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New Tool for Settling Open Medical Claims

The almighty dollar is often just one component of a successful workers’ compensation settlement. Savvy negotiators recognize that they have several tools at their disposal when it comes to bridging the gap between the payer’s offer and the plaintiff’s demand, many of which dictate how and when the settlement dollars can be used.

On both sides of the negotiating table, many are adept at minimizing or maximizing the medical cost projection or the amount that goes into a Medicare Set Aside (MSA). Many in the industry also understand how a structured settlement (annuity) can unlock value and allow for the pacing of stable income for the claimant.

Now, a small but growing number in the industry are beginning to understand how offering professional administration (PA) of the claimant’s future medical funds can help facilitate a settlement. PA provides the claimant with a dedicated support team after he settles the case, along with technology to ensure he saves money when he actually spend the settlement dollars on healthcare.

What settlement issues can you use PA to help address?

The most often cited concerns of injured workers when they face the prospect of settling are regarding: 1) access to their medical treatment and 2) how long it takes to get a response from their adjuster, attorneys or the board as they go through settlement process. Examples of these concerns are easily found by reading the comments directly from injured workers in a survey by the New York Workers’ Compensation Board. Issues like “denied treatment” and “delayed processes” are at the core of nearly every complaint.

PA is effective in addressing these concerns because PA services do not restrict the claimant’s access to medical treatment via utilization review or a medical provider network (MPN); PA services provide expanded choices for treatment. In addition, many PA services have call centers that offer support to their clients, the injured workers. CareGuard, for instance, offers 24/7 coverage to its members and prospective members to answer any questions they may have as they navigate the complex healthcare maze after settlement.

Through the life of their claim, many injured workers simply lose trust in the attorneys, judges or system in general. This is often because the settlement process sets the parties up at a table for purposes of a one-time transaction, but then each group walks their own separate way.

There is sparing research done on injured workers’ attitudes toward settling their case, but a survey in Minnesota in 2013 scratched the surface of what a daunting undertaking settling is for the injured individual. The study found that about one-third of injured workers did not fully understand their settlement. Further, it revealed that around three-quarters of injured workers did NOT believe they achieved a “fair” settlement. The sample used were folks who actually overcame their concerns and settled regardless of the negative sentiment the process evoked. Many claimants do not have the courage to push forward with settlement and instead decide to leave their future medical claim, if not their entire claim, open.

PA can be a valuable tool, whether for adjusters, defense attorneys or plaintiff attorneys, to inject trust and solutions into a contentious situation. A team becomes available to address claimants’ concerns about their future medical treatment. PA also introduces a party to the settlement negotiation whose interests are aligned with the claimant’s, because the PA provider will be the only party continuing to provide service to the claimant after settlement. This can give the claimant much-needed peace of mind that a partner is looking out for his best interests, and it is this peace of mind that helps reluctant claimants see that settling could in fact be their best decision. PA services give claimants comfort and confidence that life after settlement can be a rewarding and hassle free experience.

How can you leverage PA in a settlement?

To leverage PA effectively, negotiators on either side of the table should introduce the service early on in the process and clearly explain its benefits to the claimant. Often times, it’s useful to connect the PA provider directly with the claimant or her attorney so that a relationship is established and the service is well-understood. After all, the agreement between the PA provider and the claimant will exist for years beyond the settlement; it’s better to begin that relationship early on rather than try to throw it in last minute.

The PA provider can serve as a neutral party that helps explain to the claimant what she can expect after settlement. Some PA providers, like CareGuard, can go further to provide cost analyses of what treatments will cost on their platform and demos of how their service works. PA providers understand that they do not get paid until the case settles, so they are a source of information and guidance toward settlement for all parties involved.

Why to Self-Fund Health Benefits

The passage of the Affordable Care Act in 2010 continues to redefine the employer-sponsored healthcare market. Increased regulatory and fiduciary responsibilities, employer mandates and rising medical premiums have forced employers to evaluate all cost-effective strategies for providing health benefits to employees. One strategy, self-funding, remains an attractive alternative to the traditional fully insured and association-style health plans.

In a self-funded environment, the employer will assume the role of the insurer and agree to pay the medical claims incurred by the plan’s members and dependents. A good percentage of self-funded plans will also use reinsurance and captive risk tools to provide protection from both large individual claims and the plan’s collective utilization.

While self-funding has gained momentum as a result of healthcare reform, it is not a new concept. In 1999, a Kaiser Family Foundation (KFF) study reported that 44% of employer-sponsored healthcare was self-funded. That number has now reportedly grown to 61% in 2014.

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Why Is Everyone So Interested?

Health benefits continue to be one of the greatest expenses for employers. This fact, compounded with the continual rate increases (with little to no justification), leaves employers feeling stuck in an endless cycle. Some also may feel that their employees are a generally healthy group that is a good candidate to self-fund.

Many turn to self-funding because of:

  • Lower fixed costs-The majority of the expense is incurred in the payment of actual medical claims, increasing the margin for savings when the plan performs well.
  • Improved transparency-An increase in premiums is easier to swallow if the employer can get an accurate understanding of its claims experience. Self-funded health plans provide employers with a tremendous amount of data. Accurate claims data strengthens the group’s ability to effectively control spending on claims.
  • Control of the plan design-Self-funded health plans are in a better position to adjust benefits and control increased provider costs. Unlike fully insured products, a self-funded plan design can be structured to meet the specific needs of the group and not an insurer’s overall population.
  • Tax savings-Fully insured premiums continue to jump to accommodate new provisions as a result of the ACA. Self-funded plan sponsors avoid items like the new Health Insurance Industry Tax, which will increase from 2% to 5% in coming years.

With the increased interest comes new strategies and opportunities as the self-funding marketplace evolves. Self-funded plan sponsors are reaping the benefits of evolving provider network and cost containment strategies. Meanwhile, employers that have yet to make the transition see obstacles lessen because of changes in the reinsurance and captive markets.

What Does This Mean for Employer Groups?

Self-Funded Feasibility Studies Are a Must

There is a strong likelihood that every corporation or public entity with 1,000 employees or more has at least heard about self-funding. However, depending on the number of employees on your health plan, it is quite possible that you have not evaluated self-funding, at least in a thorough way.

A deeper look into the composition of employers participating shows us that group size typically has a direct correlation on whether a self-funded strategy is being used. According to the 2014 KFF study, the breakdown of corporations self-funding is:

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Historically, size has mattered. While all groups with more than 200 employees have a responsibility to evaluate the method as an alternative, those employer groups in the less-than-200 range are seeing more opportunity to make the transition. Lessening participation thresholds to lease competitive provider networks and new reinsurance and captive products are creating total-cost scenarios where the right employer can realize the advantages of self-funding. It can still be a challenge when certain market dynamics are present (i.e., lack of claims data, available provider network options, pending legislative actions, etc.), but more and more companies are finding success.

One More Step

The large insurance companies have noticed the changing market, as well, of course, and have introduced a number of bundled plans that look like self-funding. These products are typically entirely owned by one entity, like an insurance company or trust, and allow the employer to participate in a pre-determined portion of any surplus when the group experiences lower-than-expected claims. These products are attractive because they pull together under one brand all the component vendors of a self-funded health plan (i.e., claims administrator, network, reinsurance, etc.). These products can be a great first step for employers weary of self-funding through their own independent health plan. The products will allow them to gain insight into their claims performance while alleviating some of the additional work associated with the wholly owned approach.

For those groups already in these products, it may be time to evaluate taking that next step and realizing the benefits of a wholly owned approach. Reinsurance policies with specific advance and monthly aggregate accommodation can give these employers the ability to still limit their maximum exposure, lower their plan’s fixed costs and keep all of the savings when the plan performs well.

With the tools available today, any employer group in a packaged, shared funded or full ASO model plan is a candidate to complete the transition to a self-funded plan. While the packaged, branded approaches employed by some of the major insurance companies may work for a season, deconstructing the bundled product may be the next step in the employer’s long-term strategy.

Fine-Tuning Your Self-Funded Plan

There are many companies that have been enjoying the benefits of self-funding for years. As a result of the ACA, however, these employers have had to react to escalating medical costs, expensive specialty drugs and increased regulatory and fiduciary responsibilities.

For instance, self-funded health plans typically “lease” provider networks from a large insurance company. But, in 2010, the ACA removed lifetime and annual maximums from health plans, and the number of high-dollar claims has increased substantially. The networks provide discounts on fees, but the question is how important they are given the increasingly large charges they are being applied toward.

Self-funded health plans are adept in using different types of analytics both to measure historical data and to predict outcomes. This has empowered these health plans to fine tune their plans and integrate various cost-containment strategies.

Tips on Evaluating a Wellness Program

This is news you can use.

If you want to evaluate the cost/benefit ratio of a wellness program, the following is a list of costs that are almost always overlooked in wellness evaluations. These are not the only things that need to be evaluated, just the ones most commonly overlooked.

When the items in the following list are fully considered, wellness evaluations can look entirely different.

1. The cost of staff hired to manage the program. A rule of thumb is to multiply their salary times two to account for FICA, benefits, office space, training, workers comp, management, etc.

2. The cost of wages for workers while attending wellness events at work. One company I looked at was spending about $175 per employee per year on this, not a trivial sum.

3. The opportunity cost of the HR staff running the program.

4. The full cost of wellness communications. Sending wellness communications to people at work has a wage cost. See #2 above.

5. The total cost to evaluate the program periodically.

6. The cost of false positives, which come from sending employees to doctors when they’re not sick. This is especially pernicious if you’re paying for wellness exams for employees. At one company, the cost of the false positives, sometimes as high as $80,000 per event, nearly cost more than the physical exams themselves. You have to examine claims data to see this.

7. If you have a fitness center, you need to take into account sports injuries for users. (Understanding this also involves access to claims data.) I’ve evaluated the impact of fitness centers for three very large companies. Taking into account sports injuries, etc., you could not make the case for an ROI for any of the three of them. In one company, we examined claims data on a) moderate or occasional fitness center users, b) people who used the fitness center regularly, and c) nonusers. Nonusers had the lowest average medical costs. Moderate users had higher medical costs than nonusers and regular users had the highest medical costs, a perfect reverse correlation.

Surveys of employees are notoriously unreliable. They measure employee opinions, at best, and opinions are not facts. As we all know, sometimes in employee surveys people will say what they think the surveyor wants to hear.

Medical claims and sick pay data are about the most meaningful ways to measure wellness outcomes. Short- and long-term disability data can be useful, too, as can life claims experience when compared with norms. If you only use employee surveys and other surrogate data, too bad.

I met an actuary who spoke at a conference on this topic and used the measurements above to evaluate wellness programs. He said he’d never seen one that had a positive ROI, except ones that used payroll deduction penalties.

A Secret for Comparing Workers’ Comp Costs

Workers’ compensation claims and medical managers are continually challenged by upper management to analyze their drivers of workers’ comp costs. Moreover, upper management wants comparisons of the organization’s results to that of peers.

The request is appropriate. Costs of doing business directly affect the competitive performance of the organization. Understanding drivers of workers’ comp costs is key to making adjustments to improve performance. Still, it’s not that simple.

Executing the analysis is the lesser of the two demands. More challenging is finding industry or peer data that is similar enough to create an apples-to-apples study. In a recent article, Nick Parillo states, “Regardless of the data source, whether it be peer-related or insurance industry-related, risk managers must be focused on aligning the data to their respective company and its operations.” Parillo emphasizes that the data should be meaningful and relevant to the organization.

Aligning the data to the situation can be challenging. Industry or peer data may not be situation-specific enough or granular enough to elicit accurate and illuminating information. State regulations vary, as do business products and practices, along with a multitude of other conditions that make truly accurate comparisons difficult.

Variability in the data available for benchmarking can be especially disconcerting when considering medical cost drivers, which now account for the majority of claim costs. Differences in state fee schedules and legislation such as required utilization review (UR) and the use of evidence-based guidelines can produce questionable comparative results. Additionally, whether the contributed data is from self-insured or self-administrated entities can skew the results.

Other variables that make comparing industry or peer data less valid are unionization, physical distribution of employees, employee age and gender, as well as industry type and local resources available. Potential differences are unlimited.

External sources such as local cultural and professional mores, particularly among treating medical providers, can play a significant role in disqualifying data for comparison. For instance, my company’s analysis of client data has uncovered consistent differences in medical practice patterns in one large state. In one geographic sector, referrals to orthopedists with subsequent surgery and higher costs are far more frequent than in another sector of the state for the same type of injury.

Parillo continues, “Given the uncertainty and limitations on the kinds of peer group data a risk manager would need to perform a truly “apples to apples” comparison, the most “relevant and meaningful” data may be that which a risk manager already possesses: His own.”

Analyzing internal data can be highly productive. First, the conditions of meaningful and relevant are guaranteed, for obvious reasons. The geographical differential across one state was found in one organization’s internal data, which ensures that data variability is not a factor.

Analyses can be designed that dissect the data at hand. Follow up to the above example might include looking for other geographic variables in costs, in injury types and in medical practice patterns. Compare physician performance for specific injury types in the same jurisdiction and then look for differences within. To gain this kind of specificity and relevance, drill down for other indicators.

Evaluate how costs move. Look at costs at intervals along the course of claims for specific injury types. In this case, utilizing ICD-9s is more informative than the National Council on Compensation Insurance (NCCI) injury descriptors. One client found that injury claims that contained a mental health ICD-9 showed a surge in costs beginning the second year. Now, further analysis can begin to discern earlier indicators of this outcome. In other words, dive further into the data to find leading indicators.

Industry data is not likely to contain the detail necessary to evoke subtle mental health information during the course of the claim. Most analysis ignores the subtlety and sequence of diagnoses assigned. Few would uncover the mental health ICD-9 because few bother with ICD-9s at all.

Drilling down, analyze claims that fall into this category for prescriptions, legal involvement and other factors that might divulge prophetic signs. It is an investigative trail that relies on finite internal data analysis.

Too often people disrespect their own data, thinking it is too poor in quality, therefore of little value. It’s true, much of the data collected over the years is of poorer quality, but it still has value. Begin by cleaning or enhancing the data and removing duplicates. Going forward, management emphasis should be on collecting accurate data.

Benchmarking data sourced from the industry may be useful but should not necessarily be considered the most accurate or productive approach. Internal data analysis may be the best opportunity for discovering cost drivers.