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Medical Management

Telemedicine Growing But Obstacles Remain

Diverse state regulations create hurdles that are impeding broader utilization of telemedicine.
By: | January 29, 2018 • 4 min read

As Concentra moves forward with an aggressive effort to provide telemedicine services for treating  occupational injuries nationwide, it is uncovering limits imposed by existing state workers’ compensation regulations.

Those limits raise due-diligence considerations for anyone weighing the implementation of telemedicine programs providing treatments, such as first doctor visits following a workplace injury and follow-up exams.

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Telemedicine holds great promise for providing such injured-worker care and is poised to expand significantly. But an array of established workers’ comp laws and regulations are slowing its advance into some jurisdictions, said Ann Schnure, VP of Concentra Telemedicine.

In some states, laws remain silent on treating worker injuries through telemedicine. But given a strong interest in telemedicine, the potential for laws to emerge in those states must be considered. That potentially creates risks for implementing telemedicine systems before knowing what parameters such regulations could bring, she added.

“You are making a risk decision going forward in a state that says ‘we are going to make regulations, we just haven’t written them yet,’ ” said Schnure, who is passionate about telemedicine’s potential.

Concentra, a national employee healthcare provider, currently offers telemedicine occupational injury treatment in California and will soon launch those services in Illinois, Michigan, and New Mexico. It expects to add many more states to its roster after that.

Ann Schnure, vice president, Concentra Telemedicine

In attempt to spread Concentra’s workers’ comp telemedicine offerings into additional jurisdictions, Schnure is methodically discussing each state’s existing regulatory environment with their workers’ comp regulators.

Despite existing impediments, Schnure expects state laws will evolve to favor telehealth. But it could be a few years for that to occur nationwide. Meanwhile, she believes moving forward requires careful due diligence, as she has found a few states where it is not yet a good idea to implement telemedicine.

“I think telemedicine is game changer,” she said. “ But you can’t [instantly] turn the switch on. You have to really think through what you are doing and what state you are in.”

Jill Allen, president and CEO of Consumer Health Connections, said that amid recent legal and regulatory advancements, every state now allows for telemedicine.

“Telemedicine in the last year and a half has been very widespread and very accepted,” Allen said. “There is nothing saying you can’t do this in workers’ compensation. It is very favorable.”

Actual implementation of workers’ comp telemedicine systems, however, has moved slowly. But it is expected to accelerate in 2018 and into 2019, said Allen, whose company provides telehealth solutions.

“I think 2018 we are going to see a massive uptick [in workers’ comp]. The interest is enormous with payers and employers asking how do I get it implemented.” — Ann Schnure, vice president, Concentra Telemedicine

Schnure also believes 2018 will be a year of rapid growth, especially with telehealth’s expanding adoption for non-occupational health care treatment.

“It really is exploding,” Schnure said. “I think 2018 we are going to see a massive uptick [in workers’ comp]. The interest is enormous with payers and employers asking how do I get it implemented.”

While state laws may not specifically prohibit telemedicine’s application in workers’ comp there are, however, other existing regulations that can be impediments in some states, Shnure said.

Some states, for example, require a “wet signature” for documents the injured worker and treating physician must complete . An electronic signature is not allowed, defeating telemedicine’s promise of eliminating employee travel for doctor visits.

While discussing the current regulatory environment with Washington officials, as another example, Schnure said she learned that the state’s workers’ comp code requires a medical report completed by a doctor who conducted a “hands-on” physical exam.

In other states, fee schedules have yet to include modifier codes for billing telemedicine services. Does that mean such treatments will be considered “unapproved care?”

There are other areas of uncertainty. California, for instance, does not currently have regulations stipulating whether specific requirements exist when using medical provider networks and telemedicine.

Regulators in states where such ambiguities exist are often helpful and will provide advice on what they think eventual regulations may say. But that is not the same as having regulations in hand.

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New regulations, meanwhile, may emerge in other areas of workers’ comp telehealth services.

So far, most states have been silent on the application of physical therapy services known as Telerehab, said Mary O’Donoghue, chief clinical and product officer at MedRisk, which offers the services nationwide, but currently provides them in six states.

Few limitations for telerehab’s application for workers’ comp treatments exist. But regulatory rigor will likely follow an increased used in the services, O’Donoghue added.

“I think over time that will change,” she said. “As the volume increases I think there will be more regulations making sure there are certain things in place, like making sure you have HIPAA-compliant technology.”

That assessment, though, implies that the telerehab use will expand. &

Roberto Ceniceros is senior editor at Risk & Insurance® and chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at [email protected] Read more of his columns and features.

More from Risk & Insurance

More from Risk & Insurance

High Net Worth

High Net Worth Clients Live in CAT Zones. Here’s What Their Resiliency Plan Should Include

Having a resiliency plan and practicing it can make all the difference in a disaster.
By: | September 14, 2018 • 7 min read

Packed with state-of-the-art electronics, priceless collections and high-end furnishings, and situated in scenic, often remote locations, the dwellings of high net worth individuals and families pose particular challenges when it comes to disaster resiliency. But help is on the way.

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Armed with loss data, innovative new programs, technological advances, and a growing army of niche service-providers aimed at addressing an astonishingly diverse set of risks, insurers are increasingly determined to not just insure against their high net worth clients’ losses, but to prevent them.

Insurers have long been proactive in risk mitigation, but increasingly, after the recent surge in wildfire and storm losses, insureds are now, too.

“Before, insurance was considered the only step in risk management. Now, our client families realize it is one of the many imperative steps in an effective risk management strategy,” said Laura Sherman, founding partner at Baldwin Krystyn Sherman Partners.

And especially in the high net worth space, preventing that loss is vastly preferable to a payout, for insurers and insureds alike.

“If insurers can preserve even one house that’s 10 or 20 or 40 million dollars … whatever they have spent in a year is money well spent. Plus they’ve saved this important asset for the client,” said Bruce Gendelman, chairman and founder Bruce Gendelman Insurance Services.

High Net Worth Vulnerabilities

Laura Sherman, founding partner, Baldwin Krystyn Sherman Partners

As the number and size of luxury homes built in vulnerable areas has increased, so has the frequency and magnitude of extreme weather events, including hurricanes, harsh cold and winter storms, and wildfires.

“There is a growing desire to inhabit this riskier terrain,” said Jason Metzger, SVP Risk Management, PURE group of insurance companies. “In the western states alone, a little over a million homes are highly vulnerable to wildfires because of their proximity to forests that are fuller of fuel than they have been in years past.”

Such homes are often filled with expensive artwork and collections, from fine wine to rare books to couture to automobiles, each presenting unique challenges. The homes themselves present other vulnerabilities.

“Larger, more sophisticated homes are bristling with more technology than ever,” said Stephen Poux, SVP and head of Risk Management Services and Loss Prevention for AIG’s Private Client Group.

“A lightning strike can trash every electronic in the home.”

Niche Service Providers

A variety of niche service providers are stepping forward to help.

Secure facilities provide hurricane-proof, wildfire-proof off-site storage for artwork, antiques, and all manner of collectibles for seasonal or rotating storage, as well as ahead of impending disasters.

Other companies help manage such collections — a substantial challenge anytime, but especially during a crisis.

“Knowing where it is, is a huge part of mitigating the risk,” said Eric Kahan, founder of Collector Systems, a cloud-based collection management company that allows collectors to monitor their collections during loans to museums, transit between homes, or evacuation to secure storage.

“Before, insurance was considered the only step in risk management. Now, our client families realize it is one of the many imperative steps in an effective risk management strategy.” — Laura Sherman, founding partner, Baldwin Krystyn Sherman Partners

Insurers also employ specialists in-house. AIG employs four art curators who advise clients on how to protect and preserve their art collections.

Perhaps the best known and most striking example of this kind of direct insurer involvement are the fire teams insurers retain or employ to monitor fires and even spray retardant or water on threatened properties.

High-Level Service for High Net Worth

All high net worth carriers have programs that leverage expertise, loss data, and relationships with vendors to help clients avoid and recover from losses, employing the highest levels of customer service to accomplish this as unobtrusively as possible.

“What allows you to do your job best is when you develop that relationship with a client, where it’s the same people that are interacting with them on every front for their risk management,” said Steve Bitterman, chief risk services officer for Vault Insurance.

Site visits are an essential first step, allowing insurers to assess risks, make recommendations to reduce them, and establish plans in the event of a disaster.

“When you’re in a catastrophic situation, it’s high stress, time is of the essence, and people forget things,” said Sherman. “Having a written plan in place is paramount to success.”

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Another important component is knowing who will execute that plan in homes that are often unoccupied.

Domestic staff may lack the knowledge or authority to protect the homeowner’s assets, and during a disaster may be distracted dealing with threats to their own homes and families. Adequate planning includes ensuring that whoever is responsible has the training and authority to execute the plan.

Evaluating New Technology

Insurers use technologies like GPS and satellite imagery to determine which homes are directly threatened by storms or wildfires. They also assess and vet technologies that can be implemented by homeowners, from impact glass to alarm and monitoring systems, to more obscure but potentially more important options.

AIG’s Poux recommends two types of vents that mitigate important, and unexpected risks.

“There’s a fantastic technology called Smart Vent, which allows water to flow in and out of the foundation,” Poux said. “… The weight of water outside a foundation can push a foundation wall in. If you equalize that water inside and out at the same level, you negate that.”

Another wildfire risk — embers getting sucked into the attic — is, according to Poux, “typically the greatest cause of the destruction of homes.” But, he said, “Special ember-resisting venting, like Brandguard Vents, can remove that exposure altogether.”

Building Smart

Many disaster resiliency technologies can be applied at any time, but often the cost is fractional if implemented during initial construction. AIG’s Smart Build is a free program for new or remodeled homes that evolved out of AIG’s construction insurance programs.

Previously available only to homes valued at $5 million and up, Smart Build recently expanded to include homes of $1 million and up. Roughly 100 homes are enrolled, with an average value of $13 million.

“In the high net worth space, sometimes it takes longer potentially to recover, simply because there are limited contractors available to do specialty work.” — Curt Goetsch, head of underwriting, Private Client Group, Ironshore

“We know what goes wrong in high net worth homes,” said Poux, citing AIG’s decades of loss data.

“We’re incenting our client and by proxy their builder, their architects and their broker, to give us a seat at the design table. … That enables us to help tweak the architectural plans in ways that are very easy to do with a pencil, as opposed to after a home is built.”

Poux cites a remote ranch property in Texas.

Curt Goetsch, head of underwriting, Private Client Group, Ironshore

“The client was rebuilding a home but also installing new roads and grading and driveways. … The property was very far from the fire department and there wasn’t any available water on the property.”

Poux’s team was able to recommend underground water storage tanks, something that would have been prohibitively expensive after construction.

“But if the ground is open and you’ve got heavy equipment, it’s a relatively minor additional expense.”

Homes that graduate from the Smart Build program may be eligible for preferred pricing due to their added resilience, Poux said.

Recovery from Loss

A major component of disaster resiliency is still recovery from loss, and preparation is key to the prompt service expected by homeowners paying six- or seven-figure premiums.

Before Irma, PURE sent contact information for pre-assigned claim adjusters to insureds in the storm’s direct path.

“In the high net worth space, sometimes it takes longer potentially to recover, simply because there are limited contractors available to do specialty work,” said Curt Goetsch, head of underwriting for Ironshore’s Private Client Group.

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“If you’ve got custom construction or imported materials in your house, you’re not going to go down the street and just find somebody that can do that kind of work, or has those materials in stock.”

In the wake of disaster, even basic services can be scarce.

“Our claims and risk management departments have to work together in advance of the storm,” said Bitterman, “to have contractors and restoration companies and tarp and board services that are going to respond to our company’s clients, that will commit resources to us.”

And while local agents’ connections can be invaluable, Goetsch sees insurers taking more of that responsibility from the agent, to at least get the claim started.

“When there is a disaster, the agency’s staff may have to deal with personal losses,” Goetsch said. &

Jon McGoran is a novelist and magazine editor based outside of Philadelphia. He can be reached at [email protected]