2019 US Insurance Awards: Zurich North America, Managed Care Provider Team of the YearPosted On: May. 1, 2019 12:00 AM CST
Early intervention is the best way to mitigate the risks of injured workers becoming addicted to opioids and other controlled substances — a cornerstone of Zurich North America’s playbook for handling potentially complicated claims.
And while the notion of addressing claims at first light appears simple, Zurich’s “multifaceted approach” of deploying data, predictive modeling, claims flagging, nurse case managers and real-time insights have helped the workers compensation insurer produce better outcomes, said Dr. Nina McIlree, the company’s Schaumburg, Illinois-based vice president of medical management.
Zurich introduced its system of managing claims about a decade ago, but it has been enhanced year after year by gathering claims characteristics to better understand issues that could prolong and complicate a claim, such as overutilization of drugs.
The latest tool is Zurich’s Vital Signs predictive model, which evaluates claims variables, including prescription drug use and injury information, to weigh whether a claim requires more attention. Vital Signs has resulted in nurse case management referrals that come in 2.5 times faster than before the tool was deployed two years ago, resulting in cost-mitigation savings between $6,000 and $26,000 per claim, according to company statistics.
“This is utilizing data through predictive modeling that starts at day one of the loss,” she said. “As the claim matures and more data is obtained, there are tools to identify issues, such as triggers for potential overutilization” of such drugs as opioids and benzodiazepines — both nervous system depressants that can hinder recovery.
The strategy in terms of opioids alone has resulted in a 50% average reduction in prescribing the drugs to injured workers since 2017, according to company data. Targeting opioid and benzodiazepine overuse and misuse has resulted in a 49% lower spend, 62% fewer claimants and 63% fewer prescriptions, the company reported.
Knowing that case histories could help steer new claims, the challenge was to create a user-friendly system for claims managers and nurse case managers that put to use an “enormous amount of data” on past claims, said Dr. McIlree. “We created a dashboard that is very clear,” she said of the simplified platform that provides users alerts similar to traffic stoplights, warning claims managers that the predictive model is showing a claim may be problematic. “If something goes from green to yellow, you have to see what is driving it, if it goes to red you have to see what is driving it.”
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• Gallagher Bassett Services Inc. — The Return to Work team identifies and addresses issues that impact an early return to work such as employee perceptions of injuries, poor communication between the individual and employer, and the lack of a return to work plan.
• Liberty Mutual Insurance Co. — Liberty Mutual and its wholly owned third-party administrator Helmsman Management Services continually refine the care of catastrophically injured workers, securing the right care at the right facilities, facilitating appropriate home health care, home modifications and durable medical equipment, and managing their return to work through managed care enhancements.
• Sedgwick Claims Management Services Inc. — Sedgwick’s surgery nurse program helps manage high-cost surgical claims more effectively by proactively engaging injured employees, providing dedicated nurse resources and technology to help injured employees prepare for surgery and recover afterward using a prehabilitation/ rehabilitation model to improve outcomes.