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Costly catastrophic claims are emerging in the workers compensation sector, partly driven by comorbidities and prescribing of expensive brand-name drugs, experts say.
Comp payers must quickly identify seemingly innocuous claims that have the potential to balloon out of control and proactively work to mitigate those costs, they say.
More than 80% of medical costs in workers comp are for claims between $10,000 and $500,000, according to Boca Raton, Florida-based National Council on Compensation Insurance Inc. And although overall comp claims are declining, the number of claims exceeding $10 million in comp jumped to 10 in 2016, according to NCCI, compared with just four during the prior year.
While catastrophic injuries affect those figures, comorbidities, lower-body fractures, back strains and shoulder injuries can also lead to substantial claims in some cases, experts say.
Comorbidities, such as hypertension and diabetes, can increase the cost of an injury that seemed to be a $30,000 to $40,000 claim to six or seven figures, said Anita Jovic, vice president of operations at Home Care Connect LLC in Winter Park, Florida, which provides home health services for injured workers.
“The injured worker may not know they have an underlying diagnosis,” she said. “For instance, in a crushing injury, if you find out (the worker has) diabetes, that claim balloons. The patient may have a wound that may not be healing as quickly … that prolongs the care.”
“Comorbidities in general are something we keep at the forefront of our purview,” said Helen Froehlich, the vice president of case management services for Wayne, Pennsylvania-based Genex Services LLC. “What I have seen have a drastic impact on our claims has been very consistently high blood pressure, obesity and adult onset diabetes. Being aware of where a comorbidity is, whether it has a direct potential impact on that individual case … is imperative.”
Patchez Pirtle, the director of catastrophic services for Owings Mills, Maryland-based Restore Rehabilitation LLC, said she’s seen pelvis fractures, heel fractures and rotator cuff injuries grow into very expensive claims.
Those injuries don’t “necessarily set off alarm bells, but do tend to become very expensive claims,” she said. Often complications from those types of injuries aren’t realized until the employee has been sitting home for months on pain medications, making it more difficult to get that claimant going in the right direction.
Brand-name medications can be a big concern, said Dan Anders, an attorney and chief compliance officer for Tower MSA Partners in Delray Beach, Florida, which specializes in Medicare set asides in workers compensation.
“If there’s a brand-name medication … that comes out during the course of their treatment that the doctor thinks is the next wonder drug, it gets placed on the claim and drives up the cost,” he said. “Opioids, for the most part, are available as generic and may not be too pricey, but it’s the long-term effects … they require a lot more management by a physician, which means more visits, and tend to have side effects. The side effects can increase such that there’s more medications being prescribed that are nonopioids to deal with those side effects.”
Injuries like back strains or shoulder trauma, which at the outset seem like a standard claim, can also become catastrophic claims because if the initial treatment doesn’t work, “brand-name medications are prescribed and then pain management escalates into a psychiatric issue,” Mr. Anders said.
The key is identifying which claims could escalate, including those driven by expensive medications, said Amy Bilton, shareholder at Nyhan, Bambrick, Kinzie & Lowry P.C. in Chicago. For example, one of her current cases involves a man in his 20s who had a previously asymptomatic condition become symptomatic due to his exposure to fumes at work, ultimately leading to renal failure. His monthly infusion drug, Soliris — which was the only treatment option — costs $1 million a month. However, she said they’re constantly looking to see if any new drugs or treatment options are in the works.
“This is obviously an extreme example, but that’s what a lot of these (high cost) cases come down to — extreme examples,” she said.
Tracy Ryan, chief claims officer of global risk solutions at Boston-based Liberty Mutual Insurance Co., said in the past 10 years the company has used a predictive model for claims it designates as “slow developing medical” to help identify these types of expensive claims earlier. The model looks at medical bills, comorbidities, pharmaceuticals and treatments, and by combing through that data constantly, it can send an alert to the claims adjuster to review it before the costs potentially soar.
“We have seen significant reductions that we associate with putting that model in place, and the ability to get nurses on those files sooner, engage with doctors, talk about treatment plans … it’s an area that is always important because (these types of claims) can look innocuous at the beginning.”
Warning signs that a claim may require more scrutiny may also be evident. “You can see the writing on the wall when a worker goes in and asks for an opioid by name — you know you’re in trouble,” said Ms. Bilton. “And intuition is super important. If you feel like the claim could go bad, treat it as if it’s going to.”
Another key is maintaining a “settlement mindset” from the day the claim is filed, according to Mr. Anders, and ensure that you’re clearly communicating with the worker and getting medical case management early on in the claim.
“You should be thinking about what should be addressed in that claim to ensure, of course, that the injured worker gets the treatment that they need, that the treatment doesn’t go beyond what’s reasonable, and that you’re not paying for treatment that’s unrelated to that injury,” said Mr. Anders.
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