Tag Archives: disability

What Digital Can Do for Disability Claims

Healthcare is being transformed by advances in artificial intelligence, virtual reality, machine learning, sensors and other innovative technologies. Practically everybody has a smartphone, making it easier than ever to gather data and consent to third-party access. Unique data insights mean providers can offer people products and services tailored to them individually.

For insurers, digital technology offers new ways to manage risk that relies less on face-to-face and traditional clinical assessment; this is why there is so much interest in understanding how innovation might work. Selected comments from four key players in the digital health ecosystem make clear the appeal of putting two and two together.

Thomas Lethenborg at Monsenso, a mobile platform for mental health, said, “Digital technology helps an individual move from reactive behavior to being more proactive – and this changes the paradigm in particular with engagement.”

It’s a view shared by David Forster of Thrive, a digital interventions app for mental health: “Data drives our understanding of what works best for the individual.” According to Forster, the success of digital technology in clinical settings points to real opportunities in insurance: “It makes it possible to provide policyholders help with illness prevention, early detection and assistance on a personal level.”

Ian Prangley, of exercise rehabilitation service TrackActive, continued the theme when he said, “For insurers, digital solutions can drive connectedness, engagement and customer satisfaction while enabling people to self-manage their health. Harnessing data insights and implementing artificial intelligence (AI) is key to achieving this.”

See also: Why to Digitize Disability Claims  

A comment by Danny Dressler of AIMO, an ecosystem integrating intelligent motion analysis into musculoskeletal care, added further confirmation: “As more and better data is gathered and processed safely, AI offers the most promise to take care of people’s health, and fix issues in both healthcare and the life and health insurance sectors.”

By using digital means, insurers can create scalable, automated, speedy ways of supporting people when they need help the most. Proponents argue it offers better health outcomes for policyholders that will reduce the costs associated with long disability claims – a win-win for both insurers and consumers.

Dressler also said that “technology like ours lets insurers offer customers new solutions such as dynamic pricing and automated claims and even help to prevent claims from happening.” Lethenborg says it represents “an opportunity to ensure the data collected gives holistic insights and analytics that we can use to intervene more rapidly, when help is needed.”

But it’s crucial the highest levels of privacy and data protection are guaranteed and operators are in full compliance with regulations. An imperfect balance of privacy with innovation is a deal-breaker for consumers.

Forster is clear how delicate this balance is: “We recognize our responsibility to safeguard users’ data, but at the same time information technology empowers people to make choices and participate actively in managing their own health – it puts them in the driving seat for the first time.”

For digital solutions to be convincing, research and scientific evidence are needed, but with newly made services, long-term experience is scarce, and a leap of faith is required.

Dressler spoke for all in saying, “We maintain strong links to scientific institutions because the general technologies underpinning our solutions emerges from scientific thesis…[This means] we only implement new features or functions after a rigorous validation process, especially because we are asking people to trust us with their health and well-being.”

Dealing with high volumes of data is not without risk, particularly when it’s shared with third parties.

See also: Digital Innovation in Life Insurance  

Prangley has pointed to recent concerns over how sensitive data is being used to highlight the challenges faced, “The key is to anonymize and protect data, and have customers consent to sharing it on the understanding it will be used solely to improve their health.” This insight is driven home by Lethenborg, who said, “Transparency about how the data will be used is essential to building trust.”

Digitization has already brought new products and services that have had positive medical and scientific impact. As Prangley said, “Technology has connected people and changed how we relate to each other. There [are] arguments for and against this of course, but in the context of health and wellbeing we believe it’s a great thing.”

With mental health and musculoskeletal problems as the leading causes of disability claims in every market, these companies can bring digital solutions and opportunities – and health insurers can also feel great about them.

New Regulations for Disability Claims

In December 2016, the Department of Labor issued final regulations under ERISA governing claims procedures for group disability plans, which became effective Jan. 1, 2018. The new regulations govern employee benefit plans subject to ERISA that offer disability benefits, not just disability plans. ERISA plans must strictly comply with the new regulations for all claims filed on or after Jan. 1, 2018, including any necessary amendments to plan documents and internal claims-handling procedures. However, some parts of the regulation took effect Jan. 18, 2017.

Although the DOL announced on July 20, 2017, that the new regulations might be amended or delayed, they were scheduled to take effect for all claims for disability benefits filed on or after
Jan. 1, 2018. These new disability claims regulations would not apply if a plan does not make the determination of disability, but instead relies on a third party’s determination of disability, such as a determination of disability made by the Social Security Administration or the employer’s long-term disability plan. Further, the new regulations do not apply when parties to a collective bargaining agreement have agreed to use a grievance and arbitration process to adjudicate disability claims.

For claims filed between Jan. 18 and Dec. 31, 2017, the DOL is imposing the following additional standards (as applicable) on denial notices to ensure a full and fair review has occurred.

  1. The notice either needs to provide (i) the specific rule, guideline, etc., that was relied upon in making the adverse determination relied; or (ii) a statement that that such a rule was relied upon and notice that a copy will be provided for free upon request.
  2. If the claim is denied based upon medical necessity, experimental treatment or a similar exclusion or limit, the notice must provide (i) an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to the claimant’s medical situation; or (ii) a statement that the explanation will be provided for free upon request. (Note: this standard will continue to apply in 2018.)

See also: How to Win at Work Comp Claims  

For claims filed on or after Jan, 1, 2018, these are the new requirements:

  1. Loss of discretionary authority. If a plan violates any of the rules for disability claims, the claim is deemed denied without the
    exercise of discretionary authority. This gives the claimant the right to file a lawsuit without further delay and will allow a court to decide the merits of the claim de novo, without any deference to the fiduciary who violated the rules. The only exception to this rule is if the plan’s violation was: (i) minor; (ii) non-prejudicial; (iii) attributable to good cause or matters beyond the plan’s control; (iv) in the context of a continuing good-faith exchange of information; and (v) not reflective of a pattern or practice of non-compliance. In addition, a claimant may request that the plan explain in writing any violation. The plan must respond within 10 days by specifically explaining the violation and why it believes the claimant should not be permitted to file a lawsuit at that time.
  2. Impartiality. A plan’s claims procedure must be designed to ensure impartiality. This means that a plan cannot
    make hiring, compensation, promotion or termination decisions based on the likelihood that a claim adjudicator or supporting expert will support the denial of disability benefits. This rule also applies to vocational experts, medical consultants and in-house medical reviewers.
  3. Disclosure Requirements. Denial notices must include the following:
    1. Disagreement with Experts. A discussion of the basis for disagreeing with any healthcare professionals treating the claimant or any medical/vocational experts who evaluated the claimant. The discussion must include an explanation of why the plan disagrees with any medical/vocational experts whose advice was obtained in connection with the determination process, regardless of whether the advice was relied on when making the determination (This is designed to prevent “expert shopping”).
    2. Disagreement with SSA. If the Social Security Administration (SSA) has determined the claimant is disabled for Social Security purposes, the plan must discuss why it disagrees with the SSA’s determination. If the plan’s definition of “disabled” is similar to the SSA’s definition, the plan must provide a more detailed justification.
    3. Medical Necessity/Experiment Treatment. If a denial is based on medical necessity or experimental treatment, the notice must include an explanation of the scientific or clinical judgment used for the denial, or a statement that such explanation will be provided free of charge upon request.
    4. Internal Guidelines or Standards. If internal rules, guidelines or standards were relied on in making the plan decision, the plan must provide such rules, guidelines and standards. This disclosure requirement is more onerous than the requirements applicable to group health plans. The claims decision maker must affirmatively provide the rule, guideline or standard (or state that none was relied on). It is not sufficient to simply state that it will be provided upon request.
    5. Relevant Documents. For claim denials, the notice must provide that all documents relevant to the claim denial will be provided upon request. This requirement already exists for appeal denials.
    6. Contractual Limitations for Bringing Suit. All appeal denial notices must describe any time limit for filing suit in court set forth in the plan documents (any contractual limitations), and must include the specific date by which a lawsuit must be filed to be considered timely.
  4. Right to Respond to New Evidence or Rationales. A claimant must be given the right to respond to new evidence or rationales relied on or generated during the pendency of an appeal (even if supportive of the claimant). The plan must provide such evidence and rationales to the claimant as soon as possible and sufficiently in advance of the date on which the plan will reach its determination, so that the claimant has the opportunity to respond prior to the plan’s appeal decision.
  5. Rescissions of Coverage. Rescissions of coverage (the termination of coverage with a retroactive effect) must be treated as a denial of a claim. As such, a participant is entitled to use the plan’s claims procedure to appeal a rescission of coverage. This does not apply to retroactive termination of coverage for failure to pay premiums.
  6. Translation Requirements. If a denial notice is being mailed to a county where 10% or more of the population is literate only in the same non-English language, the denial notice must include a prominent statement in the relevant non-English language about the availability of language services. The plan would also be required to provide an oral customer assistance process (i.e., telephone hotline) in the non-English language and provide written notices in the non-English language upon request.

See also: Claims Litigation: a Better Outcome?  

PLEASE NOTE – On Oct. 6, 2017, the Department of Labor signed a proposed rule “to delay for ninety (90) days – through April 1, 2018 – the applicability of the final rule amending the claims procedure requirements applicable to ERISA-covered employee benefit plans that provide disability benefits.”

There is a 60-day period to submit comments providing data and other relevant information regarding the merits of rescinding, modifying or retaining the final rule. The DOL has received many complaints about the added costs to benefit plans (estimated at 6% to 10% increase in premiums, according to several insurance carriers). In light of these complaints, the DOL believes it is appropriate to seek additional public input and additional reliable data.

I believe there will be some changes to the final rule and do not believe they will just scrap it.

How to Win at Work Comp Claims

So many people want to blame the injured worker for the high cost of workers’ compensation; they say the worker doesn’t want to get better.

But consider these two patients, limping into two different medical clinics with the same complaint. Both have trouble walking and appear to require hip surgery. The first patient is examined within the hour, is X-rayed the same day and has a time booked for surgery the following week. The second sees the physician after waiting three weeks for an appointment, then waits eight weeks to see a specialist, then gets an X-ray, which isn’t reviewed for another week, and finally has surgery scheduled for six months later, pending the review of a utilization board, which will determine the employee’s remaining value to his employer. Why the different treatment for the two patients? The first is a Golden Retriever taken to a veterinarian. The second is an injured employee entering the workers’ compensation system.

Maybe we need to send our injured employees to a good vet!

The No. 1 cost driver of a workers’ compensation claim is that the injured worker is not getting better. But the sad reality is that the injured worker isn’t even given an honest opportunity. Everyone just wants to kick the can down the work comp road, believing the best way to save money is by limiting treatment opportunities.

Look at back pain, which is the most expensive industrial injury and the most common cause of disability in patients under 45 years of age. More than five million Americans are disabled by back pain, and more than half of those will develop a permanent condition. Studies show that direct healthcare expenditures exceed $20 billion annually, and indirect expenditures associated with back-related injuries are greater than $30 billion. Disorders of the musculoskeletal system are the most common causes of absence from work in both men and women between the ages of 30 and 65. Back pain is the dominating subgroup and is the second leading cause of workplace absenteeism.

See Also: How Should Workers’ Compensation Evolve?

There are plenty of statistics showing the direct costs associated with occupational back injuries average $37,000. Indirect costs range from $147,000 to $300,000.

It therefore follows that if an employer could redirect its resources and attention to the aggressive treatment of the acute back pain patient, with a view to preventing chronicity, the company would be able to reduce costs.

In fact, we have a proven system that has direct and indirect cost savings; however, it requires the employer to take control of its workers’ comp group and change the way business is being done.

Unfortunately, only a small minority of employers play at the tip of the spear and way too many employers who sit on the sideline and expect everyone else to take care of the issues.

So, we are challenging you, the employer, to get in the game, change your team line-up and win the game of managing your workers’ compensation division.

Here’s how:

Once the injured employee enters the world of workers’ compensation as either a medical, indemnity or future medical claim, the healthcare professional becomes one of the key decision makers in the employee’s recovery and return-to-work. Usually, the professional helps the injured worker recover through minimum symptomatic treatment protocols authorized by utilization review boards and return to her job in a modified duty capacity with appropriate restrictions.

The employee comes back to work, with restrictions, and in most cases the safety supervisor or human resources person assists in monitoring the employee to verify that the healthcare professional’s recommendations are being reasonably accommodated.

In a perfect world, this scenario may work. The employee recovers, the medical bills are paid and the work tasks are re-evaluated. However, in most cases, once the employee is injured, delayed treatment ensues, the injured worker develops co-morbidities associated with his injury, an applicant’s attorney gets involved and the reserves then begin escalating. At this point, any optimal solution becomes a distant thought. The only player who has the incentive to change the game is the one paying the bills… the employer!!

How can an employer change the workers’ compensation cycle to bring about solutions for all the players involved? It takes moral courage to change your team line-up and manage your claims better. Can it be done? Absolutely, and we’ve done it.

Employers have historically taken an adversarial approach to workers’ compensation claims even though the law is on the employee’s side. It makes sense to immediately engage the injured employee and set the expectations for recovery. This is part of the overall strategy to create a claims handling “team” that will align with the core competencies of the business environment. Setting the team line-up to implement an active approach to claims management will be a game changer.

As an employer, here’s an outline of what this would look like:

  1. Identify your team members; business unit manager, risk manager, safety professional, claims examiner manager, claims examiner, medical director, healthcare providers, nurse case manager, legal counsel and medical fitness consultant.
  2. Have a prominent seat at the workers’ compensation round table, whether you are fully insured or a self-insured employer.
  3. Know the workers’ compensation claim life cycle and your role in influencing outcomes.
  4. Be sure the claim examiners on your files know and understand the employer’s risk management goals and objectives.
  5. Have essential job functions (EJFs) for all positions readily accessible for the healthcare professionals and claims examiner.
  6. Perform quarterly claim review meetings on all open and recently closed claims. The meetings should include your entire workers’ comp team, so discussions can progress around treating the whole person and not just the affected body part. Remember, at some point a body part adds to the potentially new claim of cumulative trauma.
  7. As the employer, limit the claim examiner case load to 100 claims or less per examiner. This allows for more in-depth understanding of claim resolution solutions in addition to claims handling by regulatory deadlines.
  8. Make sure your insurance broker supports your desire to incorporate a medical aftercare program managed by a medical fitness organization that understands the workers’ compensation process and your strategic claims management system.

Savvy Health Solutions has worked strategically with employers as part of their claims management team and addresses the whole person by focusing on improving overall strength and flexibility, postural responsiveness to activities of daily living and a motivational element that embeds the components of the program into sustainable lifestyle changes. Savvy has found that, the sooner an employee begins the program, the quicker the employee is returned to full duties, and the claim is closed:

  1. The safety person, now having a more comprehensive understanding of musculoskeletal issues, can revisit the company’s job hazard analysis for accuracy and completeness. This technique breaks each job down into individual tasks to identify hazards and focuses on the worker, the task, the tools and the work environment. The analysis is also a key component for compliance with OSHA’s injury and illness prevention program requirements.
  2. The claims examiner is educated on the work environment. With fewer claims to handle, the examiner can spend extra time on the job to better understand the work environment from an employee’s perspective. Essential job functions and job hazard analysis have more meaning once seen in action. Claims examiners will begin to understand how people do the work, in addition to meeting the expectations of the Department of Workers’ Compensation in managing a claim.
  3. A team approach helps the claims examiner to think more like a business person. Outside consultants, like Savvy Health Solutions, help the employer see a new way of claims resolution and prevention of further injuries.
  4. The effectiveness of the workers’ compensation team can be measured with metrics created as part of your annual insurance renewal process/contract or as part of your third party administrator contract renewal.

Too many internal silos and “leaving it to the claims experts” can run against a culture of treating employees with respect and dignity when injured. The employer needs to be the key stakeholder in the process, having the same key performance indicators (KPIs) for workers’ compensation as it is done for safety metrics and profitability.

This methodology is counterintuitive to the typical workers’ compensation claims handling structure. Success starts with the employer and involves every single team member, business unit manager, risk manager, safety professional, claims examiner manager, claims examiner, medical director, healthcare providers, nurse case manager, legal counsel, insurance agents and brokers and medical fitness consultants.

Developing a winning line-up with your team will improve your ability to control costs and reach a desired outcome for the employee first, and then the organization. Because when the injured employee recovers from his injury, restores normal function and improves quality of life, then everyone wins.

Waiting for Your Disability Benefits?

If you are suffering from an injury or illness that is preventing you from working, it’s likely you have lost a livable income, and you may be facing the threat of economic hardship. Many people, who are unable to work due to a serious illness or injury, are able to receive Social Security benefits as compensation. But, according to John C. Shea, a disability lawyer in Richmond, VA, applying for Social Security benefits is often a long and arduous process, whether because you are gathering all of your medical documents, making sure you ask all the right questions or patiently waiting to hear if you qualify,.

The Waiting Period and Financial Help

Once you have applied and are waiting for a response as to whether you qualify for benefits, the Social Security Administration (SSA) reports that the decision process can take anywhere from three to five months (keep in mind that the process can take even longer if you’re initially denied and file an appeal). Waiting nearly half a year is not “financially doable” for most individuals. Here are some helpful tips for getting financial help while waiting for SSA’s answer:

  • Are You Able to Work?: In some cases, individuals seeking SSDI benefits may be able to work, but there limitations on how much you can earn. Chances are, your illness or injury may limit your ability/length of time to work, anyway. If you’re interested in working, even very part-time while applying for SSDI benefits, it’s a good idea to talk to SSA; to avoid any extra issues or confusion, consult with a disability lawyer.
  • Apply for Supplemental Programs: If your life is put on hold due to a life-changing illness or injury, unfortunately, your needs and expenses won’t take a break. Groceries and other utilities are life essentials but are often big financial expenses. If you’re running into financial problems, rather than skipping bills and risking having your heat or electricity shut off, consider applying for energy assistance and take a look at programs like SNAP for food assistance.
  • Creating a Budget and Cutting Expenses: Downsizing on your monthly budget may be one of the easiest ways to save you some money while waiting for SSDI benefits. Although you may not want to give up certain “luxuries” like cable television or your costly cell phone plan, making some budget cuts here and there may save you hundreds of dollars a month. It’s also a good idea, while planning out your budget, to look ahead as much as a year. While SSA’s decision may take a few months, you may encounter some discrepancies that lengthen the process.

Accept Assistance

Asking for and accepting help can be difficult, especially if you’re struggling to come to terms with a lengthy illness or injury. If a friend or family offers to help you, strongly consider accepting the offer. Whether you insist on treating the help as a loan or a gift, the offer can help keep you financially afloat while you wait for your benefits.

Managing Behavioral Health at Work

At the RIMS 2016 Annual Conference, Kimberly George, senior vice president of Sedgwick, and Scott Daniels, director of disability for Comcast, discussed an approach to managing mental and behavioral health in the workplace. The discussion focused on how Comcast deals with these issues. Comcast has a very diverse workforce, owning a cable company, multiple television networks and even theme parks.

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Behavioral health claims not only affect your employees directly, but they also can have a significant impact on your business. According to a recent study by IBI, four of the top six employment-related concerns of employers related to the health of their workforce. The study also found that mental health was the second-highest duration of disability diagnosis for their short-term disability programs.

Comcast has had 1,300 to 1,600 behavioral health claims per year, paying millions of dollars in benefits. One area of concern for the company is that 60% of those being treated were not being seen by licensed behavioral health experts. Instead, they were being treated by general practitioners who lacked the expertise to adequately address the issues. Comcast is trying to focus on being an advocate for its workers on health issues, and part of that includes assisting them in being treated by the appropriate medical providers.

See Also: A New Focus for Health Insurance

Comcast’s program is currently focused on the group benefits side. The company hopes to someday expanded to workers’ compensation. If employees have a behavioral health diagnosis, they are required to treat with a practitioner specifically licensed in that area. Comcast does not direct to specific providers but instead work with the employee to help identify providers in the network. The Comcast employee assistance program (EAP) comes into play as the employee can receive a certain number of behavioral health visits under this at no cost to the worker. The program has been in place less than a year, but Comcast is already seeing  significant decreases in duration of disability for behavioral health claims.

There is hope that this program can have a positive impact on workers’ compensation claims, as well. Under the EAP program, Comcast can provide the behavioral health treatment outside the workers’ compensation claim to help address the psycho-social issues that could have an impact on the claim. This approach recognizes that you must treat the whole person to effectively manage workers’ compensation claims, and you cannot ignore psycho-social issues that may be affecting the case.

One of the first resources that Comcast tapped into in developing its program was its EAP provider. The  provider offers a variety of resources to the workforce, not just in the area of behavioral health but also with a variety of lifestyle issues. The EAP was being underutilized before this program started, but the change in focus helped employees to fully understand the benefits under their EAP.

Resilience is a also very important issue that can affect both disabilty and workers’ compensation claims. Comcast is working with a vendor partner to assist employees in developing coping skills and being more resilient. Comcast feels that by strengthening the resilience of its workforce it can significantly reduce all disability in the workplace.

Comcast is also using more telehealth, which is yielding positive results. It makes it easier for the employees to receive medical care in a timely manner. This has been especially useful with behavioral therapy.

The company is also hoping that the focus on getting the employee the proper care will decrease relapse in disability. Oftentimes, relapse is driven by the employee’s not receiving the appropriate treatment.

The overall focus at Comcast is establishing a culture of health for the workforce. The company wants employees to engage in the healthcare experience and become educated consumers. The hope is this culture will ultimately lead to healthier employees, which will result in fewer disability and workers’ compensation claims.