Expert Perspective | Set the Tone for Successful Claims From the Very Start

Plotting out steps to recovery at the onset of a claim helps engage injured workers in their treatment and can minimize treatment delays.
By: | February 3, 2020

For every workers’ compensation injury, there are probably dozens of ways that injury could unexpectedly spiral out of control, compromising a worker’s recovery and dramatically hiking up costs.

Payers and employers strive to spot red flags and address them swiftly. But, too often, issues aren’t flagged until treatment has already been compromised.

Advertisement


That’s why strategic engagement at the beginning of a claim matters, said Melissa Burke, vice president and head of managed care and clinical at AmTrust.

Risk & Insurance® spoke with Burke about achieving best practices by engaging at the onset of a claim, managing expectations and maintaining transparency.

In your experience, what are some of the biggest obstacles that you see getting in the way of successful injury outcomes?

It starts in the beginning of the claim.

When you get injured at work, there are a lot of fears that run through your mind. Where will you get treatment? Who will pay for the treatments? Where’s your next paycheck coming from if you’re out of work?

How else does fear impact recovery?

So many of us really identify who we are by work. It’s a big part of who each person is. It’s important for an injured employee to maintain their identify as part of the workforce and being connected to their coworkers.

The unknown factors in a workplace injury can create fear. The best ways to prevent that is with information right at the beginning of a claim. If information isn’t provided early on, fear can start to take over and impact the recovery.

Many times if you end up putting a nurse on a file later in the claim, now you’re trying to unravel what it is that got them there, and we’re finding many times that there is some fear, or some unknown co-morbidity that’s been driving their chronic pain.

Had we addressed it earlier, we may have had a different outcome for that claim.

What other factors can negatively impact a claim early on?

There are a lot of traps out there for injured employees — empty promises or bad roads that a claim can go down if we don’t set them up right from the beginning. The goal is to make sure injured employees are informed and understand not only their rights but also that this is about them returning to work as soon as medically appropriate.

It’s also about setting an expectation about pain. There’s going to be certainly some pain involved, right? If you’re having an injury, you’re going to have acute pain and we’re going to manage that and work through it, but this is not who they’re going to become. They’re not an injured employee. They’re still going to get back to their life that they had prior to their injury as best they can.

We need to set expectations with the injured employee. I think the word expectations is one of the biggest lessons in managing a workers’ comp claim. Expectations will change the outcome. It’s important right from the beginning, whether it’s a catastrophic claim or a simple sprain or strain.

The more that the care team drives information to the injured employee, the better it will be as well. Information really is power. It allows the injured employee to feel that they own their claim process, they own their health care, they own their recovery.

We know based on other health care studies that the more activated and the more ownership an individual has for their wellness, the better off they’ll be. That’s why we want to drive those same concepts in workers’ compensation.

How does engaging a nurse early help set the tone for success?

Right from the beginning a nurse can be that resource for an injured employee. They can be a source of medical information, their partner in their journey to recovery, setting the expectation about what doctor will do, about how the doctor will help them, about how we’re going to return them to their prior functional ability. The nurse can set those expectations right away and work with them.

Nurses can also engage with injured employees to let us know what else could be impacting their health. Do they have other chronic conditions that we need to be aware of that may be impacting their injury or their ability to recover? We want to engage the injured employee and let them tell their story so that we can find out what else is important and how we can best support them.

A nurse can really drive the patient engagement in their own claim and help them to be active in their own health care, in their own wellness so that they can get back to work as soon as appropriate.

Can the same approach help payers keep prescriptions in check?

All of our prescriptions that require a clinical review are routed directly to nurses, When nurses look at these medications, they can assess, is this the right drug at the right dose for the right injury, at the right time, and then review that against evidence-based guidelines. We want to use the most conservative and safe treatment for an injured employee. That’s what our nurses are able to verify.

What helps injured workers to connect with nurses and to feel like they can trust the process?

In order to drive trust with any professional and an injured employee, you really need to start with transparency. Give them information, let them know what the process is so they know what to expect.

Engagement, expectations, documentation, transparency — those are all very big components to building that trust with an injured employee. Letting them know who they’ll hear from, who they’ll interact with and when they are expected to return to work based on their injury. Get their input on what happened and finding out what their needs are, so that we can address them to help them return to work.

All parties being in communication, the adjuster, the nurse, the provider, the employer — they all need to work together. The whole care team needs to work together to drive an optimal outcome.

We’ve been talking about engaging early in a claim life cycle, but what can be done before claims occur to help facilitate better outcomes, and ensure that there are no organizational barriers to getting injured employees back to work?

It’s about having the right programs available. If an injury occurs, what are the transitional or modified duty programs that you have available? We work with the employer so that we understand the job description and what’s truly involved in the job. Is it lifting 30 pounds up? Is it lifting 30 pounds up and over your head?

Advertisement


Having job descriptions ready that are clear and concise for the provider, so that they know when an injured employee is ready to return to work based on what they can do.

Being able to understand the details behind each job description can help the rest of the team, the adjuster, the nurse, the provider, all work together to identify the best way to get an injured employee back to work as soon as appropriate.

It’s also about letting employees know what to do ahead of time if they have an injury, who to report to, who to go to for that initial information. Having the network available so they know where to look for care.

We know that drives a difference in the outcomes — making sure that those lines of communication are open, that an injured employee isn’t fearful of reporting an injury, so that they do come to them right away. It’s about having those resources available. &

Michelle Kerr is workers' comp editor for Risk & Insurance. She can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

Risk Scenario

The Betrayal of Elizabeth

In this Risk Scenario, Risk & Insurance explores what might happen in the event a telemedicine or similar home health visit violates a patient's privacy. What consequences await when a young girl's tele visit goes viral?
By: | October 12, 2020
Risk Scenarios are created by Risk & Insurance editors along with leading industry partners. The hypothetical, yet realistic stories, showcase emerging risks that can result in significant losses if not properly addressed.

Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.

PART ONE: CRACKS IN THE FOUNDATION

Elizabeth Cunningham seemingly had it all. The daughter of two well-established professionals — her father was a personal injury attorney, her mother, also an attorney, had her own estate planning practice — she grew up in a house in Maryland horse country with lots of love and the financial security that can iron out at least some of life’s problems.

Tall, good-looking and talented, Elizabeth was moving through her junior year at the University of Pennsylvania in seemingly good order; check that, very good order, by all appearances.

Her pre-med grades were outstanding. Despite the heavy load of her course work, she’d even managed to place in the Penn Relays in the mile, in the spring of her sophomore season, in May of 2019.

But the winter of 2019/2020 brought challenges, challenges that festered below the surface, known only to her and a couple of close friends.

First came betrayal at the hands of her boyfriend, Tom, right around Thanksgiving. She saw a message pop up on his phone from Rebecca, a young woman she thought was their friend. As it turned out, Rebecca and Tom had been intimate together, and both seemed game to do it again.

Reeling, her holiday mood shattered and her relationship with Tom fractured, Elizabeth was beset by deep feelings of anxiety. As the winter gray became more dense and forbidding, the anxiety grew.

Fed up, she broke up with Tom just after Christmas. What looked like a promising start to 2020 now didn’t feel as joyous.

Right around the end of the year, she plucked a copy of her father’s New York Times from the table in his study. A budding physician, her eyes were drawn to a piece about an outbreak of a highly contagious virus in Wuhan, China.

“Sounds dreadful,” she said to herself.

Within three months, anxiety gnawed at Elizabeth daily as she sat cloistered in her family’s house in Bel Air, Maryland.

It didn’t help matters that her brother, Billy, a high school senior and a constant thorn in her side, was cloistered with her.

She felt like she was suffocating.

One night in early May, feeling shutdown and unable to bring herself to tell her parents about her true condition, Elizabeth reached out to her family physician for help.

Dr. Johnson had been Elizabeth’s doctor for a number of years and, being from a small town, Elizabeth had grown up and gone to school with Dr. Johnson’s son Evan. In fact, back in high school, Evan had asked Elizabeth out once. Not interested, Elizabeth had declined Evan’s advances and did not give this a second thought.

Dr. Johnson’s practice had recently been acquired by a Virginia-based hospital system, Medwell, so when Elizabeth called the office, she was first patched through to Medwell’s receptionist/scheduling service. Within 30 minutes, an online Telehealth consult had been arranged for her to speak directly with Dr. Johnson.

Due to the pandemic, Dr. Johnson called from the office in her home. The doctor was kind. She was practiced.

“So can you tell me what’s going on?” she said.

Elizabeth took a deep breath. She tried to fight what was happening. But she could not. Tears started streaming down her face.

“It’s just… It’s just…” she managed to stammer.

The doctor waited patiently. “It’s okay,” she said. “Just take your time.”

Elizabeth took a deep breath. “It’s like I can’t manage my own mind anymore. It’s nonstop. It won’t turn off…”

More tears streamed down her face.

Patiently, with compassion, the doctor walked Elizabeth through what she might be experiencing. The doctor recommended a follow-up with Medwell’s psychology department.

“Okay,” Elizabeth said, some semblance of relief passing through her.

Unbeknownst to Dr. Johnson, her office door had not been completely closed. During the telehealth call, Evan stopped by his mother’s office to ask her a question. Before knocking he overheard Elizabeth talking and decided to listen in.

PART TWO: BETRAYAL

As Elizabeth was finding the courage to open up to Dr. Johnson about her psychological condition, Evan was recording her with his smartphone through a crack in the doorway.

Spurred by who knows what — his attraction to her, his irritation at being rejected, the idleness of the COVID quarantine — it really didn’t matter. Evan posted his recording of Elizabeth to his Instagram feed.

#CantManageMyMind, #CrazyGirl, #HelpMeDoctorImBeautiful is just some of what followed.

Elizabeth and Evan were both well-liked and very well connected on social media. The posts, shares and reactions that followed Evan’s digital betrayal numbered in the hundreds. Each one of them a knife into the already troubled soul of Elizabeth Cunningham.

By noon of the following day, her well-connected father unleashed the dogs of war.

Rand Davis, the risk manager for the Medwell Health System, a 15-hospital health care company based in Alexandria, Virginia was just finishing lunch when he got a call from the company’s general counsel, Emily Vittorio.

“Yes?” Rand said. He and Emily were accustomed to being quick and blunt with each other. They didn’t have time for much else.

“I just picked up a notice of intent to sue from a personal injury attorney in Bel Air, Maryland. It seems his daughter was in a teleconference with one of our docs. She was experiencing anxiety, the daughter that is. The doctor’s son recorded the call and posted it to social media.”

“Great. Thanks, kid,” Rand said.

“His attorneys want to initiate a discovery dialogue on Monday,” Emily said.

It was Thursday. Rand’s dreams of slipping onto his fishing boat over the weekend evaporated, just like that. He closed his eyes and tilted his face up to the heavens.

Wasn’t it enough that he and the other members of the C-suite fought tooth and nail to keep thousands of people safe and treat them during the COVID-crisis?

He’d watched the explosion in the use of telemedicine with a mixture of awe and alarm. On the one hand, they were saving lives. On the other hand, they were opening themselves to exposures under the Health Insurance Portability and Accountability Act. He just knew it.

He and his colleagues tried to do the right thing. But what they were doing, overwhelmed as they were, was simply not enough.

PART THREE: FALLING DOMINOES

Within the space of two weeks, the torture suffered by Elizabeth Cunningham grew into a class action against Medwell.

In addition to the violation of her privacy, the investigation by Mr. Cunningham’s attorneys revealed the following:

Medwell’s telemedicine component, as needed and well-intended as it was, lacked a viable informed consent protocol.

The consultation with Elizabeth, and as it turned out, hundreds of additional patients in Maryland, Pennsylvania and West Virginia, violated telemedicine regulations in all three states.

Numerous practitioners in the system took part in teleconferences with patients in states in which they were not credentialed to provide that service.

Even if Evan hadn’t cracked open Dr. Johnson’s door and surreptitiously recorded her conversation with Elizabeth, the Medwell telehealth system was found to be insecure — yet another violation of HIPAA.

The amount sought in the class action was $100 million. In an era of social inflation, with jury awards that were once unthinkable becoming commonplace, Medwell was standing squarely in the crosshairs of a liability jury decision that was going to devour entire towers of its insurance program.

Adding another layer of certain pain to the equation was that the case would be heard in Baltimore, a jurisdiction where plaintiffs’ attorneys tended to dance out of courtrooms with millions in their pockets.

That fall, Rand sat with his broker on a call with a specialty insurer, talking about renewals of the group’s general liability, cyber and professional liability programs.

“Yeah, we were kind of hoping to keep the increases on all three at less than 25%,” the broker said breezily.

There was a long silence from the underwriters at the other end of the phone.

“To be honest, we’re borderline about being able to offer you any cover at all,” one of the lead underwriters said.

Rand just sat silently and waited for another shoe to drop.

“Well, what can you do?” the broker said, with hope draining from his voice.

The conversation that followed would propel Rand and his broker on the difficult, next to impossible path of trying to find coverage, with general liability underwriters in full retreat, professional liability underwriters looking for double digit increases and cyber underwriters asking very pointed questions about the health system’s risk management.

Elizabeth, a strong young woman with a good support network, would eventually recover from the damage done to her.

Medwell’s relationships with the insurance markets looked like it almost never would. &

Bar-Lessons-Learned---Partner's-Content-V1b

Risk & Insurance® partnered with Allied World to produce this scenario. Below are Allied World’s recommendations on how to prevent the losses presented in the scenario. This perspective is not an editorial opinion of Risk & Insurance.®.

The use of telehealth has exponentially accelerated with the advent of COVID-19. Few health care providers were prepared for this shift. Health care organizations should confirm that Telehealth coverage is included in their Medical Professional, General Liability and Cyber policies, and to what extent. Concerns around Telehealth focus on HIPAA compliance and the internal policies in place to meet the federal and state standards and best practices for privacy and quality care. As states open businesses and the crisis abates, will pre-COVID-19 telehealth policies and regulations once again be enforced?

Risk Management Considerations:

The same ethical and standard of care issues around caring for patients face-to-face in an office apply in telehealth settings:

  • maintain a strong patient-physician relationship;
  • protect patient privacy; and
  • seek the best possible outcome.

Telehealth can create challenges around “informed consent.” It is critical to inform patients of the potential benefits and risks of telehealth (including privacy and security), ensure the use of HIPAA compliant platforms and make sure there is a good level of understanding of the scope of telehealth. Providers must be aware of the regulatory and licensure requirements in the state where the patient is located, as well as those of the state in which they are licensed.

A professional and private environment should be maintained for patient privacy and confidentiality. Best practices must be in place and followed. Medical professionals who engage in telehealth should be fully trained in operating the technology. Patients must also be instructed in its use and provided instructions on what to do if there are technical difficulties.

This case study is for illustrative purposes only and is not intended to be a summary of, and does not in any way vary, the actual coverage available to a policyholder under any insurance policy. Actual coverage for specific claims will be determined by the actual policy language and will be based on the specific facts and circumstances of the claim. Consult your insurance advisors or legal counsel for guidance on your organization’s policies and coverage matters and other issues specific to your organization.

This information is provided as a general overview for agents and brokers. Coverage will be underwritten by an insurance subsidiary of Allied World Assurance Company Holdings, Ltd, a Fairfax company (“Allied World”). Such subsidiaries currently carry an A.M. Best rating of “A” (Excellent), a Moody’s rating of “A3” (Good) and a Standard & Poor’s rating of “A-” (Strong), as applicable. Coverage is offered only through licensed agents and brokers. Actual coverage may vary and is subject to policy language as issued. Coverage may not be available in all jurisdictions. Risk management services are provided or arranged through AWAC Services Company, a member company of Allied World. © 2020 Allied World Assurance Company Holdings, Ltd. All rights reserved.




Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]