Tag Archives: U.S. Department of Labor

Global Insurance CRO Survey 2016

Risk functions have evolved from “check-the-box” compliance to being a key enabler for business decision-making. This change has provided chief risk officers (CROs) with a seat at the table in the highest levels of the organization.

2016 has been a year of black swans, characterized by prolonged low interest rates, political uncertainty in key markets and increasing competitive forces challenging insurers’ business models. Together with the rise of risk-based capital regimes across the globe, these factors are tending to align the CRO and CFO agendas, establishing a tighter link between risk, capital and value.

The CRO role will always have a strong regulatory-driven rationale. But as the role evolves, we see an opportunity in ERM to take stock of teams, toolkits and processes — and use them to achieve greater effectiveness.

See also: The Myth About Contractors and Risk  

This shift is occurring at different rates in different regions, but the direction is clear. Our survey explores five key themes around the risk function and CRO role:

1. There has been a high degree of operationalization in prudential regulation around the globe:

  • In Europe, in response to Solvency II demands
  • In the U.S., as a consequence of the NAIC’s ORSA requirement and for the larger insurers, SIFI demands from the Federal Reserve Board
  • In Asia-Pacific, with the implementation of risk-based capital regimes (e.g. C-ROSS in China, LAGIC in Australia, ORSA requirements in Singapore and ICAAP in Malaysia)

2. We are seeing a sharper focus on consumer-conduct regulation:

  • The U.S. Department of Labor is shaking up focus on the advice model.
  • The European Parliament is debating significant advances in policyholder communications, and various European home regulators are demanding redress for past failings in sales process, transparency of charges and continuing product suitability.
  • Depending on the region, it is more or less common for CROs to have compliance report through to them.

3. Governance models are now largely converging to reflect the three lines of defense principles.

Although differences exist across geographies, CROs are consistently seeking to strengthen risk accountability and understanding across the workforce. In particular, while we are seeing an increased awareness that risk ownership starts with the first line, there still are opportunities to strengthen risk accountability and improve communication to help everyone understand risk appetite and consequences.

4. Risk functions are becoming more involved in producing and monitoring risk metrics.

Larger insurers subject to Solvency II and now required to obtain approval of their internal economic capital models are partly behind this shift in risk functions.

Beyond Europe, other jurisdictions have a variety of approaches. For example, U.S. insurers subject to Federal Reserve regulation are required to use more extensive stress and scenario testing in their internal capital management processes (with the eventual requirement to publicly disclose the results).

See also: Minority-Contracting Compliance — Three Risks  

In general, even where there is no regulatory mandate, CROs and their risk teams are increasingly involved with stress testing and more advanced financial models to quantify risk.

5. CROs are aware of the potential for improvement in operational risk management.

While businesses generally understand the “known knowns,” risk plays an important role in emphasizing the need for a systematic approach to the full spectrum of exposures. Cyber risk in particular is one of the biggest areas of concern for most CROs, who consider it a key focus area of operational risk.

Download the full North American report here.

Download the full EMEIA report here.

How Should Workers’ Compensation Evolve?

Workers’ compensation has been around for more than 100 years. It was developed as a grand bargain between labor and employers to ensure that injured workers received appropriate medical care and wage-loss benefits while employers received protections against tort lawsuits arising from workplace injuries.

The workplace is vastly different than it was when workers’ compensation was conceived. Workers’ compensation has also evolved in some ways, but in other ways it has not kept pace with changing workplace demographics and injury exposures. There are discussions in our industry around whether workers’ compensation is still meeting the needs of both employers and injured workers. Even the U.S. Department of Labor and OSHA have recently questioned the adequacy of workers’ compensation benefits. Some employers are actively pushing for an alternative option to workers’ compensation because they feel workers’ compensation no longer provides suitable protection for employers and injured workers.

As a person who has been very actively engaged in the workers’ compensation industry, I see a variety of issues within the current system and I hear complaints from a variety of stakeholders about it. Industry groups are starting to engage in discussion about the future of workers’ compensation. With that as a backdrop, here are my thoughts around how workers’ compensation needs to evolve.

Change Medical Delivery Model

The single biggest flaw in workers’ compensation is the current medical delivery model. Medical costs keep rising, and outcomes are often poor. This is because, historically, the medical delivery model in workers’ compensation has been focused on two things: discounts and conflict.

See Also: Workers’ Comp Market Trends

Too often, medical treatment in workers’ compensation claims is used as a weapon for secondary gain. Certain attorneys consistently refer injured workers to certain physicians who extend disability, perform unnecessary treatment and ultimately produce poor medical outcomes for the injured workers. These physicians producing the poor outcomes are well-known by the payers, yet they are allowed to continue to ruin the lives of injured workers so that the settlement will be larger and the attorney fee higher. This is just wrong.

The reimbursement model has prominently focused on who will deliver the cheapest care, not necessarily the best care. In fact, sometimes the best physicians refuse to treat workers’ compensation patients because of the low reimbursement rates. In addition, unnecessary utilization review delays workers from receiving care. Bills are not submitted at fee schedule rates, which necessitates spending money on bill review services to ensure that the appropriate amount is paid. There is a lot of money wasted on the bill churn that would be better spent on medical care.

We need to start over completely on the medical delivery model and look at what is happening in group health and Medicare for guidance. Under those models, insureds are not free to treat with any provider they choose; they must treat with someone “in network.” Certain treatments must be pre-authorized, and prescription drugs must be on an approved formulary to be covered. Both group health and Medicare are now scoring medical providers to see which of them produce the best outcomes. Those that consistently produce poor outcomes are excluded from coverage. Everyone with medical insurance, including Medicare, has operated under these rules for years. Yet, when the same rules are proposed under workers’ compensation, there is outrage that the injured worker would be denied the right to treat as he wishes.

The industry and regulator needs to focus on identifying which medical providers produce the best outcomes for injured workers and also which providers follow established treatment guidelines. These physicians, and only these physicians, need to be treating workers’ compensation patients. Let’s eliminate the “plaintiff and defense” doctor mentality and just have good doctors treating our injured workers. Once we have identified those physicians, we need to get out of their way and let them treat the patient. There is no need for utilization review when an approved physician is following treatment guidelines and dispensing off the pharmacy formulary.

Let’s change the focus from conflict and discounts to better outcomes and expedited treatment. These won’t be easy changes to make, but the result will be better outcomes for injured workers and lower costs for employers. Win-Win!

Reduce Bureaucracy

The administrative bureaucracy around workers’ compensation is complex, time-consuming and extremely costly. It also does little to enhance the underlying purpose of the workers’ compensation system, which is to deliver benefits to injured workers and return them to the workplace in a timely manner. States create a never-ending mountain of forms that must be filed and data that must be reported. These requirements vary by state, forcing carriers and TPAs to comply with more than 50 different sets of rules and regulations.

Also, why are penalties for compliance errors not based on a pattern of conduct instead of being issued with every violation? If a payer is 99%-compliant across thousands of claims, it is making every effort to comply. But mistakes happen when humans are involved, so perfection is not obtainable. The focus of compliance efforts should be ensuring that every effort is being made to comply, not simply generating revenue from every error.

State regulators need to take a critical look at their administrative requirements with a focus on increasing efficiency, reducing redundancy and lowering the costs to both payers and the states themselves.

Tighten Thresholds of Compensability and Eliminate Presumptions

The threshold for something to be a compensable workers’ compensation claim varies from 1% (aggravating condition) to more than 50% (major cause). Workers’ compensation benefits should be reserved for injuries and diseases caused by the workplace environment, not a simple aggravation. In addition, the normal human aging process should not produce a compensable workers’ compensation claim under the theory of “repetitive trauma.” There should not be workers’ compensation benefits for simply standing, walking, bending and other basic activities related to daily living.

States should adopt a consistent threshold that the work injury is the major cause of the disabling condition. If work is not more than 50% responsible for the condition, then it belongs under group health.

While we are at it, presumptions for certain conditions and occupations should be eliminated. These laws are based more on politics than science, and they add significant unnecessary costs to public entity employers, which, in turn, increases the tax burden on every person in this country. They also fly in the face of equal protection under the law by creating a preferred class of injured workers. If the facts of the case and the science support a compensable claim, then it should be compensable. However, a firefighter who has smoked two packs of cigarettes a day for 20 years should not automatically receive workers’ compensation benefits for lung cancer because of a presumption law.

Eliminate Permanent Partial Disability and Focus on Return to Work

The human body is a remarkable machine because it has the ability to heal itself. In addition, medical treatment is specifically meant to restore function. Most injuries do not result in some type of permanent impairment, yet most states have a permanent partial disability benefit. Why? This is how workers’ compensation attorneys get paid. Permanent partial disability benefits represent a tort element injected into this no-fault benefit delivery system, and this is the leading cause of litigation in workers’ compensation.

The goal of workers’ compensation is to return injured workers to employment. If they can go back to their regular earnings, then the goal is accomplished. If they cannot, then there should be a wage-loss benefit. This gives incentive to employers to return injured workers’ to employment, and it would significantly reduce litigation and conflict in the system.

Eliminate Waiting Periods

The suggestions I have provided thus far would all reduce workers’ compensation costs. The savings should allow us to increase certain benefits without increasing employer costs. Let’s start eliminating the waiting period. Why should someone have to go without pay for three to seven days because they suffered a workplace injury? This creates an unnecessary financial hardship on injured workers. You don’t have a waiting period when taking sick days from work, so why is there a waiting period for workers’ compensation benefits? Yes, a change would result in more indemnity claims, but we are talking small dollars in additional benefits when compared with the benefit this would provide to injured workers by reducing the financial strain caused by a workplace injury.

Eliminate Caps on Indemnity Benefits

All states cap the weekly indemnity benefits that injured workers can receive. These caps range from a high of $1,628 (Iowa) to a low of $469 (Mississippi). In 34 states, the benefit cap is less than $1,000/week.

Think about that for a moment. In most states, if you are earning more than $78,000 per year, you will be subject to the benefit cap. This is not something that only affects the top 1% of the workforce. This cap affects skilled trade workers, factory workers, teachers, healthcare workers, municipal employees, police, firefighters and a variety of others. It is truly a penalty on the middle class. For workers subject to the cap, their workers’ compensation benefits will be significantly less than their normal wages. How many of us could avoid financial ruin if our income was suddenly reduced by a significant percentage?

See Also: Why Mental Health Matters in Work Comp

Workers’ compensation benefits are designed to be a backstop for those unfortunate enough to suffer a workplace injury. Having a workers’ compensation claim should not mean someone suffers a significant financial hardship simply because they earn a decent living. Eliminating the benefit cap would solve this problem.

Define and Cover Known Occupational Diseases

One area where workers’ compensation really needs to evolve is the coverage of occupational diseases. This concept was not contemplated when workers’ compensation statutes were drafted because the focus was on sudden traumatic injuries, but we know that occupational diseases are a reality. Science tells us that there are certain conditions that may be caused by workplace exposures. These conditions can take years to manifest.

The industry and regulators need to work together to identify those diseases that are caused by the work environment and ensure that benefits are available to address them. This means eliminating statutes of limitations that are shorter than the latency period for the condition to develop.

I refer back to my comments on thresholds of compensability. If the workplace exposure is more than 50% responsible for the condition, then it should be covered. If not, then it should be paid under group health.

Reduce Inconsistency Between States

Workers’ compensation is a state-based system, so there will always be variations between the states. However, there are some areas where the inconsistency increases costs and does not treat all workers equally.

If states could agree on a common data template for carrier reporting, it would significantly reduce the administrative costs associated with gathering and reporting data. All the states don’t need to use the same data elements, but they could accept the feed and simply ignore what they did not need. There have been efforts in this area for years with no resolution. In addition, a common workplace poster for coverage and common forms would also significantly reduce the costs associated with compliance in these areas. As mentioned previously, the bureaucracy of workers’ compensation adds unnecessary cost to the system. We should be able to make some small changes to common templates to reduce costs and increase efficiency.

Another area of inconsistency is the simple definition of who is an employee subject to workers’ compensation coverage. If two people work for the same company performing the same job in different states, one should not be subject to workers’ compensation while the other is not, yet this occurs. States vary on their definitions of employees vs. independent contractors. Some states exclude farm workers and domestic servants from workers’ compensation, while others mandate coverage for those workers. Whether or not you are eligible for workers’ compensation should not vary based on your state of employment.

Ensure That Permanent Total and Death Benefits Are Adequate

Having a family’s breadwinner die or become permanently totally disabled (PTD) is both emotionally and financially devastating. Workers’ compensation benefits are supposed to help reduce the financial impact. Yet there are four states that have hard caps on all indemnity benefits (DC, MS, IN, SC). If you are permanently totally disabled in those states, benefits only pay for 450-500 weeks. That means, by design, those states shift PTD claims to the social welfare system.

Things are even worse with death benefits. There are 19 states that cap death benefits, including the four listed above. In Georgia and Florida, death benefits are capped at only $150,000. Some would argue that there may be life insurance to provide additional funds, but there is certainly no guarantee of that.

The most devastating injuries should not result in even more devastating financial consequences for the injured worker and the family.

Adopt an Advocacy-Based Claims Model

In many ways, workers’ compensation is a system based on conflict. We have “adjusters” who “investigate” your claim. A very small percentage of claims are ultimately denied as not being compensable, yet the claims review process is based on those claims rather than the vast majority, which resolve without any issues. Businesses stress the importance of customer service, and most employers agree that the workforce is the most valuable asset of any business. However, many businesses often fail to treat their own injured employees with the same consideration they give to their customers. That customer service focus needs to be extended not just to customers but to employees.

In discussions around creating an “Advocacy-Based Claims Model,” employers adopting this approach are seeing less litigation, lower costs and greater employee satisfaction. Rather than just denying a claim and inviting litigation, workers are told about benefit options that are available when workers’ compensation is not appropriate. Changing this model is about changing attitudes, the language we use to communicate and even the workflow. It can be done.

Workers’ compensation is still a valuable protection for both injured workers and employers. However, the time has come for it to evolve to better reflect the realities of the current workforce, risks present in the workplace, and advances in science and medicine. If workers’ compensation is to remain relevant for another 100 years, it needs to keep up with changes in society.

Stepping Over Dollars to Pick Up Pennies

The U.S. Department of Labor (DOL) is determined to establish regulation over excessive loads and charges built into and sometimes hidden inside 401(k) plans. The costs are known as basis points, called “Bps” (Bips) in the industry, and they represent hundredths of a percent. For example, a load of 60 basis points equals 0.6%, and 100 basis points equals 1%. The DOL’s logic is that trustees and plan fiduciaries are too often oblivious to the excessive costs built into the plan and the resulting reduction in the investment performance for the plan participants.

But why are we being distracted about 401(k) pennies when the real culprits have created a healthcare system where hundreds and thousands of excessive cost “Bps” are annually overcharged to plan participants and employers?

Where is the outrage over the lack of transparency for disclosing fees, charges, expenses and loads built into the healthcare system and health plans offered to employers by insurance companies and HMOs?

Why is no one demanding accountability for massive claim payment errors, overcharges, hidden charges and compensation, excessive fees, hidden spread pricing or medical errors?

Health plan fiduciaries are typically oblivious to the true costs hidden inside their plans in the same way they don’t understand the all-in costs of their 401(k) plan. The major difference is that healthcare waste can easily be 10 times greater than the “Bps” being scrutinized inside 401(k) plans.

Imagine if the plan sponsor was held accountable to a fiduciary standard when managing the health plan. Ignorance is not a defense available to a fiduciary.

How will you change the way you manage healthcare when the DOL’s Employee Benefit Security Administration declares that health plans are subject to 408(b)(2) regulations?

Do you know what questions to ask? Here are a few to think about. See if you know the answers. If you don’t know the answers, then ask yourself, why not? Are you going to wait until regulations mandate that you act in a prudent manner in the best interest of the plan and the participants?

  1. What is the claims payment error rate by your insurance company, health maintenance organization (HMO) or third-party administrator (TPA)? What’s the impact when 3% to 10% of plan expenses are errors?
  2. How much does spread pricing by the pharmacy benefits manager (PBM) cost the health plan participant?
  3. Which physicians are the bad actors whose practice patterns are more than 300% outside established medical evidence protocols?
  4. Which hospitals charge 1000%-plus above Medicare payment rates?
  5. How much did iatrogenic disorders cost the plan?
  6. What percentage of readmissions were preventable?
  7. How much are labs, urgent care, MRIs and Emergency Departments upcoding and overcharging the health plan? What happens when you are accountable because your health plan and participants are paying four to 10 times more for the exact same services?

Health plan court cases about violating ERISA and fiduciary standards are starting to attract the attention of the DOL. Plan sponsors need to change their focus and look at what is really happening inside their health plan(s) and the all-in costs of their providers, just like they are doing now with the pennies in the 401(k) plan.

The dollars you are stepping over will have a dramatic impact on the bottom line of the health plan and its participants. Be prepared in the not too distant future to manage healthcare to a fiduciary standard. But, what you should be thinking now is, why wait?