Workers Compensation (WC) Fall 2018

Bribery charges Physician Opioid TPA selection for safety official, outreach reduction requires pot rulings improves strategies attention plus more news outcomes need buy-in to detail PAGE 6 PAGE 12 PAGE 18 PAGE 22WORKERS COMPENSATION FALL 2018 | ISSUE 3 VOL. 4SOCIALMEDIAFRAUDCLUESMalingering workersoften leave evidence trailthrough online postsPAGE 14 A PUBLICATION OF



CONTENTS FALL 2018 | ISSUE 3 VOL. 4 12 1814 22 26COVER STORY Q&A14 Peeking over social media shoulders 10 Wesley HyattUsing social media to investigate suspected workers comp Wesley Hyatt of Liberty Mutual and Helmsman discussesfraud is evolving, with more questions than answers. In an workers comp trends in claims and technology.online social setting where one can have hundreds of “friends,”one question is how close can an investigator get? COLUMNSBy Louise Esola 12 Risk matters DEPARTMENTS The best medical doctors may still have knowledge gaps 4 EDITORIAL when it comes to workers compensation processes. 6 STATE-BY-STATE By Lance J. Ewing 9 STATE PROFILE 29 THE FORUM FEATURESA PUBLICATION OF 18 Keeping tabs on opioids TPAs and PBMs address opioid use by injured workers. By Gloria Gonzalez 22 Finding the right fit How to leverage data and analytics when choosing a TPA. By Leslie M. Batterson 26 Consequences of polypharmacy Simultaneous use of drugs can do harm and raise costs. By Silvia Sacalis WC FALL 2018 3

EDITORIALA new world of claims fraud WORKERS COMPENSATIONA s anybody who uses social media will attest, it’s amazing what some peo- FALL 2018 | ISSUE 3 VOL. 4 ple are prepared to share. Photographs, videos, anecdotes and opinions that only a few years ago people would, at a stretch, share with their CEOmost intimate friends are now routinely posted for the world to see. Adam Potter PUBLISHERIn addition to providing sociologists with a rich new source of information Peter Oxner [email protected] human behavior, Facebook, Twitter and other online platforms can pro- EDITOR Gavin Soutervide crucial evidence and tips to help prosecute workers compensation fraud. [email protected] DEPUTY EDITOR We’ve all rolled our eyes at stories about comp Gloria Gonzalez [email protected] claimants busted after posting videos of themselves REPORTER Louise Esola water skiing, salsa dancing or doing some other activ- [email protected] COPY CHIEF ity that they should not be able to perform given their Katherine Downing [email protected] alleged disabling lower back pain, but it goes much COPY EDITOR Brian Gaynor deeper than that. Even careful fraudsters can’t use [email protected] ART DIRECTOR self-restraint or privacy settings to stop friends and Jeremy Werling [email protected] Souter family from posting photographic evidence that con- HEAD OF ADVERTISING SALES EDITOR tradicts their comp filings. Jeremy Campbell [email protected] While social media has been a tremendous boon to MARKETING MANAGER Katie Kettworkers comp fraud investigators and has helped them reduce claims costs, [email protected] SUBSCRIPTIONS & SINGLE COPY SALESas we report in our cover story, there are limits to how they can obtain the [email protected] 954-449-0736evidence. Legal concerns over privacy rights and obtaining evidence through WC is published four times a year and coversdeception are just as valid in online settings as the physical world. the trends and topics of interest to professionals responsible for the cost-effective resolution of workersAnother wider societal trend that has had a significant effect on the comp compensation claims — risk and litigation managers, insurance and claims professionals, corporatesector is overprescription of opioids. The highly effective but cruelly addic- counsel, outside counsel and services providers. Copyright © 2018 by Business Insurance Holdings.tive painkillers have been used for years to treat workers injured on the job, All rights reserved. No part of this publication may be reproduced or transmitted in any form or byat the same time prolonging absences from work and increasing claims costs any means, electronic, mechanical, photocopying, recording or otherwise, without prior writtenas patients get hooked on drugs, develop other problems and stay at home. permission of the Business Insurance Holdings.As we report on page 18, however, progress is being made in the effort to A PUBLICATION OFenforce stricter opioid prescription protocols, and there is now wide recog- The views expressed in contributed articles are solely those of the authors and do not necessarily reflectnition of the problem of overprescribing. But it’s not a problem that can be the views or opinions of Business Insurance Holdings or the companies in which the authors are employed.tackled easily or by any single entity. Doctors, third-party administrators,regulators, injured workers and their families all have a role to play in curbingthe problem.Opioids, of course, are just one family of drugs that are used to treatinjured workers. While other drugs may not raise the same concerns whenused individually, as expert Silvia Sacalis writes on page 26, when patientsare prescribed multiple drugs, numerous problems can arise endangeringpatients and worsening claims. Again, a multipronged approach calling onthe expertise of many stakeholders is required to manage the problem.4 FALL 2018 WC

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STATE-BY-STATE WORKERS COMPENSATION NEWS FROM ACROSS THE USCAL/OSHA STAFFER um rates since 2015, totaling 37% from theCHARGED WITH BRIBERY Jan. 1, 2015, level.n An employee of California’s workplace The 75-page report also notes that thesafety regulatory agency was arrested on decreases in rates are primarily the resultbribery charges after allegedly soliciting of S.B. 863, a comp reform packagea bribe from a construction company passed in 2012 that aimed to rein in med-in exchange for reducing penalties the ical costs, compensation fraud and othercompany was facing for safety violations. problems deemed costly. Yet the state’s higher-in-comparison rates are driven by California Attorney General Xavier Becerra announced the arrest of Richard Fazlo- “a high frequency of permanent disabilityllahi, a district manager with the California Department of Industrial Relations-Di- claims, a more prolonged pattern of medi-vision of Occupational Safety & Health, in a statement. cal treatments and much higher than aver- age costs of handling claims and delivering The arrest resulted from an investigation conducted by the California Department of benefits,” according to the report.Justice’s Bureau of Investigation, and the case will be prosecuted by the Attorney Gen-eral’s Financial Fraud and Special Prosecution Section. The investigation was initiated The current “rates are at the low-when the company from which the defendant sought a bribe alerted law enforcement. est level in a decade and are lower than rates charged in the 1970s and 1980s, as After the company exercised its right to challenge citations, the defendant allegedly long-term declining claim frequency andused an informal conference as an opportunity to solicit concrete work for his personal increasing wage levels have offset risingresidence in exchange for a reduction in citations, according to the complaint. Operat- medical costs,” the report states.ing under the assumption that the concrete work would be completed, Mr. Fazlollahithen represented Cal/OSHA at an administrative hearing where he reduced the EX-NFL PLAYER DENIEDcitations, according to the complaint. WORKERS COMP BENEFITS ications by requiring preauthorization n A former Indianapolis Colts defensive that includes “medical certification of the tackle and California resident cannot file a patient’s inability to tolerate treatment cumulative-injury workers compensation by other noncompounded medications,” claim in the state because there’s no proof according to the rules. he signed his National Football League contract while in California and he onlyARKANSAS CALIFORNIA played two games in the state during his six-year career, the California Court ofDRUG FORMULARY RATES FALL BUT REMAIN Appeals ruled in June.IMPLEMENTED HIGHEST IN THE US Larry Tripplett, who played for the Indi-n Arkansas became the latest state to n Although workers compensation insur- anapolis Colts and later for the Buffaloadopt a drug formulary to limit opioid pre- ance rates in California have dropped 22% Bills and the Seattle Seahawks, in 2009scriptions for injured workers, launching since 2014, the state still has the highest filed a claim for workers compensationnew rules for prescribing starting July 1. rates in the United States, representing benefits, alleging injury to multiple body one-fifth of the premium collected nation- parts throughout the course of his National The formulary, adopted by the Arkansas wide with only 11% of the national work- Football League career. Each of the defen-Workers’ Compensation Commission in force, according to a report released in July dant football teams and insurers denied his2017, limits opioid prescriptions to five by the Workers’ Compensation Insurance claim, according to the ruling in Larry C.days on the first fill and requires preau- Rating Bureau of California. Tripplett v. Workers’ Compensation Appealsthorization for refills. The formulary also Board, Indianapolis Colts et al., filed in Cal-poses a 90-day limit on opioids, calling for The annual report reveals the state of ifornia’s 4th District Court of Appeal, 3rdsubsequent preauthorization, documenta- the comp system in California, where the Division, in Santa Ana, California.tion on improved function and a weaning insurance commissioner has approvedplan, among other requirements. seven reductions in advisory pure premi- At issue is jurisdiction, according to the court record. Mr. Tripplett claimed that Doctors will also have to check the state’s because he was a California resident when heprescription drug monitoring program signed the contract he is entitled under Cal-database prior to prescribing opioids or ifornia law to file a comp claim in the state.benzodiazepines, anti-anxiety drugs saidto be addictive and sedative. “Although the workers compensation judge found jurisdiction was established by The formulary limits compounded med- the fact (Mr.) Tripplett’s agent had ‘nego- tiated’ his contract with Indianapolis while6 FALL 2018 WC

located in California, the (Workers’ Com- Workers’ Compensation Commission a comp benefits to a roofer severely injuredpensation Appeals Board) reversed (this notice of intent to reduce or discontinue after being hit by a drunk driver whileclaim). It suggested instead that the salient Mr. Williams’ comp benefits and initiat- walking from a bar to the hotel where hequestion in assessing whether Mr. Trip- ed a fraud investigation of his claim, court was staying for an out-of-town job.plett was ‘hired’ in California was wheth- records show.er he or his agent executed the written Jesse Atkins was employed by Hutchison,employment agreement in this state.” The During the investigation, Mr. Williams’ Kansas-based Webcon Inc. when he wascourt found little proof that the football doctor “testified at his deposition that he sent to help repair the roof of a grain elevatorplayer signed his contract in California. had reduced the plaintiff’s work hours to in Enid, Oklahoma, in June 2009. As part accommodate the plaintiff’s desire to per- of the schedule for the work crew, workers The court ruling also cited case law form his second job and that there was no stayed at the Baymont Inn in Enid, whichanalysis that “suggests (Mr.) Tripplett’s medical reason for the restriction.” There- sat across the street from another hotel thatcumulative injury likewise occurred at his after, the commissioner granted the city’s had a bar. One evening, on his way backretirement rather than during any partic- request to reduce the benefits and, after from having a drink with a co-worker, heular game — including either of the two giving him notice of its intent to do so, the was hit by a drunk driver, sustaining “severe”games he played in California. Thus, his city conducted a pre-termination hearing to injuries resulting in blindness in one eye andcumulative injury had not ‘ripened into determine whether the plaintiff’s employ- a leg amputation, according to a Kansasdisability’ when he played two games in ment should be terminated, records state. high court ruling in June in Jesse Atkins v.California.” He played 110 games in his Webcon and Kansas Building Industry Work-career and was declared 67% permanently Following his termination in late 2012, ers Compensation Fund.disabled after he retired, records state. Mr. Williams’ union then filed a grievance in line with its collective bargaining agree- Months after his injury, Mr. Atkins sub- The appeals court upheld the earlier ment claiming that the worker “had been mitted an application for a hearing withdecision that Mr. Tripplett is not entitled fired without just cause.” the Division of Workers Compensation ofto workers compensation benefits under the Kansas Department of Labor. Follow-California law. HAWAII ing a preliminary hearing, an administra- tive law judge determined that his injuriesCONNECTICUT SHARP RISE IN WORKPLACE were the result of a hazard created by the ACCIDENTS REPORTED conditions of his employment, namely hisHIGH COURT CLEARS WAY required travel to Enid. The judge orderedFOR RETALIATION CLAIM n The Hawaii State Department of Labor temporary total disability benefits and & Industrial Relations reported that the directed Webcon to pay Mr. Atkins’s med-n A New Haven, Connecticut, city worker state saw a surge in workplace incidents ical treatment. The workers compensationwho claims he was fired for filing a workers over a 20-day period in May, with fatali- board affirmed the preliminary order.compensation claim can pursue his case ties, amputations, burns and other seriouseven though an arbitrator did not find injuries on the list. In April 2014, the administrative lawthat he was wrongly terminated when the judge conducted a regular hearing, ulti-employee’s union officials pursued a sepa- From May 2-21, the state saw four fatal- mately concluding travel was an intrinsicrate complaint, the Connecticut Supreme ities and seven serious injuries that the part of his job and that he “was injured asCourt ruled in July. Hawaii Occupational Safety & Health the result of traveling to Enid to complete Division is investigating. a work-related errand.” But the board Simon Williams was employed in the reversed the finding, disagreeing that travelcity’s refuse department from 1993 until KANSAS was intrinsic to Mr. Atkins’s work.his employment was terminated in 2012following a neck, shoulder and back injury COURT DENIES CLAIM The Kansas Court of Appeals affirmedin early 2011 that caused him to be out BY ROOFER HIT BY DRIVER that decision, stating Mr. Atkins’ injuriesof work for more than a year, according did not “arise out of or in the course of histo documents in Simon Williams v. City of n The Supreme Court of Kansas affirmed employment.”New Haven et al. a lower court’s decision to deny workers MAINE Mr. Williams was assigned to light duty,which he claimed came with hours that EMPLOYER NOT OBLIGATEDinterfered with his second job, which his TO PAY FOR MEDICAL POTdoctor testified was unnecessary as hecould fully function in his normal duties. n Addressing for the first time the inter-The city subsequently filed with the state section of Maine’s state laws that per- WC FALL 2018 7

STATE-BY-STATE WORKERS COMPENSATION NEWS FROM ACROSS THE USmit medical marijuana and federal law Township, the worker has “a documented n A bill that would reinstate impairmentthat deems cannabis illegal, the Maine medical need” for medical marijuana. Mr. ratings in Pennsylvania passed the HouseSupreme Judicial Court ruled in June that McNeary, whose injuries and vocation in June and is being considered by a statean employer does not have to pay for the were not identified in court documents, Senate committee on labor and industry.medical marijuana a man testified had expressed concern that he might becomebeen helping him with severe chronic back addicted to opioids if he did not receive The move comes nearly a year after thepain stemming from a workplace injury. medical marijuana. It was the concern Pennsylvania Supreme Court deemed that spurred the judge to rule in his favor, unconstitutional impairment ratings, Paper machine laborer Gaetan H. Bour- according to the transcript. which have historically helped employ-goin is on total disability as a result of an ers and workers compensation insurersinjury suffered at work in 1989. Part of OHIO deem whether a worker is partially orhis treatment included consultations with fully disabled based on guidelines set“a number of pain management special- DEFUNCT TEMP AGENCY forth in the American Medical Associa-ists” who offered a variety of treatments, MUST PAY COMP INSURANCE tion Guides to the Evaluation of Perma-including opioid medications, according to nent Impairment.documents in Gaetan H. Bourgoin v. Twin n The Supreme Court of Ohio ruled inRivers Paper Co. L.L.C. et al. June that a temporary employment agency The latest push to bring back impair- will have to pay its former workers comp ment ratings comes in the form of H.B. Due to adverse side effects of his con- insurer about $3.5 million in unpaid pre- 1850, which would reinstate the 104-weektinued use of opioids, and on the recom- mium it owed after closing up shop but permanent disability marker for when anmendation of his primary care physician, continuing operations under the name of insurer can request an impairment ratingMr. Bourgoin stopped using narcotic med- another temp agency it owned. evaluation and assign the latest draft ofications and in January 2012 obtained a the AMA guide, the sixth edition, as themedical marijuana certification. The ruling names Ryan Mason as the prescribed guide. The proposal also sets owner of both Daily Services, a temp guidelines for impairment: 35% impaired Mr. Bourgoin successfully petitioned the agency that provides short-term or daily or greater equals permanent disability,state’s Workers’ Compensation Board for staffing, and I-Force, another temp agency 35% or lower is partial disability.an order requiring his former employer that focuses on long-term staffing. Bothto pay for the medical marijuana, which are based in Columbus, Ohio, according The bill would also limit an injuredbecame legal in Maine in 2009. The case to documents in State ex rel. Daily Services worker’s partial disability rating after 500came before Maine’s highest court on L.L.C. v. Morrison. weeks, giving insurers an opportunity toappeal from the decision of the Appellate seek a medical evaluation based on theDivision affirming that award. June’s rul- The ruling, which reversed an earli- current AMA guide.ing vacated that decision, stating that fed- er Court of Appeals ruling vacating theeral law that prohibits the use of marijuana bureau’s position that it is owed money, TEXAScomes before state law. confirmed “BWC’s decision to declare Daily Services liable for I-Force’s obliga- FIRST FEMALE COMPNEW JERSEY tions is justified by the BWC’s fiduciary COMMISSIONER APPOINTED duty to protect the state insurance fund.”EMPLOYER MUST PAY n Gov. Greg Abbott in June appointedMEDICAL POT COSTS PENNSYLVANIA Cassie Brown as commissioner of Work- ers’ Compensation at the Texas Depart-n A New Jersey Division of Workers’ BILL COULD REINSTATE ment of Insurance, the first female to holdCompensation judge has ordered Freehold IMPAIRMENT RATINGS this role.Township to pay for a municipal worker’smedical marijuana following a workplace Ms. Brown is deputy commissioner forinjury, according to court transcripts. regulatory policy at the Texas Department of Insurance, where she has served since Judge Lionel Simon noted that he is 2011, according to an announcement onaware of the federal law prohibiting the use the governor’s website. She replaces Ryanof marijuana, a Schedule I drug, but that Brannon, who left his post in May.in the case of Steven McNeary v. Freehold8 FALL 2018 WC

STATE PROFILEWest Virginia UPDATESWest Virginia’s highest court released a batch of workers compensation cases DATE OF INJURYin May, affirming a review board’s decisions in a number of rulings published onMay 29. Among them, the state Supreme Court of Appeals affirmed the Board In Asplundh Tree Expert Co. v.of Review’s decision to modify the date of an injury not initially reported as a John Lafon, the West Virginiacomp claim and therefore outside the six-month window to file the claim in the Supreme Court of Appealsstate. In another case, the review board affirmed the denial of a dentist’s claim affirmed the Board of Review’sfor additional medical treatment for an injury. Additionally, the court affirmed decision to modify the date ofdisability benefits and firefighter dependent benefits for claimants. an injury and remand the case to the claims administrator withINSURER PERFORMANCE CIVILIAN instructions to assess the merits LABOR FORCE of the compensability of theDirect written premiums for West Virginia workers comp coverage fell claim. “The medical record inagain in 2017, contributing to a total decline of $115.1 million since 2012. 688,530 this appeal demonstrates thatThe combined ratio improved for insurers operating in the state in 2014 the self-insured employer hadand again in 2015, but worsened in 2016. (May 2017) actual knowledge of Mr. Lafon’s injury and the informationInsurer premiums Combined ratio POPULATION necessary to proceed with a workers compensation claim,”$374M $337.5M $318.5M $323.1M $262.3M $258.9M 1.8 the Supreme Court said.86.0% 86.1% 78.0% 72.9% 76.6% million (2017) MEDICAL CLAIM DENIAL2012 2013 2014 2015 2016 2017 COMPANIES In Kelly E. Heal-Ortiz v. Drs.Source: National Council on Compensation Insurance Ortiz and Heal-Ortiz, the 36,607 Supreme Court affirmed theESTIMATED AVERAGE COST review board’s own affirmationPER INDEMNITY CLAIM (2016) of a claims administrator’s denial of a request for additional Indemnity cost Medical cost* AREA medical treatment. Diagnosed with right carpal tunnel $13,300 $14,900 $15,900 $15,000 $16,100 24,038 syndrome and taken off work for several weeks, Dr. Heal-Ortiz’s$12,700 square miles claim was originally denied by the claims administrator, $19,300 $18,000 $19,000 $17,600 $20,100 GROSS STATE but ruled compensable for a PRODUCT CHANGE herniated disc in August 2010.$14,600 The claims administrator denied 2.6% the request for additional 2010 2011 2012 2013 2014 2015 medical treatment on April 8, (2017) 2016, as Ms. Heal-Ortiz had* Excludes medical-only claims GOVERNMENT not had significant medicalSource: National Council on Compensation Insurance 16% STATE RANK FOR treatment in the past five years. HIGHEST COMPLARGEST INDUSTRIES EDUCATIONAL PREMIUM RATES DEPENDENT BENEFITS SERVICES, ALL OTHERS 48th In McMechen Volunteer Fire 41% HEALTH CARE Department Inc. v. Jeannette & SOCIAL (2016) Rose, the Supreme CourtPROFESSIONAL affirmed dependent benefits & BUSINESS ASSISTANCE for Ms. Rose, the widow of SERVICES 10% Garry Rose, a firefighter and 7% emergency medical technician, FINANCE, who died in February 2015. MINING, INSURANCE, Mr. Rose, 67, was on the job QUARRYING, REAL ESTATE, when he brought a patient to OIL & GAS the emergency room. While EXTRACTION RENTAL & there, he collapsed and died LEASING of cardiac arrest. A claims 13% administrator denied Ms. Rose’s 13% request for dependent benefitsSource: U.S. Bureau of Economic Analysis in March 2015 following a physician review saying the cardiac arrest was most likely caused by arrhythmia and had no relation to his employment, but the Office of Judges reversed the decision and granted dependent’s benefits. “Mr. Rose had an exceptionally strenuous EMS call immediately prior to his death, and it is just as likely as not that the physical and emotional exertion contributed to his sudden cardiac death,” the Supreme Court said in its ruling. WC FALL 2018 9

Q&A Wesley Hyatt LIBERTY MUTUAL INSURANCE AND HELMSMAN MANAGEMENT SERVICESA newly sharpened focus on QWhen you think about the key QCould you give me a fewthe injured worker and the trends in comp claims over the examples of this newer focusincreasing use of technology last three to five years, what jumps on the injured worker?to identify trends and issues out at you, and is that different fromand automate claims processes what you saw prior to that period? AThese injured workers use technologyare having a major impact on in their personal lives, so we’ve triedthe management of workers AFor brokers and buyers, seeking to introduce that in a comfortable waycompensation claims. Wesley value through managing their total into the claims process. We launchedHyatt, senior vice president, cost of risk is a trend that continues. something called SmartVideo, which reallyworkers compensation claims We have some sophisticated buyers and just augments the human connection withat Liberty Mutual Insurance Co. brokers who really want programs that their claims adjuster, but it is somethingand Helmsman Management both address helping to prevent losses up they can play on their smartphone or onServices L.L.C. in Boston, recently front and then helping to have effective their email easily, and it just walks themspoke with Deputy Editor Gloria claims management techniques to get the through what the process will look like.Gonzalez about these trends. best possible outcome for their injuredEdited excerpts follow. workers. I do think buyers continue to Another example from this past year would be with the catastrophe playbook10 FALL 2018 WC be pretty savvy in the total cost of risk in workers compensation. In the industry, mindset. But a trend that is newer that we tend to think of catastrophes and auto has emerged more prominently over or property because damage happens to the past few years … would be a newer buildings or cars. But with this focus on focus on the injured worker. Obviously, the injured worker experience, our teams the workers comp system is centered realized that with the catastrophic events around helping injured workers and their of 2017 … we have hundreds or thousands employers when they need it most. And (of injured workers) in Texas or California there’s always been a human element of or Florida where these weather events are claims handling, and empathy and care happening, and we started to realize that and compassion are important. But at their workers comp experience could be least in my opinion, sometimes in the impacted. If they couldn’t receive paper industry that hasn’t been in focus enough. checks because mail was interrupted in their area, that was an issue for their lives. If they couldn’t go to the pharmacy and pick up their prescriptions, that was a big issue. And so the catastrophe playbook for us really focused on those two elements. Let’s expedite the process to get people electronic funds. We tend to go through a lot of steps. Insurance is highly regulated, and we were able to work with our legal teams and break down some of the barriers to quickly get people on electronic funds transfer so they’re not waiting for paper checks via mail when we know mail is going to be interrupted in their areas. We were able to do something similar with pharmacy delivery and even sometimes coordinating care. We had one

example where (for) a badly burned injured adjusters on when opioids are appropriate, but it’s the right thing for injured workers.worker we actually had to coordinate what it means to me is that our adjustershim and his family leaving the area. They and our nurses are going to get more QTell me about technology andlost power and he just couldn’t continue proactively engaged or get alerts when a how it’s having an impacthis treatment, and so we got him to a prescription is inappropriate, and have an on claims management?different state to continue treatment. opportunity to talk to the provider and talk to the injured worker and see really what’s AWe’re always looking for ways toQWhat lessons did you take away going on, and see if we can’t suggest harness new technology and speed from last year’s catastrophes something different or better. We don’t things up for our own folks, for the injuredthat perhaps you could apply from a think opioids are typically the first-line workers, and just to make things simplerclaims perspective going forward? therapy, so we try to work with providers and more like our everyday lives. I firmly to establish time frames and goals for believe that there are so many elementsAFirst of all, proactive outreach. pain and function. Opioids are sometimes of the claim handling process that are so Hurricanes — we often know that appropriate, no doubt, but we need to human and do require empathy and that wethey’re coming. Next time we will have be talking about what do we need to see will never automate. For us, how can youadjusters and nurses, and not just in as far as pain reduction and increase in eliminate tasks that are not valued-addedTexas, but we’ll bring in adjusters from function for that injured worker? When and don’t require a human connectionthe rest of the country and have a list of are we going to go be ending the opioid so that we can reinvest people’s timeinjured workers who live in those areas prescription? Having those conversations in the things that really do require thatand proactively call them and just talk with the providers is pretty meaningful. human connection? We’ve implementedto them and say: “What’s going on? Are We’ve seen a 9% reduction in patients some new technology to reduce the timeyou evacuating? Or do you have any with opioids since we’ve implemented required for a piece of our claim intakeconcerns? Do you think your mail is going the CDC guidelines. And when we look at process. Automation of this very smallto get interrupted?” We started that, but our total prescription drug spend, opioids piece of the process took it from fournow we actually have a system where are down 12% as a percentage of the hours to a few minutes. Robotic processwe’ll start that earlier and we’ll do that overall spend. If this were three, four, automation is an area that’s definitelymore regularly when storms are coming. five years ago, all those numbers were on attractive to us. We want to look for more the incline, and to see them coming down tasks that have to be done but they’re And then the other lesson learned is is a positive. Not only is it good from an not value-added, so that we can reinvestI honestly think our electronic funds outcome and total cost of risk perspective, people’s time into meaningful tasks.transfer process was too slow, andsome of the walls we broke down out of PMS We help employers and insurersnecessity we’re going to keep down to ® settle workers’ compensationget people electronic funds faster versus claims quickly, regardless ofrelying on paper mail, which is obviously complexity.fairly outdated but how people in workerscomp still tend to get paid. We’re trying Offices Nationwideto expedite that payment process.Small things but big impact, I think. TEAMARCADIA.COMQWhat impact are you seeing from 800-354-4098 the opioids epidemic from a claimsperspective, and what actions are being WC FALL 2018 11taken to try to mitigate the impact?AFewer people are receiving opioids. The opioids spend as a percent of thewhole is on the decline. We feel goodabout the direction we’re headed. Onething that we did at Liberty was with the(U.S. Centers for Disease Control andPrevention) publishing opioid prescriptionguidelines … we incorporated thoseguidelines into our pharmacy benefitstrategy. Now that we have thoseguidelines in place and we’ve trained our

RISK MATTERSThe ins and outs of workers compcan trip up even the bestmedical professionalsBY LANCE J. EWING“ I am a professional and I can help.” All third-party administrators play an integral every four workers comp injuries is treat- of us have heard those words, and in role in the workers comp system and other ed by a primary care doctor. Many of these most cases they ring true. Profession- nuances in the process. physicians are not aware that in certainals who are skilled in their craft help those states the injured employee can pick fromwho need their services and who rely on Treating medical professionals in the a panel of treating physicians. In othertheir expertise. In workers compensation workers comp arena can include, but states, the choice of workers compensa-claims, however, that is not always the are not limited to, general practitioners, tion treating physician is solely up to thecircumstance. ophthalmologists, osteopathic specialists, employee. In some instances, the employ- podiatrists, psychiatrists and chiropractors. er or the insurer can’t speak to the doctor, The medical professionals who treat Many of these medical professionals need except to request records.injured workers almost always provide education about the workers comp system.their services with proficiency and integ- In certain states, a risk manager orrity and follow the Hippocratic Oath. Yet One of the major players, if not the workers comp claim leader can contactat times, through no fault of their own, major participant on the stage in any the treating physician and inquire aboutthese professionals do not fully under- workers comp claim, is the primary care the injured employee’s medical treatmentstand their own state workers comp rules physician or family doctor. One out ofor get to know the company the employeeworks for. The injured employee is scared,in pain and confused about medical pay-ments and the entire workers comp pro-cess. They look to their doctor to helpthem. As risk professionals, our role isto assist and educate not only the injuredemployee but the doctor as well. When going through medical school,physicians are only occasionally taughtabout workers comp treatments, return-to-work programs, how to interface withemployers for injured employees, howWhen going through medicalschool, physicians are onlyoccasionally taught aboutworkers comp treatments (and)return-to-work programs.12 FALL 2018 WC

plan, restrictions, the length of medical Educating and fostering a communications relationship with thetreatment, type of treatment and return to treating physician or medical provider is paramount in smoothing thework. In many cases, however, risk profes- workers comp claims process.sionals do not exercise those rights to helpeducate the treating medical professional. claims staff, insurance carrier, etc. unteer opportunities in the program andKeeping the doctors informed as to what n Determine if the physician has elec- union matters as it relates to the program,they can expect related to communication tronic technology so workers can access as well as the timeline and action plans towill help in developing a relationship. clinicians via their cellphone or laptop get the employee back to their prior inju-Some other recommendations when it computer for occupational injuries. ry job. Open and honest communicationcomes to working closely with workers with the treating doctor and the employercomp physicians are: If your company or organization uses about return to work is of benefit to all then Set up a lunch-and-learn either in the a dedicated work injury clinic or has an parties involved.doctor’s office or at your facility. Such an on-site medical injury professional, theoffer demonstrates your goal to help edu- above can still apply. Educating and fos- The first step to a successful resolutioncate physicians about your company, your tering a communications relationship of a workers comp injury is assuring thephilosophy in treating injured workers with the treating physician or medical treating medical professional, the injuredand your employees. Alternatively, work provider is paramount in smoothing the employee and your company are on thewith hospitals or medical facilities and workers comp claims process. same channel. Educating your companyoffer a learning seminar for physicians on workforce on workers comp is only theworkers comp. One major area for educating physicians first step in the process. Assuring then Ask the doctor to share any recom- is on return-to-work programs, which treating physician, rehabilitation specialistmendations when it comes to injured almost all employers have in place for or other medical professional is educat-employees and how you can improve the their injured employees. Communicat- ed is a major ingredient in the recipe fordoctor-company relationship. ing with the treating physician about the workers comp success.n Prepare and send the worker’s job program should include candid discus-description — with the entire physical sions on employee expectations, company Lance Ewing is executive vice presidentskills essential of the preinjury work that expectations, transition from healing to for global risk management anda worker was involved in — to the doctor return to work, psychological transition client services at Cotton Holdings Inc.or doctors. to return to the workplace, working from in Katy, Texas. He can be reached atn Provide a video or live stream of home in a return-to-work program, vol- [email protected] employee carrying out the injuredemployee’s same job to the doctor forassessment. The physician will then havea visual of what the restrictions could orcould not be for the injured employee.Check with legal counsel before sending.n Draft, approve and implement a list oftemporary modified-work jobs availablefor injured employees to return to, whichis approved by the physician ahead of timen Stay in communication with the treat-ing physician by requiring that the injuredworker provide the doctor’s writtenrestrictions for the temporary modifiedwork. Follow up after each visit via emailto get an update.n Ask the treating physician to visit yourcompany to show them your work envi-ronment, required physical skills for eachjob, emergency response in the event of aninjury and the modified-work positions.n Notify the treating physician of anymajor changes to the workforce, such asnew product lines, new machines, train-ing and other material changes in theworkplace.n Specifically inform the physician aboutwhom to contact for invoicing and pay-ment issues, such as a TPA, in-house WC FALL 2018 13

SOCIALEXPMOEDSIUA REFacebook, other platforms offer evidence for comp fraud cases, but privacy rights may trip up overzealous investigators BY LOUISE ESOLAF [email protected] riending a claimant on social media is the new peeking over the fence when it comes to investigating suspected fraud in the work- ers compensation system. In an online social setting where one can have hundreds of “friends,” the question raised when it comes to scouring social media for workers comp fraud is how close can an investigator get? “That’s a hard question because I don’t fraud investigation is too good an opportu-think there’s any bright line on what someone nity to ignore, experts say.can do and what they can’t do,” said LorraineD’Angelo, a New York-based attorney and “I just think back on how much stuff wepresident of LDA Compliance Consulting were missing by not having social media,”Inc., a legal and regulatory compliance and said Scott Catron, a 20-year private inves-risk advisory firm specializing in corporate tigator and co-founder of King of Prussia,ethics and compliance. “There is not much Pennsylvania-based Social Detection Inc.out there (in law) that tells an employer whatthey can and can’t do.” Workers trying to defraud the workers compensation system by collecting inju- But using social media to jump-start a ry benefits while engaging in physically demanding tasks such as lifting weights,14 FALL 2018 WC

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playing football and painting their houses quickly becoming aware that what they “Ninety-five percent of investigationis not a new phenomenon, but spotting post could be used against them, with agencies... they are looking for tips onfraud is easier than ever, thanks to social plaintiffs attorneys forbidding their cli- social media,” said Joseph Jones, Riverside,media, experts say. ents to maintain or post to social media California-based private investigator and as a first-line defense to keep investigators vice president of Bosco Legal Services Inc. “We’re more surprised each day; it’s at bay, experts say. But the trend of usingamazing what people try to do,” said Mr. social media to investigate the validity of I just think back on how muchCatron. comp claims continues to grow, they say. stuff we were missing by not having social media ... We’re This is despite the fact that people are more surprised each day; it’s amazing what people try to do. Scott Catron, Social Detection Inc.FORGOTTEN PROFILES, HIDDEN GEMS Social media is typically step one in investigating fraud, according to investi-S ocial media investigators are Investigators can go from there, he said. gators who say they take the tips from a successfully rooting out workers “We found someone who was doing Facebook page or other social media sitecompensation fraud by uncovering and then surveil the person’s activities. Inpublicly available information such a bike ride on every first Friday (of a little more than a week, it’s likely theas a worker’s old accounts or their the month) on their Myspace page injured worker can be spotted engagingfriends and families’ public posts. from five years ago,” he said. “So in the activity they posted about, said Mr. we surveilled a first Friday bike ride Jones, who estimates that the business Software is available that can dig up and we found him riding his bike.” model of using social media to investigateold or hidden screen names, linking them fraud has seen a 700% growth in the pastto email accounts and phone numbers, Friends and family, whose privacy three years.and then the activities and interests settings might be looser and whoserve as tips, according to investigators. enjoy the same activities, are another Claims examiners and employers are source of tips, said Joseph Jones, generally the ones to first spot the red Most of what is out there is public Riverside, California-based private flags, said Stacey Gunn, Torrance, Califor-information: free to see and free to investigator and vice president nia-based assistant vice president of inte-use, thus avoiding some of the legal of Bosco Legal Services Inc. grated third-party administrator operationsconcerns, said Scott Catron, co-founder and special investigation unit for Keenanof King of Prussia, Pennsylvania- “Friends and family are a gold mine,” & Associates, a unit of AssuredPartnersbased Social Detection Inc. he said. “Even if (the injured worker Inc. “We are always getting emails (saying is) trying to be careful on social a claimant) has a Facebook page and they As an example, Mr. Catron points to media, their friends and family are not. are doing this and that,” she said.old accounts on social media — the ones That’s a big piece of our deep dive.”people forgot they had — as a source Legal gray areasof information on a person’s interests: “Once you put it on social media, youwhere they might go, what they might do. lose control of it,” said Mr. Jones. But with the fast-paced growth of social media investigations comes the inevitable Louise Esola legal questions, attorneys say. “The stuff is out there, and if you have an open social media page, you have an open social media page,” Tim Kinsey, managing shareholder for the Orange County, Cal- ifornia, office of Stander Reubens Thom- as Kinsey P.C., said, adding that “we are16 FALL 2018 WC

precluded” from trying to get past publicly while collecting workers compensation In general, (investigators)accessible information. benefits. The false pretenses helped usher should be cautious and in a trespassing and invasion of privacy conservative. You want to make Attempting to bypass privacy walls could lawsuit against the insurer and the private sure your private investigatorput an employer or insurer at risk, he said. investigator. “Trickery or deception may can lay the foundation. be going too far,” she said. “It can be a gray area, but it’s not neces- Stephen Zralek, Bone McAllester Nortonsarily so gray depending on the state,” said An investigator using his or her realZoe Argento, a Denver-based associate in name on social media can also be prob- media information, she said. Other strictthe national workplace privacy and data lematic, experts say. states are Maryland, Michigan, Montana,security group at Littler Mendelson P.C. Nevada, New Jersey, New Mexico and Social media protection laws on the Wisconsin, she added. The big question is can an investigator books in about half of the states provide“friend” an injured worker to go beyond some guidance, Ms. Argento said. While Mr. Catron said his firm never goes pastthe privacy settings? What about if the many of the laws are narrow and do not what is public, even if there are easy meansinvestigator avoids the deceptive tactic of address fraud investigations specifically, to get behind a privacy-setting wall.setting up a fake profile and uses his or her some of them prohibit an employer fromreal name? requesting to “friend” an employee. “It is very similar to the surveillance world; it all has to be public information,” “In general, (investigators) should be “I think that to the extent that the he said.cautious and conservative,” said Stephen investigator would be (acting) as an agentZralek, Nashville, Tennessee-based part- of the employer ... in some states these That means no peeking over a fence, Ms.ner at Bone McAllester Norton P.L.L.C. laws (might) prohibit investigators from Gunn said, adding that with social media“You want to make sure your private inves- (requesting that an employee ‘friend’ it’s best to stick to the old privacy rules.tigator can lay the foundation and tell (a them),” she said.court) the steps he or she took to obtain “We don’t use drones to go into a per-that information.” Delaware, Maine, Nebraska and Ver- son’s backyard; we don’t try to access a mont, for example, explicitly prohibit an neighbor’s private property to peek over Ms. D’Angelo referred to a 2001 case, employer from requesting that an appli- walls,” she said.Karl Hawkes v. Commercial Union Insur- cant or employee add anyone as a “friend”ance Co., in Maine where an investigator to a social media account, according to Ms. WC FALL 2018 17posed as a person interested in doing busi- Argento. California prohibits requestingness with a claimant who was suspected of an employee or applicant to “divulge” socialworking in home repairs and construction

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ON OPIOIDSCUTTING BACK Efforts to reduce prescriptions of addictive painkillers are bearing fruit, but physician engagement is crucial to stemming the epidemic in the workers comp sector BY GLORIA GONZALEZ [email protected] he extensive use of opioids to pro- vide pain relief to injured workers all stakeholders in the process, but engage- remains a persistent problem in ment with and education of physicians the workers compensation sector treating injured workers is particularly as addicted employees take lon- important, experts say. ger to return to work, dragging “The opioid crisis that we’re having in the rest of society is also very prevalent in work-out claims and driving up costs. ers compensation, because so many injuredThird-party administrators, pharmacy workers are prescribed opioids and then theybenefit managers and others in the sec- develop some issues as a result of that, whichtor, however, are developing techniques to translates to claims being prolonged andaddress the problem. having larger payout amounts,” said MikeManaging comp claims with an opioids Christian, CEO of Boston-based brokerageelement requires the active participation of Risk Strategies Co. Inc. WC FALL 2018 19

STARTING EARLY programs still require physicians to input information, Mr. Ryan said.Long-term opioid use can often be traced back to the length of initial prescriptions. “If medical providers dispensing the30% 29.9% opioids are not active and aggressive in updating and putting the dispension of25% Length of Initial Opioid Prescription and 31 DAYS OR MORE the controlled substance into the data- Probability of Continued Opioid Use at One Year base, it’s not going to be that effective,” he said.20% Sedgwick has launched a smartphone15% app to help patients prepare for surgery via training and breathing exercises and 13.5% to cope with pain before they enter the post-operative phase, Dr. Bartlett said.10% The company plans to deploy the app for patients who had surgery years ago and5% 6% where the only ongoing element of the claim is their opioid prescription. 0% 8 DAYS OR MORE AT LEAST ONE DAY Legacy claims involving opioids remain a persistent challenge, experts say.Source: U.S. Centers for Disease Control and Prevention “A lot of clients who are looking for Sedgwick Claims Management Services integrated casualty consulting with Willis ways to target and address their portfo-Inc.’s data shows that if a patient is pre- Towers Watson P.L.C. in Short Hills, lio of older claims … are engaging drugscribed one fill of an opioid and they get New Jersey. Some PBMs are also doing utilization review and evaluation to see ifa second fill, the total cost of the claim “soft physician profiling” to identify fre- injured workers are getting medicationsincreases by 76%, said Dr. Teresa Bart- quent dispensers in the medical com- that are appropriate,” Mr. Ryan said,lett, Troy, Michigan-based vice president munity and “then maybe subtly go back adding that opioid dispensing at doctor’sof medical quality. If the patient receives and do some coaching and peer-to-peer offices and clinics remains another stub-a third fill, the total cost of the claim rises review,” he said. born challenge because “there’s no line ofan additional 39%. vision to the PBM or the TPA to know Technology can also be useful in mit- that’s been dispensed.” There has been a shift away from the igating the effect of opioids on injured“blank check mentality” of opioid pre- workers and comp claims, but the partic- The medical community is a “challeng-scriptions, with some PBMs and TPAs ipation of doctors is critical to ensuring ing population” to educate when it comestaking a holistic approach, including the effectiveness of some of these tools, to overprescribing of opioids, but oneexamining the underlying diagnosis, eval- experts say.uating the medical treatment, exploringalternative pain management options and For example, prescription drug moni-limiting or restricting prescription refills, toring programs are being established onsaid Thomas Ryan, senior principal for a voluntary basis by companies or on a mandatory basis in certain states, but thePeople are staying on theworkers comp systemfar longer than they needto because the opioidsdon’t correct a problem.They only mask it.Eric Farber,Farber & Co., and founderof the Pacific Workers’Compensation Law Center20 FALL 2018 WC

effective method has been for physicians STATE FORMULARIES MAKE HEADWAYworking for pharmacy benefit manag- IN REDUCING OPIOID DISPENSINGers to reach out to the doctors treatinginjured workers, Mr. Ryan said. W orkers compensation claims stakeholders are carefully watching the influx of regulatory restrictions on opioid prescribing. “There might be a situation where The regulatory environment “has become much more prevalent for us,” withthey’re just overwhelmed with patient the opioids epidemic gaining attention in statehouses and in Congress, said Gregload and they might not be sensitive to McKenna, Itasca, Illinois-based vice president and counsel for governmental affairs atthe fact that they are dispensing opioids a Gallagher Bassett Services Inc.little too aggressively,” he said. State formularies, including the one that took effect in California on Jan. 1, have But there is concern among lawyers been a positive step, experts say. The utilization review approval rate for opioids forrepresenting injured workers that inter- injured workers in California has declined 3.5% since the state’s prescription drugactions with doctors goes too far, with formulary took effect, according to a preliminary analysis by the California Workers’insurers, third-party administrators and Compensation Institute released in July.pharmacy benefit managers denying legit-imate opioid prescriptions. “California has been very progressive in identifying ways they can manage the dispension of opioids,” said Thomas Ryan, senior principal for integrated casualty “What we’ve really seen is the constant consulting with Willis Towers Watson P.L.C. in Short Hills, New Jersey.and increased denials of real treatmentand care by the insurance companies Legislators and regulators in about 30 states have limited the number of pills or daysthrough the process has left doctors with for first prescriptions, while some states are engaging in “closer and closer controlsno choice other than to prescribe opi- over physician dispensing,” Mr. McKenna said.oids for pain,” said Eric Farber, CEO ofFarber & Co. and founder of the Pacific “This is an area of legislative and regulatory change that is happening very quickly,Workers’ Compensation Law Center in and it’s our job to keep tabs on those kinds of changes and then ultimately help ourOakland, California. “The treatment of resolution managers inform their claims practices by adhering to new and emergingthe patients does not lie in the hands of state laws that are geared toward eliminating, mitigating and reversing the effect ofdoctors. It lies in the hands of insurance opioids in claims,” he said.companies, which I think is wrong.” But Dr. Teresa Bartlett, Troy, Michigan-based vice president of medical quality at Mr. Farber blames insurers and their Sedgwick Claims Management Services Inc., said the company is “deeply concernedpartners in the comp system for physi- for the states where there is no regulatory concern.”cian overprescribing of opioids becauseof lingering unwillingness to pay for basic “I wish that the medical community would educate physicians and regulatetreatments such as MRIs, much less alter- themselves so we don’t have to pass laws to tell doctors how to practice,” she said.native therapies for pain management. Gloria Gonzalez “People are staying on the workerscomp system far longer than they need to WC FALL 2018 21because the opioids don’t correct a prob-lem,” he said. “They only mask it.” But comp sector stakeholders say thegoal is not to interfere with legitimatetreatment practices. “We’re not trying to practice medicine,but we do know every guideline avail-able, and we’re happy to quote what thebest practices are,” Dr. Bartlett said. “Wedo this truly from a point of concern forthe injured worker. It’s not a cost situ-ation at all. We know that 115 peopledie every day from (prescription) opioiduse. It doesn’t take much for someone tobe addicted, and if we can prevent thatfrom our discussions, then we want todo that.”

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MARKET INSIGHTSFINDINGTHE RIGHT FIT Selecting a TPA can be a complex process, but hiring a firm that understands your business and culture pays dividendsBY LESLIE M. BATTERSONO ne of the most important decisions for risk management professionals they need to foster continuous improvement involves choosing a third-party in loss mitigation and prevention, and better administrator that represents the alignment with their organization’s opera- best fit for their enterprise. When tional excellence initiatives. these relationships work, risk Even with the ongoing consolidation among TPAs, risk managers in all indus-managers can expect to achieve tries still have multiple options to choosesuperior results, including a reduction in the provider that’s right for them. Today,their total cost of risk and the critical support the widespread availability of performance WC FALL 2018 23

data can help risk managers differentiate tial opportunities for savings. n How much emphasis do you need toamong providers and make optimal choic- Risk managers already using a TPA place on the TPA’s technology and dataes. Along with reliance on traditional qual- management resources, such as a riskitative measures, such as cultural fit, style should fully assess the incumbent provid- management information system, or onand comfort level, the use of quantitative er’s strengths and try to pinpoint where it the TPA’s ability to interface with yourindicators can go a long way to help risk has fallen short on service delivery or in existing RMIS and other systems?managers identify programs that support meeting stated objectives. n What does your claims volume looktheir decision-making. like? Is it concentrated in specific areas of Among other key questions to consider are: the country or in certain types of opera-Risk managers already using n What types of exposures, if any, are tions, business units or product lines?a TPA should fully assess the specific to your industry?incumbent provider’s strengths n Do you have a backlog of unresolved While this list is by no means exhaustive,and try to pinpoint where it has complex and legacy claims, and how much it provides an idea of the internal prepara-fallen short on service delivery progress has there been to resolve them? tion and types of questions that should beor in meeting stated objectives. n Is your geographic footprint local, considered to develop a robust request for regional, national or international, and is proposal that not only defines the TPA’s Assessing needs and setting goals. As a it static or evolving? priorities, but places it in the context offirst step in the TPA selection process, risk n Do you have a concentration of oper- your organization’s unique needs and char-managers might conduct a careful assess- ations and employees in states with chal- acteristics.ment of their claim administration require- lenging regulatory frameworks?ments. If current and historical claims data n What are the other dynamics of your Insist on outcomes-based results.are available, conduct a thorough analysis organization? For instance, is your enter- Another key for an effective RFP isto identify biggest cost drivers and poten- prise in a rapid growth mode, either to specify that proposals include out- organically or through aggressive mergers comes-based performance criteria that24 FALL 2018 WC and acquisitions, or is it involved in a con- demonstrate quantitatively how the TPA solidation or downsizing? Is it retooling met similar objectives in the past. The idea and re-engineering major operations and is not only to have the TPA demonstrate processes? that it has been able to achieve results, but n Do you need a provider with a track to express them in terms directly relevant record of closing difficult claims or man- to your specific requirements. aging litigation? For example, based on your stated prior-

ities, results should be shown by individual Assessment by the numbers. When Inquire about their adjuster turnover ratesgeographic location or state, industry sec- all is said and done, the fees charged by and their process for replacing any adjusterstor, and type, size and duration of claim, claim service providers represent only a assigned to your account.among other targeted, translatable and small percentage of overall claim costs.carefully defined factors. Thus, in discern- That’s why it’s critical to ask for metrics Even though some attrition may being whether or not there may be a good fit on claim outcomes rather than process. unavoidable, no one wants to be in a posi-between the TPA’s capabilities and your Determine the time and cost associated tion where they constantly have to re-edu-needs, you want to get as close as possible with various types of claim closures and cate adjusters to understand their prioritiesto an apples-to-apples comparison. On the percentages over time that might apply and culture, as well as to be in position toother hand, the inability to provide quan- to your organization. Find out the aver- assume responsibility for any complex andtifiable results based on past performance age claim duration and costs, and exam- legacy claims.in areas you’ve highlighted as priorities ine these results by state, by your industryshould raise red flags about a prospective sector and any other relevant breakouts. In addition to their qualifications andrelationship with the provider. Evaluate the medical management pro- performance, you’ll need to assess whether grams for capabilities as well as the best the TPAs are a fit with your culture and Cast a wide net. In reaching out to medical outcomes for your employees. claims handling approach, and can alignpotential TPAs, risk managers frequently seamlessly with the priorities you establish.make the mistake of limiting their options Recognize that the TPAto familiar “brand” names only. While engagement process isn’t Follow up. Recognize that the TPAthere may be some comfort for those who over when you’ve finally made engagement process isn’t over whentake this approach, it may not yield pro- your selection. Be sure to you’ve finally made your selection. Be sureviders that represent the best fit with the evaluate their performance to evaluate their performance on a regu-organization’s needs and objectives. The on a regular basis. lar basis. Track their results against whatwrong choice can result in higher costs, was expected based on the metrics theypoor outcomes and, in all likelihood, the In some cases, to demonstrate expertise shared in their RFP response as well asneed to repeat the process of changing in a specific industry, TPAs have includ- the deliverables agreed to at the start ofproviders. ed a slide with the logos of the company’s the engagement. key competitors to highlight the fact that Be aware that even with well-known pro- they’ve done work in the sector. While that Choosing the right TPA starts with aviders, there may be mismatches between might appear to be impressive, it doesn’t thorough understanding of an organiza-what the risk manager defines as priorities show how effective they’ve been in these tion’s needs, the establishment of prioritiesand the TPA’s capabilities. There also may assignments. You need to go back to your and clear objectives. It calls for the prepa-be divides between the operating cultures list of criteria and ask for specific results ration of a well-thought-out and carefullyof the two organizations, industry-specif- that show how well they performed for constructed RFP. And it entails the eval-ic expertise, and tools and resources such these clients. It all comes down to demon- uation of proposals and candidates basedas risk management information systems, strating performance outcomes that line up on objective criteria, including quantifi-among other differences. with your established evaluation criteria. able performance-based outcomes, as well as qualitative aspects such as cultural fit, Determine how well the TPA’s capa- Know who will be on your team. The chemistry, confidence and comfort level.bilities and resources meet your needs. adjusters and the account management team Ultimately, by making informed decisionsInquire about the TPA’s approach to assigned to your account ultimately will based on sound and objective criteria, riskstaffing and account management. See make a big difference in your results. Know management professionals will be wellhow their geographic locations match up who they are and how much time they will positioned to get the most value from theseagainst yours. Find out about the typical spend on your claims. If you have a number critical relationships.adjuster caseload and pricing structure, of large, complex claims that require expe-as well as reserving practices. Additional rienced adjusters with established creden- Leslie M. Battersoncapabilities and practices to check include: tials, make sure that’s what you’ll be getting. is a senior claimsn Quality assurance and training consultant with Aonn Adherence to special handling instruc- Global Risk Consultingtions and has more than 30n MMSEA (Medicare, Medicaid and years of experience inSCHIP Extension Act of 2007) reporting claims management,n Litigation and subrogation management environmental healthn Managed care components and safety, loss control and risk consulting.n Data handling and reporting She can be reached at 312-381-7120 and [email protected]. WC FALL 2018 25

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MARKET INSIGHTS MANAGING DRUGSMULTIPLEInjured workers may receive several prescriptions, but polypharmacy can create serious problems BY SILVIA SACALIST he simultaneous use of multiple drugs by an individual patient is sometimes It is very important that those involved in the necessary and appropriate, but if early care of an injured worker be aware of all drugs detection and clinical intervention do being taken by the patient, both within as well as not occur, such use can complicate the outside of workers compensation, to ensure that recovery of injured workers and raise treatment for the injury can be successful and that patient safety is not compromised.costs for those paying for their care. This requires that drug reconciliation be con-Polypharmacy — the term coined for this simul- ducted at all transitions in care — from the hospi-taneous use of multiple drugs — is often inap- tal to the physician’s office and even at the claimspropriate and can lead to patient safety concerns handler’s station. This reconciliation is done toand higher overall treatment costs. It becomes a avoid drug errors associated with polypharmacyconcern when it contributes to new adverse effects, such as duplications, dosing errors or drug inter-drug and disease interactions, incorrect dosing, actions.duplication of therapy, inappropriate drug use, lack Prescribing multiple drugs may be necessary andof benefit for the patient and lack of functional rational to gain adequate control of some condi-improvement. tions — as long as all prescribers and claims pro- fessionals are familiar with the full range of drugsWhen is polypharmacy warranted? being used, prescribed or otherwise. Appropriate use of multiple drugs may include treatment forInjured workers who require certain drugs for high blood pressure, diabetes, pain, psychologicaltheir injuries may already be taking drugs for unre- conditions and seizure disorders. Polypharmacylated conditions, or they may need additional drugs may also be required when there is a need to boostfor the side effects of their injury-related drugs. the effects of another drug. WC FALL 2018 27

When does polypharmacy signs of depression. For that, his family sonal medication record. At a minimum,become risky? physician prescribed the antidepressant the patient should be asked to bring all pre- Lexapro. This is a drug duplication. While scription bottles to an appointment. The increased risk associated with taking Cymbalta is approved for use in pain man-multiple drugs at the same time is not always agement, it is also effective for treating Intervention opportunities are multi-accompanied by increased effectiveness, and the underlying depression. Lexapro use is pronged and involve all stakeholders.polypharmacy can often lead to unintended unnecessary. In this case, use of both drugs These opportunities include coordinatingconsequences, including causing adverse could result in a very serious interaction. communication and patient care betweeneffects that worsen a patient’s health, put- prescribers and the patient; ensuring theting them at risk of serious harm and even High-risk combinations: In yet anoth- patient understands his/her drug regimendeath. Downstream effects from adverse er example of potentially dangerous drug and is adherent to it; requesting compre-events can also result in delayed functional interactions, an injured worker received a hensive drug regimen reviews; educatingimprovement and return to work — a major prescription for the opioid tramadol to treat the patient about the importance of usingconcern for insurers and employers. Adverse the pain associated with the injury. Several a single pharmacy or pharmacy network;effects can cause an injured worker to expe- weeks later, the patient was not experienc- instructing the patient to request pre-rience setbacks in the trajectory of their ing adequate pain relief and developed signs scriptions from their physicians insteadrecovery, leading to unnecessary outpatient and symptoms of depression. The prescrib- of accepting drugs from them directly;visits and hospitalizations and ultimately er added an antidepressant called citalo- requesting documentation of a patient’sresulting in longer recovery times and con- pram to help treat the depression. In this progress and treatment plan from the phy-tributing to increased overall medical costs. case, the addition of the drug citalopram sician(s); working with a clinical pharmacist to the existing treatment regimen caused to conduct a comprehensive drug regimen For instance, opioid-induced consti- a serious condition called serotonin syn- review and assess appropriateness, risks andpation can double total health care costs drome to occur. Serotonin is a chemical the opportunities to optimize therapy; and dis-during the first year of opioid therapy. body produces that’s needed for nerve cells cussing alternative, nondrug therapies such and the brain to function. But too much as cognitive behavioral therapy. As a clinical leader in the workers comp serotonin causes serious symptoms such asarena, I’ve seen many case-study examples muscle rigidity, fever and seizures. Severe It is the collective responsibility of us allof polypharmacy that are ineffective or serotonin syndrome can be life-threatening. to ensure we are focused on educating theeven dangerous for the patient. Here are injured worker and driving this importantsome common examples: Identifying and addressing awareness of the dangers of simultaneous polypharmacy drug use throughout our various interac- Drugs for drugs: Some drugs are pre- tions with the injured worker.scribed to treat side effects of other drugs, Early detection and intervention ofas is the case of an injured worker taking simultaneous drug usage is critical to pre- The injured worker also has a responsibili-Oxycontin for pain and subsequently given venting serious harm and optimizing treat- ty that consists of open and honest commu-a prescription for dextroamphetamine, a ment outcomes, and claims professionals nication, providing accurate and completestimulant to help with the sedative effects have several options available to intervene information about medical concerns, pastof the opioid Oxycontin, as well as Ambien when necessary. and current illnesses, hospitalizations andto help the patient sleep — as insomnia is a drugs, as well as other health-related mat-side effect resulting from the stimulant dex- Clinical intervention is incredibly ben- ters. Taking an active role in their care andtroamphetamine. In this case, drugs con- eficial, as it can lead to simpler drug reg- following the recommended treatment plan,tinue to be added to the treatment regimen imens, increased patient safety, improved including communicating any side effectsin response to the side effects of the other patient outcomes, and reduced costs. experienced in a timely fashion, is especiallydrugs prescribed. Those involved should important to improve functional restorationre-evaluate the initial treatment with the It is important to ensure all prescribers are and achieve overall improvement in the out-opioid and change the treatment when side aware of all drugs being prescribed to their comes associated with the injury.effects begin to develop instead of contrib- patients. There are multiple effective waysuting to unnecessary polypharmacy. to gain awareness of all drugs that a patient Silvia Sacalis is the is taking: asking the patient questions, to vice president of Therapeutic duplication from multiple get a complete medical and drug history clinical services forprescribers: Another example is the dupli- as well as a list of all treating physicians, Healthesystems L.L.C.,cation of therapy from multiple prescribers. and by reviewing the patient’s complete based in Tampa,In one situation, an injured worker received medical records. Alternatively, prescribers Florida. She can bea prescription for Cymbalta prescribed by can be informed of what patients are taking reached by email atthe workers comp physician for his pain. by asking them to share their current per- [email protected] dealing with the pain and reduction inmobility, the patient began experiencing28 FALL 2018 WC

THE FORUMGetting claimants back to work MODERATOR How do you ensure that your consistency with each request. clients are putting full effort Richard Lenkov, into returning to work? LISA JURSKI: How much of the regular capital member, job can the injured worker perform, and Bryce Downey MICHELLE M. KOHUT: Most, if not are accommodations even needed? Have & Lenkov L.L.C. all, petitioners want to return to a program that is limited to a specific work as soon as possible, so we short period of time that is meant to beMr. Lenkov’s practice areas include discuss the importance of following work-hardening and rehabilitation asinsurance litigation and workers doctors’ orders. If a question arises opposed to a specific job. Determine ifcompensation, among others. With as to the proposed treatment, then limitations are permanent vs. temporary.nearly 20 years of experience, he we will help get a second opinion toserves as co-chair of the Claims and make an informed decision with the What are some red flagsLitigation Management Alliance’s physician and treatment options. indicating that a claimant mightWorkers Compensation Committee. not return to work quickly? What strategies do you employ when it is clear that your client cannot ERIC T. LANHAM: The biggest red flag return to his or her preinjury wages? is a poor attitude, whether directed to employer, doctors, adjuster, nurse case KOHUT: If a petitioner cannot return manager or simply a poor response to to his or her preinjury wages, it is being injured on the job. Certainly, an important for them to seek other individual with a spotty attendance positions within restrictions and skill record or work history is more likely set. Pretrials on this issue have been to abuse off-work status as well. beneficial in determining whether a labor market survey or vocational ZOOK: Strained employee/employer rehabilitation is warranted. relationship, employer’s business is struggling, performance issues, How do you balance the need to employee going through personal separate from a claimant who issues, additional symptoms/ cannot perform their job with the body parts are disclosed as need to engage in an interactive others resolve, and employee is process as required by the nonresponsive to communication. Americans with Disabilities Act? JURSKI: Subjective complaints CHRISTOPHER ZOOK: These are outweigh objective findings, outside difficult situations, but we must follow personal issues that interfere the interactive process. Develop and with work/life, poor attendance implement an ADA-compliant checklist. history and recent discipline issues Flowcharts are also helpful to drive preceding the work-related injury. (Employers) need to stay connected to the employee throughout the claims process. It shows the employee they are valued. Christopher Zook, Frankenmuth Insurance WC FALL 2018 29

THE FORUMWhat is the biggest challenge credible medical expert that can assess LANHAM: We are seeing morein getting employers to physical limitations and restrictions nonprofits that provide return-to-workaccommodate a claimant? and a credible vocational expert that opportunities. Second opinions on work can opine as to the appropriate loss restrictions may be necessary if theLANHAM: Convincing an employer of access or earnings potential. The treating doctor is unwilling to work withthat an employee will not reinjure credibility of these experts is crucial. the employer on return-to-work issues.themselves upon return to work. Itcertainly helps to have the physician What innovative strategies can our ZOOK: Engage co-workers,working with direct knowledge of the readers engage in for claimants family and friends to reach out tophysical demands of the employee’s job. who don’t return to work quickly? the employee, maintaining thatA good adjuster or nurse case manager connection to work and the employeecan often work as a liaison between the KOHUT: Be proactive. By having understanding the important roleemployer and physician to make sure a return-to-work program that they play at work and in the home.that both employee and employer are accommodates petitioners withconfident in the accommodated position. restrictions, the petitioner then JURSKI: Engage the employee in feels productive and is thus the discussion of what work theyZOOK: Getting employers to understand further encouraged to return to feel they could do. Let the employeethe important role they play in achieving his preinjury health. Also, having know they are a valuable asset andan optimal outcome. They need to treatment authorized on a more they are cared about. Keep in regularstay connected to the employee expedient basis would decrease contact with the employee. Let themthroughout the claims process. It the time a petitioner is off work. know how much they are missed.shows the employee they are valuedby the organization. It is something MEET THE PANELsmall but has a huge impact. Lisa Jurski is including the Women’s BarJURSKI: Thinking outside the box. No the workers Association of Illinois, where sheone wants to add to overall staffing. compensation served as president in 2013-2014.Getting them to look at reallocation program directorof workload as a team in order to for HCR ManorCare, Eric T. Lanham hasmaintain the same staffing level can a nationally based been representingbe a challenge. Changing the mindset health care provider employers andthat every claim is a scam or a way with 70,000 employees. Based insurers into get something for nothing. To view in Toledo, Ohio, Ms. Jurski and defending workerslight duty as a way to get the injured her team handle claims with a compensationworker back to work and enhance philosophy that it is not about how claims since 1993.recovery as opposed to creating light to get out of paying a claim, but Based in Kansas City, Kansas, hisduty that is designed to punish the how to assist injured workers and concentration is in handling complexinjured worker. The mindset should get them back to work and their workers comp claims, definingbe a positive instead of a negative. preinjury life as quickly as possible. the limits of workers comp and She has been in the workers employers liability policies, andWhen a claimant is clearly not going compensation claims industry for protecting the subrogation intereststo go back to his preinjury wages, almost 40 years. of employers and insurers throughouthow do you prevent a case from Missouri, Kansas and Iowa.being an expensive wage-differential Michelle M. Kohut,or permanent total award? a Chicago personal Christopher Zook injury trial lawyer, is a claims managerLANHAM: A good place to start joined the law at Frankenmuthis within the company. Even if the firm of Corboy & Insuranceclaimant is not going back to his or her Demetrio in 2004 responsible forregular job, a legitimate but different and practices in auto, personal injuryjob offer with the same employer will all areas of personal injury law protection insurancealmost always prevent a permanent total as well as in the area of workers and workers compensation. Based inaward and reduce wage-differential compensation. She is active in Frankenmuth, Michigan, he has beenclaims. If that fails, it’s critical to have a national and local associations, in the insurance industry for 17 years.30 FALL 2018 WC

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WORKERSCOMPENSATIONCOSTS CAN BEA PAIN IN YOURBOTTOM LINE. Our 350 in-house nurses help ease that pain. Their involvement in the right cases means those claims close 12% faster and at 15% lower cost.* Their expertise and communication skills improve outcomes, helping injured employees get back to work sooner and nursing your bottom line back to health. Visit helmsmantpa.com to learn more. *Internal study based on claims results as of February 2014 on claims reported Jan. 1, 2011 through Dec. 31, 2012, which compared similar claims with and without a nurse assigned. © 2018 Helmsman Management Services LLC.