Claims Management - ESM Solutions, Inc.

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Transcript Claims Management - ESM Solutions, Inc.

Workers’ Compensation

Reducing risk and cost

Building a successful partnership

Presented by ESM Solutions, Inc.

Executive Summary

• Thank you for considering ESM Solutions, Inc. as a service provider to your company. This deck provides specific details as to the depth of service ESM can provide. • • • • • • • • • Our staff of trained professionals includes individuals who have the necessary professional designations needed to carry out the required risk management services. Designations that include: • Associate in Risk Management – ARM • Associate in Enterprise Risk Management – ARM-E Associate in Management – AIM Certified Safety Professional – CSP Workers’ Compensation Claims Management Professional – WCCP Workers’ Compensation Claims Management Associate – WCCA Certified Professional Disability Manager – CPDM Self Insured Professional – SIP Project Management Professional - PMP Masters in Project Management – MBA Please visit our website for more information:

What we Strive for

• Employer Service Objectives • Provide services focused on reducing the frequency and severity of workplace injury • • Meet with key decision makers to create an effective safety and claims management plan Establish and maintain good working relationships with employers • • Provide Workers’ Compensation management training to the reduce the risk and cost of workplace injury exposure Provide excellent value-added service • Ensure services goals are met

“Over the past seven years, ESM served an important role in helping VSP Vision Care decrease our workers' compensation claims and costs. ESM developed a deep understanding of our unique business and is a strategic partner.”

- April Bettencourt, Manager,

Benefits & Payroll,

Vision Service Plan (VSP)

ESM Engagement Strategy

INTRODUCTION REFERRAL SERVICE OBJECTIVES Work Comp Policy written WC service needed – ESM introduced Broker completes “Referral Form” sends to ESM ESM / Broker/ Client develop a POA for client ESM Service plan initiated Carrier/Broker/Client maintain presence in service stream Assist insured with mitigating Work Comp risk and cost Client and Broker results & satisfaction

Training & Education

Training Solutions

Only ESM offers:

Leading-edge Workers’ Compensation market intelligence and insight through:

• • • • • Live Lunch & Learn Onsite Safety Training Webinars (live and recorded) Development of Computer Based Training Modules (CBTs) Private branding Check out our 90 second trailer!

Safety Video Development

• • Private Branded Safety Training Videos: • Safety Videos • • E.g. IIPP Overview Legislative Updates • • E.g. SB863 Informative Videos • E.g. New Hire Safety Orientation process “Green Screen” productions available Check out our 30 second promotional video!

Safety Management

Building a Safety program Safety Foundation

Risk Assessment Define prioritized scope of work Prepare Corporate S&H Policy Develop Injury & Illness Prevention Program Develop Safety & Health Manual

Safety Application

Ongoing, structured Safety Committee Meetings Ongoing, scheduled Safety Inspections & Trending Relevant and compliant Safety Training Standardization of Processes for scalability and sustainability

Risk Assessment

• • Comprehensive Risk Assessment for employers • Workers’ Comp / Safety Audit • • Conduct an audit of written programs to ensure compliance and accuracy of organizational practices Conduct a site inspection to identify leading exposures Report • Summary of risk • • SWOT analysis of Safety & Work Comp program Recommendations • • Acceptable or unacceptable risk Roadmap for risk management improvement

Return To-Work Claims Management Insured Safety Compliance

Injury & Illness Prevention Plan

• Injury & Illness Prevention Program Review and Revision • • • Ensure compliance with Cal-OSHA’s required 8 elements • Code of Safe Practices (COSP) 9 th Construction industry element required for Ensure written programs reflect field practices Supporting forms and checklists include: • • • • • Accident investigation form Inspection checklist by industry Employee safety contact report Employee warning record Supervisor report of Injury Optional training programs: • IIPP Overview • Bloodborne Pathogens • Distracted Driving • Ergonomics • Fire Extinguisher • Hearing Conservation • Heat Illness Prevention • Housekeeping, Slip –Trip-Fall • Material handling/back safety • Industrial Truck / Forklift • • Optional: Provide Do-It-Yourself compliance based train-the trainer programs • Includes training schedule, attendance forms, learner’s guide, PowerPoint Training, quizzes and answers Private or co-branding available

Program Introduction

Customer Engagement

Phase 1 – IIPP Review

Complete IIPP Evaluation Questionnaire Collect Background Information Current Injury & Illness Prevention Plan OSHA 300 log (past three years) Training records (samples) Inspection reports (samples) Loss runs if available (most current) Review client’s current IIPP

Phase 2 – IIPP Revision

Analyze supporting documentation Revise and reformat IIPP Identify missing Cal-OSHA compliance requirements Ensure IIPP meets Cal-OSHA standards Prepare revised IIPP Outline Coordinate with client regarding questions, or additional information needed Revise / develop custom checklists for implementation and compliance

Phase 3 – IIPP Roll out

Provide revised IIPP, action items and Bi-monthly safety training modules to client Collaborate on revised program Multiple drafts may be required Ensure procedures reflect organizational practices Safety training modules include: PPT Presentation, Learner’s Guide, Quiz and Answers Adopt revised IIPP Provide IIPP training to Supervisors / Managers Provide bi-monthly safety training to employees Client ESM Joint Provide ongoing consultation and support, including annual refresher to IIPP

Safety Management Program

• •

Monthly or Quarterly Safety Management program

• • Assist with development of or attendance at insured’s Safety Committee meetings for the purpose of acting as a technical advisor. • Goals include assisting insured with effectively reviewing, revising and communicating the organizations safety initiatives. Program includes the following functions: • • Customized IIPP Safety & Health Manual • • Cal-OSHA compliance policies and training for leading exposures • E.g. Industrial truck, LOTO, Electrical safety etc.

Inspection checklist and schedule Training matrix (including tailgate schedule and material) • • • Onsite quarterly safety committee meetings Ongoing email/phone communication and support


Return-To-Work Program

• Return To Work program • • • • • • • • • Program includes: Written RTW management plan and policy statement Establishing a support team • Assign roles and responsibilities (via committee) Establish process and procedures for organization Identify and develop written Temporary Alternative Duties (TADs) Document physical requirement of job tasks (“Essential Functions”) • Develop communication tools to stakeholders Carrier, Medical provider, Supervisors, Employees Train supervisors and managers Provide ongoing consultation regarding management and ensure compliance with the “Interactive Process” per FEHA regulations

Return-To-Work Implementation

Phase 1

Foundation Write a management plan and policy statement Build a support team and assign roles and responsibilities Establish process and procedures

Phase 2

Assessment Review and Revise Job Descriptions Identify Temporary Alternative Duties (TADs) Document physical requirements Evaluate Business Benefit

Phase 3

Launch Coordinate communication Train supervisors and managers Launch RTW program to all employees


Return To Work Development Process

Program Introduction

Program Engagement RTW Evaluation Questionnaire Collect Background Information Current RTW Plan and/or Policy Recent work status report from designated Medical Provider Job descriptions Alternative duties Loss Runs X-Mod Worksheet/WCIRB

Phase 1 - Foundation

Write Management Plan and Policy Statement Build Support Team Assign RTW Coordinator Assign Roles and Responsibilities Establish Process and Procedures Planning Checklist

Phase 2 - Assessment

Review & Revise Job Descriptions to include Essential Functions Identify Temporary Alternative Duties (TADs) Document Physical Requirements

Phase 3 - Launch

Coordinate Communication Coordinate with Employee Coordinate with Medical Provider

Coordinate with Claims Administrator

Train Supervisors /Managers Flyer PPT Letter to employees Roll out to all Employees ESM Support Member

Claims Management

Why Claims Management?

• • • • • • • • • • • SB899 Reform results continue to erode SB863 legislative changes and impact X-Mod analysis and control Medical cost inflation Increase in Medicare Set Aside Abuse of medical lien process Increase in cost containment factors Legislative changes New case law impact Increasing litigation Turnover in claims examiners

"I have worked with Sharon Poston of ESM Solutions, Inc. for almost 7 years. She is the most knowledgeable person I have met, in the ever changing arena of workers' compensation. If you have a question, she has the answer. Sharon is a most supportive ally for any company in need of an advocate. I would not want to work without her valuable input. “ -Mary MacDonald, Safety Manager,

Robert Mondavi Winery

Claims Management Schedule

Policy Year Milestones Referral Form Letter of Auth from client Q1 Summary Report Claims Review Q2 Unit Stat Report X-Mod Forecast Q4 Renewal Report Policy Year Application Analyze reserves Litigation Management Ongoing management of open indemnity claims Advisor to Employer/ Agency

Why Claims Management?

• • • • • • • • • Ongoing oversight and management of key claims Ensure examiner has positioned claim for speedy, cost-effective resolution Act as liaison for employer on all delayed claims, ensuring 90- day decision is met timely Ensure current labor code and case law are applied Recommend litigation strategies to resolve claims Ensure X-Mod accuracy Communication: Ongoing phone call and email communication for clients and staff Audit of Third Party Administrators as needed For more on our Claims Management process please visit our website:

Claims Management Reporting & Oversight Process

Claims Management

Claim is classified as MO or IND MO claim processed, closed in 90 days IND claim: 3 point contact, provide benefits

Disputed Claims

Claim is delayed and investigated for 90 day compensability determination Monitors Carrier for investigation process and strategizes decision

Large Loss Claims ( >$25,000 )

Develop a POA for resolution Strategize best practices for resolution ESM Client Carrier Carrier processes claim Begin RTW coordination with medical provider and client Begin RTW coordination with medical provider and client Determination is made to accept or deny Continue 30 day ongoing oversight and direction If ACCEPTED, manage claim to conclusion If DENIED and UNDISPUTED Close in 30 days If DENIED and DISPUTED Develop litigation strategy for resolution Monitor strategy for effectiveness and accountability Monitor settlement and any future medical award ESM analyze at 90 days for potential problems Oversees resolution strategy

The ESM Commitment

ESM’s Commitment

Results Driven

• • The ESM focus is to minimize risk and cost by reducing the frequency and severity of workplace injury and time off of work.

Our service team will provide a diversified portfolio of services that can assist your organization with your ongoing Workers’ Compensation needs and profitability.

Relationship Focused:

• ESM is driven to establishing and maintaining superior working relationships with all stakeholders by meeting with key decision makers and designing a mutual plan for success.

ESM is the Solution

• • • • • • •

Expertise in Safety & Workers’ Compensation Established relationship and understanding of Safety and Workers’ Compensation needs Results driven program plan of action Successful partnership with strategic resources Designations:


Responsive and friendly Raising the “BAR”

Benefits from Activities that get Results

Injury Prevention and Workers’ Compensation Claims Management

Where there are risks, there are Solutions