By Don Duford, CEO, One Call Care Management
When we look back over the long history of workers’ compensation, it’s apparent that the basic role of workers’ compensation insurance – as financial protection for individuals injured while on the job – really hasn’t changed over time. However, what has dramatically changed is the scope and the risks inherent in managing workers’ compensation claims. Today, the healthcare system is vastly more sophisticated. Regulatory requirements in the fifty states are constantly changing and more complex. The steps required to process a claim are myriad, and the cost of failure is high. For the individual claims professional who bears the responsibility for ensuring a claim is managed appropriately, the challenges have truly exploded.
Twenty years ago, claims professionals were largely locally distributed. (The term “multi-jurisdictional” claims offices emerged in the 90’s.) Claims professionals could develop an understanding of the employers they served, specific state regulations, the local healthcare delivery system and which providers contributed to the best outcomes. Within this world, they could form their own team of readily available resources to provide consistent, quality care and effective return-to-work plans for each claim.
Today, these claims professionals are likely to work for consolidated claims operations and are responsible for managing claims across a broad geographic area and in multiple jurisdictions. On average, they handle 150 claims with less local knowledge than they had previously. Yet in this complicated environment, these claims professionals still remain the central point of claims management: directing injured workers to providers, managing referrals, and approving key elements of treatment plans and return-to-work strategies.
As the claims professional’s responsibilities have become more complex, the work load heavier, and the role more diverse, the need for excellent claims management has never been greater. Today, the average cost of a claim is $28,000 and the average duration is five to six months. Each claim is a risk that can be either quickly resolved or can evolve into a long term, open-ended costly liability. Without constant vigilance, the risk of costly litigation is increased, the cost of care can explode, the condition of the injured worker can deteriorate instead of improve, the duration of the claim drags on, and the administrative burden for the claims professional increases.
In today’s environment, the claims professional’s ability to achieve the best outcome is still dependent on the capability of pulling together a team of highly qualified healthcare and service providers who understand both efficient medicine and the unique requirements of workers’ compensation. This “A team” must facilitate and coordinate an effective care management plan that leads to efficient, optimal outcomes. Such a team would need to include high quality primary care physicians and specialists as well as injury-related providers in the areas of physical therapy, diagnostics, pharmacy, medical equipment and supplies, and in cases with more severe injuries, home health support.
Unfortunately, as the scope and size of their workload has increased, claims professionals have had to cobble together this team on their own, simultaneously playing the role of quarterback, air traffic controller, and matchmaker for the various services. As the workers’ compensation environment becomes even more challenging, claims professionals face an ever-increasing risk of missing the right intervention at the right time to keep a claim on track for best results.
Finding this team of best-of-breed providers who are available at a moment’s notice may sound like an impossibility within the fragmented environment of workers’ compensation. However, three developments over the past several years make this scenario a possibility today.
The first change is the emergence of strong national specialty networks. These networks excel at creating easy access to high quality specialty providers with easy-to-use connections for claims management. They credential the provider, match the injured worker with the right provider, ensure movement of critical data and reports, and simplify reimbursement processes.
The second development is the very real progress in using sophisticated analytics to identify high performing workers’ compensation physicians and specialists. There is clear agreement among workers’ compensation leaders and growing supporting data that some physicians produce much better outcomes than others, and that connecting injured workers with those physicians yields optimal claim results. With strong confidence in the quality of the treating physician, many oversight activities such as UR and TCM can be minimized, taking cost, time, and friction out of the system.
Finally, technology is now readily available to effectively connect these currently fragmented players into a virtual integrated team wrapped around the injured worker. All of the care required to generate the best result can be retained within a group of service providers that are all working towards a common objective. The claims professional can direct the team and be freed up to focus their expertise on critical exceptions, as opposed to trying to monitor every activity on every claim.
With these developments, claims professionals now have a ready-made integrated team that is just a phone call or e-mail away, available whenever an injury occurs or an injured worker needs to be moved further along in the care plan. The injured worker gets prompt, quality care for a faster, improved outcome. The valuable time that is saved can be focused on real risk management and customer service. The overall cost of the claim is reduced and the process is achieved with predictability, continuity and consistency – the hallmark of quality management.
As evidenced by the need for national health reform and the ongoing increase in providing health benefits for employers, the healthcare system is a difficult beast to tame. Where there are success stories in healthcare cost and quality management, there are also generally models of integrated teams of healthcare professionals connected with common information and outcomes goals.
The capabilities now available to worker compensation payers represent an opportunity to replicate those successful models and create a new era of integrated care management, leading to dramatically improved claims management results.
About Don Duford
Don Duford is CEO of One Call Care Management with responsibility for the company’s best-in-class service offerings, including high-end diagnostics, post-discharge and home care management, transportation and language services, dental and other specialty care.
Mr. Duford brings nearly 30 years of experience in delivering specialized managed care services to workers’ compensation, healthcare, and group disability plan administrators.
Prior to joining OCCM (formerly One Call Medical), Mr. Duford was President of CIGNA Integrated Care, a subsidiary created to deliver integrated services across all disability and health benefit plans. Other positions of note he has held include President of Intracorp, a national case management company, and Senior Vice President of Cigna’s HealthCare National Accounts unit. He holds a B.A. in Mathematics from Central Connecticut State University.
About One Call Care Management, Inc.
Based in Parsippany, NJ, One Call Care Management, Inc. (OCCM) is the nation’s leading partner in providing specialized services that lead to faster, more efficient and more cost-effective resolution of claims. From high-end diagnostic procedures, to transportation and language services, to post-discharge and home care management, to superior dental programs and other medical specialties, OCCM provides reliable, consistent connections to care and improved outcomes. With rapid scheduling of services, clinical oversight, coordination, and delivery of medical reports, no other partner gives you the depth of support and service excellence that OCCM provides. Our team of experts is always ready to connect you to a broad spectrum of qualified providers and specialized services. For more information, visit www.onecallmedical.com.