When it comes to successful workers’ compensation claims management, several factors must be in place: collaboration and communication among all parties must exist and should be clear, factual and consistent; data points must be organized so that they can support actionable steps in the claims process; and a strong, strategic mitigation action plan (MAP) should be in order. 

ExamWorks, a global company offering a platform of services that impact all aspects of claim mitigation, uses its multi-pronged program to look at the lifecycle of a claim from first report of injury to settlement, with the goal of offering a strategic approach to identifying barriers to return-to-work and claims settlement. 

“Our precise methodology offers the focus, attention and support that is needed, at the desk-level, to ensure that claims progress and do not get stuck in an endless, unnecessary disability loop,” said Crystal Patmore, vice president, claims mitigation solutions at ExamWorks. 

In essence, the team uses its MAP format, leveraging the power of all available tools and resources needed to mitigate each barrier, one-by-one, until a successful resolution is achieved. 

Patmore sat down with Risk & Insurance to discuss the ins and outs of its MAP process and how workers’ comp clients can benefit from this strategic approach. 

Risk & Insurance: First, can you tell us a little more about your insurance journey?  

Crystal Patmore: I didn’t start my career in insurance, nor did I anticipate that the insurance field would be part of my journey.  Initially, I set out to be an accountant, but my career path took me to a position in human resources and risk management for ExamWorks. This opened my eyes to the employer’s role in the worker’s compensation risk and insurance process.

Next, I led ExamWorks’ case management division, where I became acutely aware of the expectations and time limitations of claims’ adjustors who had very high caseloads with too little time to focus on long-term claim management strategy.   

Ultimately, the various touchpoints in my career led me to oversee the development and expansion of our results-driven claim mitigation team. No matter where a claim is in the lifecycle, and depending on the specific claim management goal, there is an ability to develop a strategic mitigation action plan, or MAP, and provide a mitigation team with the unique specialized skills required to execute targeted solutions, acquiring the actionable leverage necessary to deliver measurable results. 

R&I: You mention a strategic mitigation action plan, or MAP. What is a MAP and what function does it serve? 

CP: When we receive a referral from a client for strategic claims mitigation, there are several questions we look to immediately answer: What is the claim goal? What is our client trying to accomplish? Is the Rx spend out of control on a legacy claim? Does our client need to set reserves but wants us to review the file for mitigation opportunities first? 

In every instance, a mitigation action plan (MAP) is what we use to develop a road map to achieve the claim goal once it has been clearly established. That means we have to zero in our client’s claim goals, because the direction we take and how we get there are dictated by what our client wants to accomplish.  

R&I: What inspired the creation of the ExamWorks’ MAP? 

CP: Too often insurance carriers/employers face costs associated with an injured worker’s comorbid, pre-existing conditions and patterns of behaviors that are exacerbating and delaying a successful return to work.   

Although a great deal of time, money and resources are spent on these claims, sometimes they just seem to get stuck. This becomes particularly evident when we work with legacy, “old dog” or creeping catastrophic claims.  

It is in the reverse engineering of these legacy claims that we are able to provide insight into what we can do to assist with moving these cases to a satisfactory resolution. But we also bring to the table tools to help our clients more proactively manage new and existing claims with the same, commonly identified unmitigated variables that are known predictors of what could lead to a creeping catastrophic claim.   

When an MSA is completed, for example, only two years of medical records are considered by CMS, but the claim itself may be much older. When we are asked to provide mitigation for an MSA, the first thing we do is focus our efforts on ensuring our claims mitigation team has the complete chronological picture of the claim so they can begin collaboration with the client to develop the MAP.    

The history matters and we often find key data points in the history that are useful in a successful mitigation strategy.    

R&I: What is the benefit of having MAP for claims management? 

CP: In order to establish a successful mitigation strategy, we must first identify the unmitigated variables that are creating barriers.  

Claims with two or more unmitigated variables, such as comorbid conditions, behavioral health issues, polypharmacy, attorney representation, patient directing care/doctor shopping and more, are more likely to have a poor outcome without strategic, targeted interventions.   

A recent example of the MAP in action was from an MSA mitigation referral. The claim originated in 2014 and the medication cost-drivers were driven by chronic opioid use. 

Upon completing our deep dive in preparation for the MAP we identified the following key data points (1) concern from previous treating providers about the injured worker’s pattern of drug seeking behavior (2) a pre-existing history of substance abuse along with documented participation in NA and AA (3) pain scores were usually 9-10/10 (4) no objective functional improvement in response to the medication therapy (5) historical drug screens noted inconsistent results that were not addressed by the treating providers (6) prescription payment history revealed irregular filling patterns for some medications and (7) we noted the historical records revealed the injured worker had a consistent pattern of changing pain management providers when he was advised the practice would no longer prescribe opioids. 

This information became the foundation for the MAP and our targeted mitigation strategy resulted in 99% savings on the pharmacy spend.  

R&I: In what ways, then, does the MAP aid the claims management team? 

CP: The MAP is intended to be a tool to help the claims management team simplify and understand the existing claim challenges.  One of my favorite quotes from a client who engaged us to put together a MAP for a legacy claim that she had just inherited is, “You just saved me months of work and even with months of work I’m not sure I could have identified all the relevant details identified by the MAP on this claim.” 

For example, if the MAP includes the need for an IME as part of the litigation strategy, considerations of the claim management team should be, (1) what is the purpose of the IME, (2) what type of specialist needs to be involved (3) specifically, what type of actionable data are they trying to secure and what will the next step be once the report is received? 

Answering these types of questions, paired with a thorough understanding of key claim data points, creates the framework to collaborate effectively and develop “next-step” action plans. The goal is to anticipate what kind of follow-through will be required, how the follow-through will be achieved and what to do next.   

R&I: Who should be involved in the process? And why is collaboration among these parties important? 

CP: We cannot emphasize strongly enough that the success of any claim mitigation program begins and ends with mutual collaboration among all stakeholders to ensure clear communication during every stage of the mitigation process, from identifying the claim management goal, developing and finalizing the MAP, to executing each targeted intervention.  

Successfully executed, targeted interventions may require the expertise of multiple vendor partners. It is very important each has a clear understanding of the claim management goals, the claim history and is engaged collaboratively in the development of targeted strategies to achieve meaningful outcomes. The path to success is paved with key data, communication, collaboration and follow through.   

R&I: Any final comments to share? 

CP: Early identification and intervention is the best practice for claims mitigation.  However, with a targeted, strategic mitigation action plan (MAP) it is never too late to change the trajectory of a claim. &