze? • Prevent recurrences • Evaluate data • Make specific recommendations • Show critical behaviors • Compare trends • Identify needs

    21. What is an accident?

    22. Accident • It’s an unplanned event that interrupts the completion of an activity and includes injury, illness, or property damage. • Worker seeks medical treatment.

    23. What is an incident?

    24. Incident/Near Miss • It’s an unplanned event that interrupts the completion of an activity withoutdirectly involving the worker(s). • The worker does notseek medical treatment.

    25. When Recording Accidents And Incidents/Near Misses • Always document and keep them simple. • Clearly communicate process. • Review for trends (like injuries, locations, same equipment). • Goal should always be prevention.

    26. Types Of Tracking Forms • Shift logs • OSHA 300 logs • FROI form • Incident reports • First aid logs • Accident analysis reports

    27. Five Causal Factors • Task • Material • Environment • Human/personal • Management/process failure

    28. Task • Was a safe work procedure used? • Had conditions changed to make normal procedures unsafe? • Were appropriate tools and materials available and working properly? • Were safety devices working properly?

    29. Material • Was there equipment failure? • What caused it to fail? • Was machinery poorly designed? • Were hazardous substances involved? • Should the worker have used personal protective equipment?

    30. Environment • What were the weather conditions? • Was poor housekeeping a problem? • Was noise a problem? • Was there adequate light? • Were toxic gases, dusts, fumes present?

    31. Human/Personal • Were workers experienced? • Were they adequately trained? • Were they physically capable of doing the work? • Were they tired? • Were they under stress (work or personal)?

    32. Management/Process Failure “The process designed and administered by management is responsible for 94% of all outcomes, including accidents.” Larry Hansen, Wausau Insurance

    33. Management/Process Failure • Were safety rules in effect and enforced? • Was adequate supervision and training given? • Were there regular safety inspections? • Had hazards previously been identified? • We unsafe conditions corrected? • Was regular equipment maintenance carried out?

    34. Material Environment Task Process Human

    35. Why document an accident or incident/near miss? • Prevention • Consistency • Data analysis • Legal Issues

    36. Steps Of An Accident Analysis Process • Written program • Information gathering • Analysis • Recommendation/corrective action

    37. Written Program • Who will conduct the analysis? • What forms are available? • Where do you obtain them? • When should the incident be reported? • When will the accident be analyzed?

    38. Information Gathering • Analysis kit • Physical evidence • Interviews • Background information

    39. Analysis • Accident tree • BWC accident analysis form

    40. Recommendations/Corrective Action • Recommendations are made to management. • Management takes corrective action.

    41. Accident analysis should always be to gather facts and never to lay blame. Your main objective is prevention!

    42. Accident Analysis Share your successes!

    43. Case Study What happened to Herbie?

    44. Claims Management

    45. Initiatives • Bureau of Workers’ Compensation (BWC) • Industrial Commission of Ohio (IC)

    46. Claims Management Through Partnership • BWC • Managed Care Organization (MCO) • Employer • Injured worker • Provider • Representatives

    47. Reporting Injuries • Injured worker completes accident report. • Injured worker seeks treatment. • Certified providers • Provider contacts MCO. • MCO electronically transmits to claims to BWC. • BWC issues a claim number and notifies all parties by letter, notifies MCO electronically.

    48. Advantages To Employer Reporting • Claim will be submitted with the correct policy number. • Claim will be submitted with the correct manual number. • Claim will have a complete accident description. • The injured worker will have a claim number at or near the time of the initial treatment. • BWC will know whether or not the employer certifies the facts of the claim.

    49. Additional Information: What should employers report? • Incident report • Witness statements • Certification • Wages • Transitional work opportunities • Job description • Note, as the employer, you should also consider sharing both the job description and transitional work opportunities with the treating provider. Ask the provider if the injured worker can perform any of these duties.

    50. Claims Flow Process: What happens after reporting an injury? • Contact made with injured worker, employer and their representatives if appropriate. • Investigate details and verify information. • BWC collaborates with MCO case manager and develops action plan. • As an employer, you may ask to be part of the return to work plan. • Review with appropriate team members. • Request physician review if appropriate.