By Carlos Cordova, Director of Operations , Priority Care Solutions, a division of Genex Services
In workers’ compensation, catastrophic claims often require a significant number and various types of ancillary services – anything from a rehabilitation facility, DME, transportation, home health services and more. An ancillary service provider can assist with a catastrophic injury response that coordinates the right ancillary services at the right time for these cases. There are various ways the ancillary service provider – working with the claims adjuster and a specially-trained catastrophic case manager – can help ensure the best-possible service, results and costs, as well as a seamless continuum of care on catastrophic cases. But before we break down how that process works, let’s review what constitutes a catastrophic claim.
What is a Catastrophic Claim?
A catastrophic claim involves a debilitating, life-altering injury, such as a severe burn, a major amputation, a traumatic brain injury or spinal cord injury. In some cases, multiple traumas may be involved. These injuries demand complex coordination due to these factors:
- Occurrence and cost. Catastrophic injuries make up only about one percent of all workers’ compensation claims. However, they often constitute a significant portion of a payer’s annual claims payouts – approximately 15 to 20 percent – depending on the payer’s book of business. These claims are extremely expensive. A single incident may cost upward of $1 million or more. The costs include indemnity payments, as well as medical care that takes place across multiple facilities, providers, specialties, and service areas.
- Long tail. The duration of these claims may stretch over many years and could even last for the injured employee’s lifetime. For example, a spinal cord injury resulting in complete paralysis below the neck would require around-the-clock skilled nursing care, with may cost from $250,000 to $400,000 annually.
- Patient and family. Managing the medical needs of the injured employee is the main focus, but the catastrophic injury team must also manage the expectations of family members, who are often distraught over the accident and concerned about the well-being of their loved one. They want this person to receive the best-possible care and to enjoy a good quality of life.
- Medical volatility. Due to the nature of these injuries, a catastrophic claim may experience a significant amount of medical volatility – and corresponding financial spikes – if the injured employee’s health and well-being take a turn for the worse. For instance, this individual might suffer from an infection, bed sores, or even depression. The clinical complexities of these cases are enormous, and they often result in other issues. The key is to aggressively manage these cases, so the risks of complications are minimized.
What’s Needed in an Ancillary Service Provider for Catastrophic Injuries?
From the perspective of claims adjusters, they want an ancillary service provider they can trust to seamlessly coordinate and communicate across various touchpoints in the provision of ancillary services, particularly in the following areas:
- Transition from hospital to skilled nursing facility or rehabilitation facility, as well as the transition to home
- Home health services
- Durable medical equipment and supplies
- Transportation and translation services
- Home and vehicle modifications
- Advanced diagnostics, such as MRIs and other scans
- Physical therapy and occupational therapy
A quality ancillary service provider will take a patient-centric approach, ensuring that injured employees have the essentials for each stage of their care and recovery. In fact, this service provider has the expertise to envision all necessary services and begin to plot them out in successive steps on a timeline, so everything is in place when the injured employee needs them.
Ensuring Seamless Delivery of Ancillary Services
The following are critical touchpoints where it’s important for the provider to ensure a seamless delivery of ancillary services; otherwise, a catastrophic claim could experience delays in care and added costs:
Setting a Game Plan
Once an ancillary service provider is brought on, and hopefully this occurs as early as possible, it will immediately begin to communicate with the key stakeholders – whether it’s the adjuster, treatment team, discharge staff or catastrophic case manager – to ascertain the injured employee’s ancillary service needs. The initial plan is sent to the adjuster for approval, but due to the volatile nature of catastrophic injuries, the plan will also remain flexible to accommodate the patient’s evolving needs.
Preparing for Hospital Discharge
The ancillary service provider will know all the right questions to ask to ensure that it understands the patient’s comprehensive needs prior to discharge from the hospital. For example, the ancillary service provider will find out if the injured employee requires transportation to the facility or home, and if so, will also schedule that service.
Finding the Right Facility & Negotiating Costs
If the injured employee requires further care, recovery and rehabilitation, the ancillary service provider will match the type of injury to the best-possible facility. An ancillary service provider will have a national network of qualified facilities, and when needed, reach out to regional facilities to see if they can handle that particular injury. The provider will ensure the facility is within close proximity to the patient’s home and family. It will negotiate pricing and outline what’s included in the cost of the stay, so the adjuster can properly set reserves on the case.
Coordinating the Return Home
Eventually, the injured employee will be discharged from the hospital or facility to home. The ancillary service provider will work with the catastrophic case manager, as well as the hospital or facility staff, to understand when discharge will occur and what ancillary services the injured employee will require immediately upon return to home and over the long term.
A key value the ancillary service provider offers is the ability to proactively manage all requirements within appropriate timeframes, so equipment, modifications or other services are in place when the injured employee arrives home or, otherwise, needs them.
Home or Vehicle Modifications
Some catastrophic cases call for more extensive home or vehicle modifications. As with any renovation project, where a contractor may be necessary, the ancillary service provider will obtain several quotes. It will check references to ensure quality work and accurate estimates. The ancillary service provider may need to work with several contractors to ensure an overall cost-effective modification.
Here again, adjusters want complete cost transparency. They may want the estimate broken down by material and labor or by room – or they may even want to know the cost of a particular aspect of the project, such as the flooring.
Providing Relief to Busy Adjusters and Claims Handlers
Every catastrophic injury is complex and has a unique set of demands. An ancillary service provider has the experience and pre-established relationships with catastrophic case managers, facilities and vendors to streamline the process. It also assumes the administrative and logistical burden, which is a tremendous relief for adjusters, who are already tasked with numerous claims and other tasks.
An Integrated Ancillary and Clinical Management Model: A Smarter Approach e
When an ancillary service provider is able to offer ancillary services along with clinical oversight, it is better equipped to contain costs and optimize outcomes. Within this integrated ancillary and clinical management model, the clinical team can review ancillary services to ensure clinical appropriateness and cost-effectiveness, help expedite the delivery of those services, and reduce the risk of any disruption in patient care.
In addition, this model translates into increased efficiencies via joint processes. For example, integrated ancillary and clinical teams can collaborate more effectively through shared systems and platforms. They can combine their expertise to save customers more money at each step of the catastrophic injury management process, as well as over the long term, and they can facilitate an overall smoother process. Ultimately, this model facilitates smarter ancillary decisions for the benefit of the injured employee and payer.
About Carlos Cordova
Carlos Cordova is director of operations at PCS. He has more than 15 years of experience in the workers’ compensation industry, specializing in ancillary and pharmacy benefit management services. He has a strong history of planning, developing and executing strategies that have led to improved service and customer experiences. He also helps build leadership teams focused on improving key performance indicators, streamlining operational efficiencies, and maintaining focus on performance culture through career path opportunities and development.
About Priority Care Solutions
PCS, a division of Genex Services, is a leading specialty managed care services and network provider for the workers’ compensation industry. The company draws on the cumulative experience of its executive team with an average of 20 years in all areas of workers’ compensation. The company has used this experience to create unique, proactive solutions that mitigate risk, create operational efficiencies and reduce costs, while providing compassionate, exceptional, and timely care to injured employees.
Based in Tampa, Florida, PCS works to meet the ancillary service needs of carriers, third-party administrators, self-insured employers, government agencies and managed care organizations. Its comprehensive set of solutions has helped to tackle the industry’s most pressing challenges. The results are faster, more efficient and cost-effective claims resolution and injured employees who receive the care they need. For more information, visit www.prioritycaresolutions.com.
About Genex Services
Genex Services provides best-in-class clinical solutions that enable customers to transform their bottom lines while enhancing the lives of injured and disabled workers. Genex, a clinical management leader throughout North America, serves the top underwriters of workers’ compensation, automobile, disability insurance, third-party administrators and a significant number of Fortune 500 employers. In addition, Genex clinical services are enhanced by intelligent systems and 360-degree data analysis. Its clinical expertise consistently drives superior results related to medical, wage loss, and productivity costs associated with claims in the workers’ compensation, disability, automobile, and health care systems. Genex Services and Mitchell International merged recently to create the broadest continuum of technology and products servicing the auto, workers’ compensation, and disability markets.
Genex Services is a WorkCompWire ad partner.
This is not a paid placement.