Category Archives: Claims Management

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Workers Comp Lessons from Major League Baseball

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NEW ORLEANS—Bringing workers compensation under central control and greater oversight has drastically changed the cost and efficacy of one of Major League Baseball’s biggest expenditures. Here at the final day of the RIMS conference, Anthony Avitabile, vice president of industry risk management for Major League Baseball, shared some of his insight on implementing a unified workers comp program to reduce expenses while offering better services.

Although not every business has the high-profile brand or famous talent of a professional sports team, MLB’s example offers some valuable lessons for how large companies with different facilities or franchises can reduce workers comp spend and enhance treatment for employees.

Before 2003, clubs operated individually, placing workers comp insurance independently.

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To do so, they called upon varying philosophies related to program structure, medical provider relationships, and off-season indemnity for minor league players who were out of work during a key earnings period outside of the game. Every franchise was fending for themselves when it came to procuring coverage and securing treatment for players. Since 2003, the league has required compliance with a group policy, featuring group insurance purchasing, unified philosophies, and greater information sharing about injuries, expenses and treatment standards. In the year before Avitabile’s program was put into place, total costs incurred peaked in 2002 at about .

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3 million, while costs in 2013 were down to .

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8 million.

Critical components of the new program include a drastic effort to understand and review losses across all franchises, what he called a “relentless” effort to manage the process in every club, incentivizing good behavior and results, and instituting universal standards in the approach to coverage. The league made a unilateral decision to dedicate the greatest spend to best-in-class service providers, for example, concluding that return to maximum medical improvement offered the biggest long-term savings. Seizing on the competitive nature shared throughout the league, Avitabile also issues one-page annual scorecards for the CFO and other executives in the individual clubs and review at an organizational level. These show performance relative to other clubs, highlighting top cost drivers and key ways to improve. A workers compensation quality council was also formed to focus on provider agreements, review complex questions regarding released players, and evaluate and implement in-house physical therapy and rehab operations.

Leveraging the full size and reputation of the league also offered substantial savings in negotiating with providers, which Avitabile cited as one of the biggest areas of savings when managed in advance of any injuries. Partially thanks to volume and ensured prompt payment backed by the organization, these pre-negotiated rates are typically below workers comp state medical fee schedules. Some of his tips for negotiating these provider agreements include:

provider agreement negotiation

Bringing some services in-house also offered considerable savings while maximizing reliable access to top treatment and consistent protocols. The league-wide move to in-house physical therapy instead of third-party treatment, for example, brought total incurred PT and rehab costs down from about $1.6 million in 2002 to approximately $340,000 in 2012.

10 Insurance Tips for Risk Managers

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NEW ORLEANS—Most companies will at one time or another face coverage issues and lawsuits. In order to identify and avoid insurance-related issues and disputes before they arise, risk managers should take advantage of proven strategies for resolving difficult claims, advised Darin McMullen, attorney with Anderson Kill, P.C. at the RIMS 2015 Annual Conference & Exhibition here.

1. The purpose of insurance is to insure.

Don’t underestimate potential future problems and think of loss prevention and risk transfer rather than loss financing, he noted. Companies need to assess the types of risks they will face and make sure their program is tailored to meet these needs. Also important, he said, is making sure policies are designed to cover the losses the company will face on a day to day basis. For example, certain types of risks are seen in manufacturing and other risks are particular to an IT vendor. Risk managers need to examine any pitfalls or shortages that may exist in their current policies and seek legal opinions well in advance of renewal. They need to look at how exclusions might be interpreted as well, McMullen said.

Joshua Gold, also an attorney with Anderson Kill, added that risk managers’ jobs are more difficult than ever, with fragmentation in insurance programs existing, since many polices are purchased for a program. These may include directors and officers, product liability and cyber insurance. “There are products out there that try to assimilate them and make sure gaps in coverage are treated,” Gold said, adding that while the fine print in policies can be overwhelming, it can be key for proper coverage, especially when dealing with multiple lines, excess layers and towers of insurance.

2. Don’t limit insurance expertise to the risk management department.

All too often, “there are still going to be thorny claims and there still are going to be disputed claims, which are unavoidable,” McMullen said. He said that building expertise elsewhere within the company is critical to taking advantage of any and all available coverage. “We get the need for everybody to work together, but now, more than ever, this is important,” he said. Coverage should not just be delegated to risk or legal and collaboration is needed. For example, IT departments need to be included when planning for cyber coverage.

3. Lawyers and risk managers can be natural allies.

While there may be friction between departments in a company, legal generally recognizes the beneficial role risk managers play, McMullen said. He added that risk managers need to put any insurance-related communications in writing and assist in the analysis of policies and claims.

4. Insurance is an essential component of corporate resources and asset conservation plans.

Risk managers should purchase coverage with the intent of safeguarding the company’s own property and employees. They also need to recognize which mechanisms actually transfer risk and which do not.

5. Think insurance after a loss occurs.

This means looking to insurance coverage following all lawsuits, claim letters, product-related issues and financial losses. Risk professionals also need to analyze other sources of insurance that could possibly cover a claim.

6. Give notice of a claim or loss as soon as possible.

When faced with a claim or loss, McMullen advised risk managers not to hesitate to notify their broker, insurers and everyone in their tower of insurance as soon as possible.

7. When you make a claim, don’t accept “no” for an answer.

There is no downside to challenging an insurer’s denial of coverage. “You owe it to your company, you owe it to your organization to explore this and push back,” McMullen said, adding that determination and persistence often mean the difference between coverage and no coverage.

8. Find out where your company’s policies are.

Locate, collect and catalogue past insurance policies. Also acquire and keep policies of all entities related to your company.

9. Don’t panic if your insurer becomes insolvent.

If this is the case, McMullen advised risk professionals to file a proof of claim as a creditor and file a claim against the state guaranty fund in one or more possible jurisdictions. He recommended that they request the next layer of insurance companies to “drop down,” and also to consider litigation options.

10. Make sure your insurance team is conflict-free.

This means the team should be untainted–risk managers need to know where loyalty lies and if an attorney is representing both sides, McMullen said. “You want a conflict-free insurance team to take on the insurance company and to fight for the coverage that you are paying for,” he concluded.

 

New in Workers Comp: “Lifestyle Risk” and the Dangers of Telecommuting

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NEW ORLEANS—While controlling workers compensation costs often focuses on mitigating the risk of slip-and-falls or ensuring employees have proper safety gear, some notable exposures exist in employees’ everyday personal lifestyle choices. In the Thought Leader Theater at RIMS 2015, Fred Hubbs, a partner in the lawfirm Hall Booth Smith, P.C., discussed how different trends—from the obesity epidemic to telecommuting—can increase risk exposure in the workplace.

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As the workers comp system is based on principles of no fault and no personal responsibility and there are broad state definitions of what is medically necessary or what an employer is responsible for, employers are often vulnerable to what Hubbs calls “lifestyle risk.” Obesity, smoking, non-compliance with treatment for diabetes, and telecommuting can all put employees at risk, and either contribute to a compensable event or complicate the recovery process.

Obesity, which affects approximately 37% of Americans and is expected to his 50% by 2030, is a well-documented factor in workers comp, with obese workers filing twice as many claims that tend to be up to seven times more expensive and see these workers missing thirteen more days a year, while indemnity benefits paid can be five times higher. And some states have ordered employers to pay for weight loss that is medically necessary to facilitate recovery.

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Smokers are also drastically more likely to be injured at work, and smoking while on the job can lead to specific accidents in the workplace that are compensable. In fact, courts have ruled that, if smoking is only a slight deviation from job duties, an accident that occurs while a worker is on a smoke break is compensable. In at least two states, employers are also now required to pay for smoking cessation programs if doctors deem it necessary to help with recovery from surgery.

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For diabetic employees, a refusal to comply with treatment can expose employers, whether because of the increased risk of seizure, making a minor injury worse, or delaying recovery. Some treatments for injuries sustained on the job can also aggravate pre-existing diabetes, which can be a compensable event.

For all of these issues, Hubbs recommended that employers get more proactive to help employees be healthier, reduce workers comp costs, and even benefit from some incentives from new healthcare laws. Stop-smoking campaigns and weight-loss or activity-boosting initiatives can all aid in these efforts, and these employee-sponsored wellness programs are promoted under new healthcare laws, which may offer direct incentive to businesses that introduce them. Ensuring that employees are complying with doctors’ orders regarding these required efforts is also important, and may be actionable if employees are refusing. There are laws that require employees to comply if they are receiving workers comp benefits, Hubbs said, and employers should seriously examine their legal ability to stop compensation if an employee refuses to submit to a reasonable examination or treatment.

Finally, Hubbs cautioned that many employers should be more cognizant of the risks of telecommuting. While working remotely is certainly nothing new, it is continuing to grow, especially after President Obama signed the Telework Enhancement Act requiring government agencies to establish policies for working outside the office. These arrangements can severely complicate workers comp questions, however, as the lines blur surrounding whether an accident that occurs in the home is compensable and whether an employee is on or off the clock at any given time. To mitigate some of these risks, he recommended that employers:

  • Visit the “jobsite” to evaluate where employees will be working
  • Email or otherwise communicate when an employee is on or off the clock
  • Create a written and signed agreement that designates hours and breaks, designates rooms in the house as “office” space, specify what duties are included in the telework, designate “personal comfort” areas, and attach panel of physicians in states where appropriate

Survey Finds Alliance with Organizations and Risk Reporting Structures

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NEW ORLEANS—Seventy-nine percent of companies are aligned with their risk management reporting structure, however, only 27% of risk professionals believe that emerging risks will be a company priority in the coming year, according to the 12th annual “Excellence in Risk Management Survey” released here by Marsh and RIMS.

In the last five or six years, “We have seen significant narrowing of the gap, where there is better alignment of what risk managers and risk executives are providing their organization and what their C-suite and management is looking for and needing in this riskier world that we all live in,” said Brian Elowe, a managing director at Marsh and co-author of the report. Findings are based on more than 300 responses to an online survey and a series of focus groups with leading risk executives.

Elowe explained that the study focused on organizational alignment, risk management effectiveness, data analytics and technology and cyberrisk.

In their study of organizational dynamics, he said, “We looked at priority setting, organizational structure and performance measurement standards to understand effective execution of a risk management strategy.”

The first insight was in respect to structures risk management reports to inside an organization. “We also asked whether the people responding to the survey felt risk management was reporting to the correct area inside the organization. We found that 79% of the respondents said they felt risk management was reporting into the appropriate area inside their organization,” Elowe said.

Looking deeper, he said the survey found that 50% of executives report into the finance area. The other half reports into a wide number of areas inside the company–12% report to general counsel, 8% to other C-suite members, 5% to internal audit, 5% to operations, 2% to human resources and 11% to “other” functions.

“We found that while they are all in the risk management function, those that report to areas outside of finance tend to be involved in areas deemed to be more strategic in nature. So they are more likely to be involved with things like ERM strategies, IT, privacy and security.”

Elowe said, “We think that finance executives might be well-served to help facilitate greater connections inside their companies to help broaden the perspective that risk executives reporting into finance might be able to have inside their own companies.”

In addition, only 27% of risk professionals reporting to the CFO or treasurer said they expected an increase in spending for training risk management staff. This is compared to 46% in increases expected by those reporting to other areas.

The top-five programs reporting to risk management were insurance management (92%), claims management (88%), enterprise risk management (67%), captive operations (65%) and emergency response (63%).

Looking at functions that report into risk management, he said that while the traditional functions of insurance and claims were well aligned, there is a significant alignment with IT. This is compared to several years ago when IT “operated in and of itself in an organization. That is an outcome of the growing cyberrrisk and the need for organizations to have a multi-disciplinary approach to how cyber is affecting their organization.”

Discussion groups agreed that the “here and now” is most important to their companies and that more needs to be done to develop understanding of emerging risks. “Risk managers are concerned they are not looking far enough ahead,” Elowe said, adding that company focus is largely directed to regulations and compliance. Carol Fox, director of the strategic and enterprise risk practice at RIMS and co-author of the report observed that organizations focused on operations are generally not as involved in strategy. She said management understands risks, but fell off in actually planning for emerging risks.

Findings include:

  • Risk management departments that do not report into finance are generally better aligned with other strategic functions within their organizations — most notably in the areas of enterprise risk management, compliance, information technology (IT) risk management, privacy, and security.
  • Despite the importance placed on emerging risks by many board members, senior leaders, and risk executives, only 27% of survey respondents said that identifying emerging risks would be a priority in the coming year.
  • Over the next two years, 42% of organizations expect to increase the level of investment in risk analytics, according to our survey, with 57% saying it would remain flat.
  • Nearly 60% of respondents said their organization has no formal communications plan in anticipation of a cyber event.
  • Risk professionals who report into the CFO or treasurer are much less likely to expect an increase in spending for training risk management staff in the coming year compared to those reporting elsewhere.