The What, How and Why of Medical Roundtables for Complex Claims

When a claim stalls, it’s time to call in medical professionals to apply fresh clinical eyes to the case at hand.
By: | December 18, 2018 • 6 min read

In workers’ compensation, there are a handful of known risk factors that signal a complex and potentially costly claim — things like invasive surgeries, opioids, and long stays in rehabilitation. But inevitably, some claims will start accumulating costs for less obvious reasons, when the treatment initially prescribed is not particularly aggressive, but a persistent lack of recovery keeps the claim open far longer than expected.

Advertisement




When a claim stalls, it’s time to call in medical professionals to apply fresh clinical eyes to the case at hand.

That was the argument made by Suzy Braden, Workers’ Compensation Claims Manager, Encompass Health and JJ Schmidt, head of analytics and innovation for York Risk, during a recent presentation on the implementation of medical roundtables for complex claims at the National Workers’ Compensation and Disability Conference in early December. They outlined the purposes, challenges, and ultimate benefits of implementing medical roundtables in addition to regular standard claims reviews.

Here are a few key takeaways:

What are medical roundtables?

Medical roundtables are version 2.0 of the standard claims review, reserved for claims that have stalled out or “jumper claims” that have the potential to devolve in high-cost complex claims. As their name implies, they focus primarily on the clinical aspects of a claim and pull in medical professionals to evaluate what needs to change in a patient’s treatment plan in order to bring a claim to close. Those professionals include physicians, pharmacists and medical case managers.

Suzy Braden, Workers’ Compensation Claims Manager, Encompass Health

“Most of us that manage workers’ comp claims aren’t medical professionals. We think we know the right treatments after seeing so many of the same injuries, but it’s helpful to get the fresh perspective of a clinician to tell us if we can do something better,” Braden said.

Unlike normal claims reviews that happen monthly and may run through dozens of claims, medical roundtables require a more intensive process and typically are done quarterly, focusing on just a handful of carefully selected claims.

How do claims get selected?

At Encompass Health, Braden and her team began by selecting claims based on drug utilization.

“For our first roundtable, we looked at morphine equivalency dose (MED). Anyone who was greater than 100 and had not recently had surgery could be a candidate for a medical roundtable,” she said.

Other candidates include claims with multiple surgeries or ones that have been open for a long period of time but have seen little activity or improvement. Schmidt said that often the claims that present the biggest issue are those that start out as medical-only but transition into lost-time payment because the injured workers has been receiving treatment but not nearing any resolution.

Advertisement




For their second medical roundtable, Encompass Health examined claims that were within their self-insured retention but had been open nearly a decade and were approaching $100,000 in medical spend.

“A couple of years ago we also started looking at jumper claims. What can we do to intervene early and prevent this claim from going south?” Braden said. “The roundtables provide a chance to see if it’s best, for example, for pay for surgery and 21 weeks of rehab now, or try a more conservative treatment first but risk prolonging the claim even further.”

How does the process work?

Medical roundtables do not focus on reserve amounts or legal jurisdictional hurdles. The sole objective is to review the medical aspect of the claim and determine what has to change in the treatment plan in order to either bring the claim to a conclusion or ensure it stays on track.

Adjusters and medical professionals typically come to the table with two distinct perspectives, with adjusters focused on the state regulations governing what care they can and cannot direct, while doctors are naturally focused only on the appropriateness of the treatment.

Adjusters may take it personally when one of their claims is called up for a medical roundtable. It’s important to reinforce to adjusters that this is not a criticism of their handling of the case.

“One thing we’ve learned is to make sure our adjusters understand the differences between a medical roundtable and a normal claim review. They have to come prepared to present all the facts of the case — what’s been done, what’s worked, and what hasn’t,” Braden said.

Adjusters may take it personally when one of their claims is called up for a medical roundtable. It’s important to reinforce to adjusters that this is not a criticism of their handling of the case.

“Know that the first one won’t be easy. You’re going to have to work the kinks out,” Braden said. “After our first roundtable, we had a debriefing and realized that there should be some education for the adjusters coming into the call. The goal is to find a better path forward, not criticize what’s already been done.”

What’s the objective?

Education is an important component of the medical roundtable, and a piece that is absent from a standard claims review. Braden said that roundtables should be treated like brainstorming sessions, and that conversations between adjusters and doctors should be allowed to run freely.

“Banter can be a good thing. It’s important to leave time for questions and not to rush the process, because it might mean missing out on some key insights from the doctor,” Braden said. “Even if it means we don’t get to all of the claims on the schedule, it’s beneficial because inevitably adjusters will come across the same injuries and the same claim challenges again in the future, and now they’ll have a better idea of how to navigate those.”

The ultimate goal, however, is to walk away from the meeting with a clear action plan in place that will either move treatment forward or find some alternative path to close the claim.

“Sometimes the legal hurdles can’t be overcome, but in two or three cases so far we have been able to use the input of our medical professional to adjust treatment for injured workers,” Braden said.

“We’re dealing with patients who have been out of work, they’re not getting better. Being able to bring them back some quality of life is why we do these.” – Suzy Braden, Workers’ Compensation Claims Manager, Encompass Health

In once case, for instance, a patient suffering from chronic back pain was not seeing any improvement, but utilization review had denied a request for a discogram — in invasive X-ray procedure used to examine injured discs in the spine after other treatment like medications and physical therapy have failed.

“We felt that the request was justified and having that confirmed by another physician in the call made us more comfortable with overriding that denial and approving a discogram anyway,” Braden said.

Advertisement




In another case, a woman with a hip injury had received multiple deep injections at the site of the injury, and though follow-up MRIs showed healing, the woman was still reporting high levels of pain and did not seem to be progressing. The adjuster and case manager we ready to throw in the towel, and another medical professional agreed they had done everything they could to that point — but one more injection might just do the trick.

“Sure enough, we had her receive one more injection, and she started to improve dramatically. She was back to work within a few weeks and was able to back off the pain medication she’d been taking,” Braden said. “That’s the most important outcome of these roundtables. We’re dealing with patients who have been out of work, they’re not getting better. Being able to bring them back some quality of life is why we do these.” &

Katie Dwyer is an associate editor at Risk & Insurance®. She can be reached at [email protected]

4 Companies That Rocked It by Treating Injured Workers as Equals; Not Adversaries

The 2018 Teddy Award winners built their programs around people, not claims, and offer proof that a worker-centric approach is a smarter way to operate.
By: | October 30, 2018 • 3 min read

Across the workers’ compensation industry, the concept of a worker advocacy model has been around for a while, but has only seen notable adoption in recent years.

Even among those not adopting a formal advocacy approach, mindsets are shifting. Formerly claims-centric programs are becoming worker-centric and it’s a win all around: better outcomes; greater productivity; safer, healthier employees and a stronger bottom line.

Advertisement




That’s what you’ll see in this month’s issue of Risk & Insurance® when you read the profiles of the four recipients of the 2018 Theodore Roosevelt Workers’ Compensation and Disability Management Award, sponsored by PMA Companies. These four programs put workers front and center in everything they do.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top,” said Steve Legg, director of risk management for Starbucks.

Starbucks put claims reporting in the hands of its partners, an exemplary act of trust. The coffee company also put itself in workers’ shoes to identify and remove points of friction.

That led to a call center run by Starbucks’ TPA and a dedicated telephonic case management team so that partners can speak to a live person without the frustration of ‘phone tag’ and unanswered questions.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top.” — Steve Legg, director of risk management, Starbucks

Starbucks also implemented direct deposit for lost-time pay, eliminating stressful wait times for injured partners, and allowing them to focus on healing.

For Starbucks, as for all of the 2018 Teddy Award winners, the approach is netting measurable results. With higher partner satisfaction, it has seen a 50 percent decrease in litigation.

Teddy winner Main Line Health (MLH) adopted worker advocacy in a way that goes far beyond claims.

Employees who identify and report safety hazards can take credit for their actions by sending out a formal “Employee Safety Message” to nearly 11,000 mailboxes across the organization.

“The recognition is pretty cool,” said Steve Besack, system director, claims management and workers’ compensation for the health system.

MLH also takes a non-adversarial approach to workers with repeat injuries, seeing them as a resource for identifying areas of improvement.

“When you look at ‘repeat offenders’ in an unconventional way, they’re a great asset to the program, not a liability,” said Mike Miller, manager, workers’ compensation and employee safety for MLH.

Teddy winner Monmouth County, N.J. utilizes high-tech motion capture technology to reduce the chance of placing new hires in jobs that are likely to hurt them.

Monmouth County also adopted numerous wellness initiatives that help workers manage their weight and improve their wellbeing overall.

“You should see the looks on their faces when their cholesterol is down, they’ve lost weight and their blood sugar is better. We’ve had people lose 30 and 40 pounds,” said William McGuane, the county’s manager of benefits and workers’ compensation.

Advertisement




Do these sound like minor program elements? The math says otherwise: Claims severity has plunged from $5.5 million in 2009 to $1.3 million in 2017.

At the University of Pennsylvania, putting workers first means getting out from behind the desk and finding out what each one of them is tasked with, day in, day out — and looking for ways to make each of those tasks safer.

Regular observations across the sprawling campus have resulted in a phenomenal number of process and equipment changes that seem simple on their own, but in combination have created a substantially safer, healthier campus and improved employee morale.

UPenn’s workers’ comp costs, in the seven-digit figures in 2009, have been virtually cut in half.

Risk & Insurance® is proud to honor the work of these four organizations. We hope their stories inspire other organizations to be true partners with the employees they depend on. &

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]