1 00:00:02,190 --> 00:00:03,990 Welcome to the WorkSafe podcast. 2 00:00:04,470 --> 00:00:09,840 Today we're diving into a challenging but important topic, high risk and high 3 00:00:09,840 --> 00:00:11,910 dollar workers' compensation claims. 4 00:00:12,720 --> 00:00:17,280 When a workplace injury turns serious, it's more than just a health concern. 5 00:00:17,820 --> 00:00:21,000 It can have long-term effects on the injured worker, the 6 00:00:21,000 --> 00:00:22,620 employer, and the business itself. 7 00:00:23,865 --> 00:00:25,604 These aren't your typical claims. 8 00:00:25,875 --> 00:00:30,404 They often require a different approach, closer attention, and stronger 9 00:00:30,404 --> 00:00:36,525 communication to help us understand what sets these claims apart and how 10 00:00:36,525 --> 00:00:38,474 employers can manage them effectively. 11 00:00:38,775 --> 00:00:43,394 We're joined by em's, manager of Medical Services, Lindy Baral, and 12 00:00:43,394 --> 00:00:46,035 Claims Operation Manager Shannon Fox. 13 00:00:46,724 --> 00:00:52,065 We'll talk about early warning signs, cost drivers, communication strategies, 14 00:00:52,334 --> 00:00:56,535 and what employer should focus on if they find themselves facing one 15 00:00:56,535 --> 00:00:58,184 of these claims for the first time. 16 00:01:00,675 --> 00:01:02,235 Welcome to the podcast, ladies. 17 00:01:02,235 --> 00:01:04,845 I know you've been with us before in different respects, 18 00:01:04,845 --> 00:01:06,015 so we're glad to have you back. 19 00:01:06,824 --> 00:01:08,205 Thank you for having us back. 20 00:01:08,895 --> 00:01:09,780 Yes, thank you so much. 21 00:01:11,940 --> 00:01:16,770 To get us started off, let's talk about what we mean when we say high 22 00:01:16,770 --> 00:01:19,860 risk or high dollar work comp claims. 23 00:01:20,400 --> 00:01:24,210 You know, it could be a very general term, so I wonder if you could share 24 00:01:24,210 --> 00:01:29,850 with us any common characteristics or red flags that kind of set these 25 00:01:29,925 --> 00:01:33,300 apart from a more typical claim. 26 00:01:34,290 --> 00:01:34,860 Okay. 27 00:01:34,920 --> 00:01:38,610 You know, I would say from a claims handling perspective. 28 00:01:39,135 --> 00:01:43,455 These are the files that we know could have long-term medical 29 00:01:43,455 --> 00:01:48,585 treatment, significant time away from work or even, um, high 30 00:01:48,585 --> 00:01:50,535 potentials of litigation involved. 31 00:01:50,835 --> 00:01:53,835 Um, these are the claims where medical treatment can extend 32 00:01:53,835 --> 00:01:57,015 beyond maximum medical improvement. 33 00:01:57,095 --> 00:01:59,945 And an injured worker could have complications for the 34 00:01:59,945 --> 00:02:01,565 rest of their life possibly. 35 00:02:02,065 --> 00:02:05,275 I think what sets them apart is the complexity. 36 00:02:05,935 --> 00:02:08,515 Multiple medical providers are involved. 37 00:02:08,905 --> 00:02:14,665 Extended recovery surgeries, usually it's definitely more than one or 38 00:02:14,965 --> 00:02:19,585 uncertainty around whether the employee will even return to work at all. 39 00:02:20,155 --> 00:02:24,205 So from a claims perspective, that is what I've seen in the past. 40 00:02:24,205 --> 00:02:27,265 I don't know if, Lindy, if you have anything additional to add to that. 41 00:02:28,135 --> 00:02:29,155 I completely agree. 42 00:02:29,155 --> 00:02:33,895 Those are identifying factors that can prolong the recovery of an 43 00:02:33,895 --> 00:02:38,155 injured worker and, uh, make them a more high dollar or high risk claim. 44 00:02:38,695 --> 00:02:43,345 I think Shannon's team, uh, over in claims operations, the claims representatives 45 00:02:43,345 --> 00:02:48,625 are experts in helping to evaluate when a claim comes, what are the factors that 46 00:02:48,625 --> 00:02:53,335 should, will make this a more challenging claim to manage and create a more 47 00:02:53,335 --> 00:02:55,375 long-term recovery for the injured worker. 48 00:02:55,375 --> 00:02:55,705 So. 49 00:02:55,985 --> 00:03:01,025 That the, they are the experts to evaluate and understand those factors and 50 00:03:01,025 --> 00:03:04,835 determine what additional support that they may require in managing the claim. 51 00:03:06,725 --> 00:03:10,295 Well, Lindy, that was a good point and I, this may be a question for Shannon, 52 00:03:10,295 --> 00:03:15,965 so either one of you feel free to jump in, but I wonder if something is early 53 00:03:15,965 --> 00:03:20,555 on, you know, it's gonna be pretty clear that there's gonna be a lot of providers. 54 00:03:21,100 --> 00:03:26,620 Multiple surgeries, long-term recovery plan, maybe not even a complete 55 00:03:26,620 --> 00:03:29,380 recoveries is possible with some injuries. 56 00:03:29,740 --> 00:03:36,905 So if that happens and it starts to go through our claims processes at MEM. 57 00:03:37,945 --> 00:03:41,945 Are we providing a different type of approach to those claims as 58 00:03:41,945 --> 00:03:46,214 far as do they get more of a team approach, something that, is more 59 00:03:46,394 --> 00:03:50,825 relationship building than say maybe a couple doctor visits type of claim. 60 00:03:51,244 --> 00:03:53,975 And I wondered if you could talk with us a little bit about 61 00:03:53,975 --> 00:03:55,325 how that might look different. 62 00:03:56,674 --> 00:04:00,385 You know, I would say when a claim does arrive and when 63 00:04:00,385 --> 00:04:02,424 we have the initial notice. 64 00:04:03,234 --> 00:04:06,835 That is going to be a high risk or high dollar claims. 65 00:04:06,835 --> 00:04:10,345 We do involve multiple people in our decision making process. 66 00:04:10,945 --> 00:04:11,395 Right. 67 00:04:11,495 --> 00:04:16,085 I know that, um, an example could be, which we see a lot, 68 00:04:16,145 --> 00:04:21,200 falls from high levels, a roof, a high ceiling, things like that. 69 00:04:21,605 --> 00:04:26,105 It could be a traumatic brain injury when someone falls and land on their head. 70 00:04:26,155 --> 00:04:27,415 We've had a lot of those. 71 00:04:28,240 --> 00:04:35,280 When those enter into the organization with factors that are extenuating nurse 72 00:04:35,280 --> 00:04:41,520 case management, they are on top of the claim just making sure that they utilize 73 00:04:41,520 --> 00:04:45,810 their resources effectively because we do have the ability to outsource nurse 74 00:04:45,810 --> 00:04:48,510 case manager on high dollar claims. 75 00:04:48,510 --> 00:04:49,020 Right. 76 00:04:49,440 --> 00:04:52,620 And that's in the hundreds of thousands I'm speaking about. 77 00:04:53,535 --> 00:04:59,145 And we also have all of our departments involved when high dollar claims come in. 78 00:04:59,145 --> 00:05:02,055 So it's not just claims looking at the file. 79 00:05:02,055 --> 00:05:08,635 I have claims I have the technical services unit, I have sometimes executives 80 00:05:08,635 --> 00:05:10,825 get into the file field service managers. 81 00:05:10,825 --> 00:05:11,995 So it is really. 82 00:05:12,340 --> 00:05:16,120 A team approach to assure that we're not missing anything. 83 00:05:16,120 --> 00:05:20,440 And also subrogation may come into play with higher dollar claims just to make 84 00:05:20,440 --> 00:05:27,099 sure all of the professional eyes are on the file and we're open to recommendations 85 00:05:27,640 --> 00:05:31,480 from anyone to assure that we're moving that claim along appropriately. 86 00:05:33,849 --> 00:05:36,460 Hard to add a lot to what Shannon has just indicated there. 87 00:05:36,460 --> 00:05:41,409 I think it is critically important to have experts in each area to help 88 00:05:41,700 --> 00:05:47,109 identify and eliminate any risks or untoward actions that may take place. 89 00:05:47,109 --> 00:05:51,530 So, critical to get all of those individuals involved and, um, have 90 00:05:51,530 --> 00:05:55,789 the nurse case manager assist with facilitating all of the medical care 91 00:05:55,789 --> 00:06:00,920 and help to coordinate all of those external providers, external stakeholders 92 00:06:00,920 --> 00:06:02,435 that become involved with these claims. 93 00:06:04,860 --> 00:06:08,450 Well, the way you all answered it is pretty much what I suspected. 94 00:06:08,450 --> 00:06:13,790 So what I'm taking away from that is when there is a claim that's 95 00:06:13,790 --> 00:06:17,090 classified in these areas and we know is gonna require more. 96 00:06:17,930 --> 00:06:24,080 Our policy holders and even the injured worker can expect a team approach 97 00:06:24,170 --> 00:06:29,840 and ensuring that all of the bases are covered in every way to ensure 98 00:06:29,840 --> 00:06:33,680 the best outcome, make sure nothing's overlooked and all of those things. 99 00:06:33,680 --> 00:06:35,440 So, I was just kind of curious. 100 00:06:35,440 --> 00:06:39,400 I figured it was probably a little bit different from just a typical, 101 00:06:39,460 --> 00:06:42,220 um, maybe somebody had to go to urgent care for something and, and 102 00:06:42,220 --> 00:06:43,600 then they were able to move on. 103 00:06:44,140 --> 00:06:51,099 So I know Shannon mentioned a couple of types of injuries that often result 104 00:06:51,099 --> 00:06:56,900 in high dollar and high complex claims, and she mentioned some falls from 105 00:06:56,900 --> 00:07:02,239 heights, uh, as being a big factor at something we do hear about Often. 106 00:07:02,239 --> 00:07:06,919 It's hard to come through something like that without a lot of problems. 107 00:07:07,249 --> 00:07:11,839 And so, I wondered if maybe the two of you could talk a little bit about. 108 00:07:12,364 --> 00:07:13,834 What types of injuries? 109 00:07:13,834 --> 00:07:16,024 So we know about falls, that's one for sure. 110 00:07:16,264 --> 00:07:20,284 But, and other ones too that maybe we might not think but can tend 111 00:07:20,284 --> 00:07:25,204 to escalate into a higher risk or more high dollar situation. 112 00:07:26,494 --> 00:07:26,854 Hmm. 113 00:07:27,424 --> 00:07:30,724 You know, motor vehicle accidents, they have their own dynamics when, 114 00:07:31,294 --> 00:07:34,024 um, the accident is extensive. 115 00:07:34,274 --> 00:07:35,384 Also I've seen. 116 00:07:36,244 --> 00:07:41,374 Underlying medical conditions like diabetes, I've seen lower extremity 117 00:07:41,434 --> 00:07:47,044 injuries have excessive costs because when you get an injured worker, you get 118 00:07:47,044 --> 00:07:51,814 them how they are, and that's underlying medical conditions such as hypertension, 119 00:07:51,814 --> 00:07:54,214 not just diabetes, heart issues. 120 00:07:54,574 --> 00:07:58,864 So when that comes into play you know, we can have really 121 00:07:58,864 --> 00:08:01,354 extenuating circumstances because. 122 00:08:01,849 --> 00:08:06,589 If an injured worker sustains an injury to their leg or their foot, maybe their 123 00:08:06,589 --> 00:08:12,049 healing time, their treatment time, and all of that will be extended because 124 00:08:12,049 --> 00:08:13,759 of the underlying medical condition. 125 00:08:14,130 --> 00:08:16,079 I can't think of anything additional. 126 00:08:16,079 --> 00:08:16,500 Lindy, 127 00:08:16,530 --> 00:08:17,640 can you think of something? 128 00:08:18,209 --> 00:08:19,919 Well, I think you touched on most of them. 129 00:08:19,919 --> 00:08:24,139 I would, you know, validate that our highest dollar claims are at the falls. 130 00:08:24,199 --> 00:08:26,269 We do occasionally see burns. 131 00:08:27,094 --> 00:08:30,874 Spinal cord injuries that often result from falls, but not always. 132 00:08:30,874 --> 00:08:33,855 Sometimes that is from motor vehicle accidents as well 133 00:08:33,855 --> 00:08:35,235 as traumatic brain injuries. 134 00:08:35,235 --> 00:08:41,294 But, um, I was also going to speak on even in circumstances that are outside of those 135 00:08:41,294 --> 00:08:46,680 most severe diagnoses, and those of course we know will require all hands on deck. 136 00:08:46,949 --> 00:08:50,430 But underlying personal health issues can truly impact the 137 00:08:50,430 --> 00:08:53,910 healing process and ultimately the recovery of an injured worker. 138 00:08:53,910 --> 00:08:57,749 So those are things that the claims experts have to be aware of. 139 00:08:58,050 --> 00:09:01,890 There are times when we have poor health literacy with individuals that just. 140 00:09:02,475 --> 00:09:07,355 Don't completely understand their medical recovery needs. 141 00:09:07,535 --> 00:09:09,005 There are language barriers. 142 00:09:09,185 --> 00:09:12,515 We've also discussed those injured workers that have more than one 143 00:09:12,515 --> 00:09:16,595 physician that really complicates the recovery for an injured worker, even 144 00:09:16,595 --> 00:09:20,405 outside of those higher level, uh, diagnoses that we've talked about. 145 00:09:20,405 --> 00:09:24,775 So, these claims are very complex, and if any of you have had a recent health 146 00:09:24,775 --> 00:09:29,035 issue or a family member or loved one that you've had to assist them with navigating 147 00:09:29,035 --> 00:09:32,815 out in our healthcare environment, it can be extremely challenging. 148 00:09:32,815 --> 00:09:37,855 So, in addition to these really, really severe diagnoses, it's a, 149 00:09:37,855 --> 00:09:41,380 a really a big challenge that our claims team has to all work together 150 00:09:41,380 --> 00:09:45,010 to assure that we're doing all of the right things to guide that injured 151 00:09:45,010 --> 00:09:46,510 worker through the recovery journey. 152 00:09:48,545 --> 00:09:50,015 Well, thank you for those insights. 153 00:09:50,015 --> 00:09:54,785 I think it was very interesting to hear about the different ways that 154 00:09:54,785 --> 00:10:00,565 other factors can play in, aside from just the initial impact or 155 00:10:00,565 --> 00:10:05,165 injury, but other complicating health factors communication barriers, 156 00:10:05,170 --> 00:10:09,485 things like that can also definitely get in the way of some of those. 157 00:10:09,485 --> 00:10:11,375 So it's good to think about that as well. 158 00:10:12,724 --> 00:10:17,165 In some of our previous episodes, we have discussed how 159 00:10:17,435 --> 00:10:19,714 complexity and severity can play. 160 00:10:20,570 --> 00:10:22,790 A significant role in the cost of a claim. 161 00:10:23,350 --> 00:10:28,439 But it can be difficult to identify that something is going to be 162 00:10:28,439 --> 00:10:30,689 complex from the very beginning. 163 00:10:30,719 --> 00:10:35,759 And I say that from an employer's perspective, so we may know 164 00:10:36,089 --> 00:10:39,599 what to look for, you know, as claims professionals, but. 165 00:10:39,844 --> 00:10:45,044 A business owner or a safety manager or, any of those types of folks may 166 00:10:45,044 --> 00:10:50,874 not know what some of those early warning signs, a claim could elevate 167 00:10:50,874 --> 00:10:54,054 to a more complex or costly scenario. 168 00:10:54,084 --> 00:10:59,454 So if we could share some advice with some of our listeners about what to 169 00:10:59,454 --> 00:11:04,155 look for as an early sign from their end, that might be helpful as well. 170 00:11:05,615 --> 00:11:06,094 Wow. 171 00:11:06,145 --> 00:11:07,045 Absolutely. 172 00:11:07,225 --> 00:11:12,535 You know, I would say if an employee is not improving throughout 173 00:11:12,564 --> 00:11:14,785 the medical process, right? 174 00:11:15,204 --> 00:11:20,244 If every time that you talk to them or you call and get an update 175 00:11:20,244 --> 00:11:24,175 about their work status, if they're saying that it's getting worse, even 176 00:11:24,175 --> 00:11:26,874 though treatment has been extensive. 177 00:11:27,670 --> 00:11:31,180 They've been in physical therapy, they may have steroid 178 00:11:31,180 --> 00:11:32,619 injections or something like that. 179 00:11:32,619 --> 00:11:39,069 That could be a red flag if treatment keeps on the path of not improving, right? 180 00:11:39,380 --> 00:11:41,750 Missed medical appointments is huge. 181 00:11:42,199 --> 00:11:46,069 Anytime you have an employee, they keeps saying they cannot attend appointments 182 00:11:46,069 --> 00:11:48,829 because of something happening at home. 183 00:11:49,430 --> 00:11:51,569 That could be a warning sign. 184 00:11:51,629 --> 00:11:54,420 Lack of communication is so important. 185 00:11:54,825 --> 00:11:57,465 That the policy holders stay in touch with the injured 186 00:11:57,465 --> 00:11:59,535 worker throughout this process. 187 00:11:59,925 --> 00:12:02,954 Or if there's confusion about their job duties, right? 188 00:12:02,984 --> 00:12:08,324 If someone returns to work light duty and they're not sure if they should 189 00:12:08,324 --> 00:12:13,124 show up or not, that's a gap in communication, which can cause claims 190 00:12:13,124 --> 00:12:15,494 to linger on and become more costly. 191 00:12:15,494 --> 00:12:18,734 So technically, employers should pay attention to, 192 00:12:18,834 --> 00:12:20,724 what's happening on the file? 193 00:12:20,994 --> 00:12:24,354 What's happening with this injured worker's, mental processes? 194 00:12:24,354 --> 00:12:28,614 Because sometimes employees don't feel supported throughout this whole process. 195 00:12:29,034 --> 00:12:33,664 And if an employee doesn't feel supported by their employer, that's another drawback 196 00:12:34,024 --> 00:12:36,794 which could, lead to more cost on a claim. 197 00:12:37,484 --> 00:12:40,454 You know, that was such a good answer and you've hit on many of the points 198 00:12:40,454 --> 00:12:41,684 that I was going to talk about. 199 00:12:41,684 --> 00:12:45,134 I think fundamentally communication is the key. 200 00:12:45,134 --> 00:12:50,594 And Shannon's staff, again, they are experts in, at the onset of the claim, 201 00:12:50,594 --> 00:12:55,514 assuring that they're taking in all of the appropriate information foundationally. 202 00:12:55,884 --> 00:12:59,514 Understanding what took place and learning about the injured 203 00:12:59,514 --> 00:13:03,204 worker and their role at work and communicating with the policy holder. 204 00:13:03,474 --> 00:13:07,884 All of those things start the claims process off on the right foot. 205 00:13:08,314 --> 00:13:11,765 Then you want to evaluate what is the expected timeframe of 206 00:13:11,765 --> 00:13:13,625 recovery for this individual. 207 00:13:13,625 --> 00:13:17,915 So the claims team works to determine through engaging with evidence-based 208 00:13:17,915 --> 00:13:20,584 platforms, what the expected. 209 00:13:21,159 --> 00:13:24,429 Recovery is for this injured worker with a diagnosis that they 210 00:13:24,484 --> 00:13:26,004 have their age comorbidities. 211 00:13:26,620 --> 00:13:28,750 What type of job that they'll be returning to. 212 00:13:28,750 --> 00:13:33,099 So all of these things we should be communicating with the policy holder 213 00:13:33,099 --> 00:13:36,610 and we'll be communicating with the policy holder to understand what the 214 00:13:36,610 --> 00:13:38,829 expectations are for the injured workers. 215 00:13:38,829 --> 00:13:43,270 So if we have lack of consistency of communication or missed appointments 216 00:13:43,319 --> 00:13:47,619 as Shannon indicated, those are red flags to engage and make sure 217 00:13:47,619 --> 00:13:51,279 that we're understanding why the injured worker is not recovering at 218 00:13:51,279 --> 00:13:55,119 the timeline that would be expected considering all of those factors. 219 00:13:55,504 --> 00:13:59,724 And sometimes that may indicate that the adjuster may engage with another 220 00:13:59,774 --> 00:14:04,274 team member and get them involved in helping them to evaluate the claim and 221 00:14:04,274 --> 00:14:07,664 where the action should move forward in getting that patient back to work. 222 00:14:09,374 --> 00:14:12,494 Well, it sounds like communication is really probably. 223 00:14:13,384 --> 00:14:18,784 The number one key here to ensuring things go as smoothly as possible, or helping 224 00:14:18,784 --> 00:14:20,944 to identify things early on that aren't. 225 00:14:21,394 --> 00:14:29,454 And I wonder if you ever encounter an employer policy holder who you know 226 00:14:29,454 --> 00:14:35,005 is hesitant to be involved, because obviously someone's medical information 227 00:14:35,005 --> 00:14:38,395 is, you know, HIPAA protected in many ways and those types of things 228 00:14:38,875 --> 00:14:40,400 are, are there things that are. 229 00:14:41,215 --> 00:14:47,155 Policy holders should know about what they can and can't ask about or stay in 230 00:14:47,155 --> 00:14:49,015 the loop on or, or those types of things. 231 00:14:52,585 --> 00:14:54,565 That's a very interesting question. 232 00:14:54,675 --> 00:14:57,204 . Because it is work related. 233 00:14:57,625 --> 00:15:00,925 The employer is entitled to obtain that information. 234 00:15:00,925 --> 00:15:01,405 Right. 235 00:15:01,925 --> 00:15:06,545 In all my years of handling claims, I have never encountered an employer 236 00:15:07,085 --> 00:15:11,885 that wanted to cross boundaries, right? 237 00:15:11,945 --> 00:15:18,035 Usually they allow us to share the information with them and they don't 238 00:15:18,545 --> 00:15:22,385 cross a boundary with trying to go too far into underlying personal 239 00:15:22,385 --> 00:15:24,905 medical type treatment, right? 240 00:15:25,265 --> 00:15:25,775 But. 241 00:15:26,315 --> 00:15:30,875 As the policy holder, they do have the ability to access this 242 00:15:30,875 --> 00:15:35,975 information, you know, just to know what is going on with the employee 243 00:15:36,155 --> 00:15:38,435 at every, per every level, right? 244 00:15:38,765 --> 00:15:43,115 Um, so technically I have not encountered that area of concern. 245 00:15:43,185 --> 00:15:46,875 I'm not sure if Lindy has had experiences on the nurse's 246 00:15:46,875 --> 00:15:49,455 side with matters like that. 247 00:15:49,935 --> 00:15:50,265 Right. 248 00:15:50,295 --> 00:15:53,535 Well, from the nurse case manager perspective, they are all registered 249 00:15:53,535 --> 00:15:57,935 nurses who assist in management of workers' compensation injuries. 250 00:15:57,935 --> 00:16:02,995 And there certainly is, a line where we may learn things about an injured 251 00:16:02,995 --> 00:16:04,315 worker and their personal health. 252 00:16:04,900 --> 00:16:09,280 That as a nurse is important in those conversations, but may not impact 253 00:16:09,280 --> 00:16:11,050 the workers' compensation claim. 254 00:16:11,050 --> 00:16:14,770 So those are areas in which we do not share personal health 255 00:16:14,770 --> 00:16:19,209 information that is not related to the claim or does not impact. 256 00:16:19,255 --> 00:16:23,575 The injured worker's recovery, and so it is a matter of professionals. 257 00:16:23,575 --> 00:16:24,565 I agree with Shannon. 258 00:16:24,565 --> 00:16:28,315 It has never been an issue in my many, many years of being a nurse 259 00:16:28,315 --> 00:16:32,275 case manager, but it is important for the nurse to engage with the injured 260 00:16:32,275 --> 00:16:37,225 worker holistically in order to help them through the recovery and maximize 261 00:16:37,225 --> 00:16:40,465 their potential to return to their highest level of functioning, which is 262 00:16:40,465 --> 00:16:42,355 hopefully returning to their full duties. 263 00:16:44,435 --> 00:16:47,165 Well, thank you for kind of walking through that with me. 264 00:16:47,165 --> 00:16:49,775 It sort of came to mind as we were talking and I was curious 265 00:16:49,775 --> 00:16:51,485 about that ever being a barrier. 266 00:16:52,084 --> 00:16:56,995 I know that, , Missouri Employers Mutual, NEM started obviously in 267 00:16:56,995 --> 00:17:02,275 Missouri and we now have a lot of policy holders as we've expanded our 268 00:17:02,275 --> 00:17:08,224 regional presence that have employees in either a state outside of Missouri. 269 00:17:08,595 --> 00:17:11,564 Or in multiple states and. 270 00:17:12,304 --> 00:17:16,785 That brings to light another question that maybe some of our policy 271 00:17:16,785 --> 00:17:18,405 holders might have or listeners. 272 00:17:18,435 --> 00:17:23,265 And that is in regards to work comp regulations being 273 00:17:23,355 --> 00:17:25,305 different within each state. 274 00:17:25,305 --> 00:17:28,834 So each state has its own set of rules and those types of things 275 00:17:28,834 --> 00:17:32,884 that have to be followed from a claims perspective and from a policy 276 00:17:32,884 --> 00:17:36,604 perspective, I was wondering if you could maybe share from your experience. 277 00:17:36,934 --> 00:17:42,334 Any regional differences or state to state type scenarios where you 278 00:17:42,334 --> 00:17:47,375 see that it can impact, the way a claim plays out is geography, 279 00:17:47,375 --> 00:17:49,715 access to care type of industry. 280 00:17:49,715 --> 00:17:51,695 Do those things make a difference? 281 00:17:53,975 --> 00:17:58,325 You know, in rural areas, access to specialty care can 282 00:17:58,325 --> 00:18:00,695 mean longer recovery times. 283 00:18:00,794 --> 00:18:04,274 If you're in a metropolitan area, you tend to have the 284 00:18:04,274 --> 00:18:06,435 availability of more providers. 285 00:18:06,925 --> 00:18:09,115 But then there could be higher costs, right? 286 00:18:09,295 --> 00:18:11,425 You know, even different types of. 287 00:18:12,265 --> 00:18:15,205 Employers and specific jobs. 288 00:18:15,205 --> 00:18:19,345 For example, if you're in an agricultural type area, if you are 289 00:18:19,345 --> 00:18:24,385 a truck driver, driving through different types of areas, that will 290 00:18:24,385 --> 00:18:26,754 change the dynamics of the claim. 291 00:18:27,115 --> 00:18:31,405 So yes, I mean now we are in other states, different states. 292 00:18:31,555 --> 00:18:36,745 Cost is significantly different, I would say, um, primarily in Arkansas. 293 00:18:37,389 --> 00:18:39,970 Medical cost is usually lower there. 294 00:18:39,970 --> 00:18:44,980 However, we're also in Illinois, so treatment costs could be higher there. 295 00:18:44,980 --> 00:18:48,170 So, there are definitely regional differences. 296 00:18:48,560 --> 00:18:53,630 What we try to do is, um, utilize our expertise along with the nurses, 297 00:18:53,960 --> 00:18:57,560 um, to try and figure out the best care for an injured worker. 298 00:18:57,860 --> 00:19:03,980 And when you're in a rural area, you have to drive longer, which can impact. 299 00:19:04,540 --> 00:19:07,210 An injured worker's ability to wanna go to the doctor. 300 00:19:07,210 --> 00:19:07,510 Right. 301 00:19:07,510 --> 00:19:11,950 The more you have to travel, the longer it is, the more reluctant you are to go. 302 00:19:11,980 --> 00:19:13,540 Longer healing times. 303 00:19:13,870 --> 00:19:17,590 Um, we have that even in the state of Missouri, someone's traveling from a 304 00:19:17,590 --> 00:19:22,900 rural area and they have to go to, um, a bigger city can be an area of concern. 305 00:19:22,900 --> 00:19:25,240 So that's just something that we have to work closely with. 306 00:19:25,630 --> 00:19:29,680 The nurses we try to accommodate, but sometimes it's not always possible. 307 00:19:30,070 --> 00:19:32,320 Lindy, did you have anything additional to add to that? 308 00:19:32,860 --> 00:19:33,340 Sure. 309 00:19:33,340 --> 00:19:37,210 I mean, this is such a great question because it is an important factor 310 00:19:37,290 --> 00:19:41,190 and definitely does play a role in how the claims team manages a claim. 311 00:19:41,560 --> 00:19:44,680 So there are states in which we get to direct care. 312 00:19:44,710 --> 00:19:48,610 Shannon's team can determine who the appropriate physicians are, but 313 00:19:48,610 --> 00:19:52,510 there are those in which the injured worker has the option to select care. 314 00:19:52,900 --> 00:19:57,300 We are very fortunate in that we have a very comprehensive medical network 315 00:19:57,300 --> 00:20:02,160 partner that has physicians throughout the nation, not just in our state. 316 00:20:02,160 --> 00:20:04,350 So there are a lot of opportunities there. 317 00:20:04,350 --> 00:20:08,520 However, each state has different rules and regulations regarding 318 00:20:08,520 --> 00:20:12,930 the processing of medical bills, and so there are states that have 319 00:20:12,930 --> 00:20:17,940 fee schedules that are specifically identified to say what the cost to a 320 00:20:17,940 --> 00:20:19,920 workers' compensation carrier can be. 321 00:20:20,535 --> 00:20:24,205 For each level of services provided. 322 00:20:24,295 --> 00:20:29,995 But there are also states in which there are no fee schedules and it is, these 323 00:20:29,995 --> 00:20:34,915 are usual and customary states where the providers can simply determine what 324 00:20:34,915 --> 00:20:39,505 a usual and customary amount should be paid for each of these services. 325 00:20:39,505 --> 00:20:44,345 So those are some challenges, but we work very closely with our medical network 326 00:20:44,345 --> 00:20:49,835 partner, our managed care partner, to assist us in number one, identifying the 327 00:20:49,835 --> 00:20:51,905 best providers for our injured worker. 328 00:20:52,145 --> 00:20:53,225 That's the number one thing. 329 00:20:53,225 --> 00:20:56,405 We wanna make sure that they receive the best level of care 330 00:20:56,405 --> 00:20:58,115 for whatever that injury might be. 331 00:20:58,445 --> 00:21:02,105 Um, and then we hope that we can find a provider in the network, which is 332 00:21:02,105 --> 00:21:07,065 generally very easy to do with the nature of our network being very comprehensive. 333 00:21:07,095 --> 00:21:12,525 But as Shannon indicates in certain areas, there may be a distance to be traveled. 334 00:21:12,525 --> 00:21:16,095 So we engage with other partners to say, are there options? 335 00:21:16,845 --> 00:21:21,585 Looking at virtual opportunities for care at times, which isn't always possible 336 00:21:21,585 --> 00:21:23,385 as you get into treat with specialists. 337 00:21:23,385 --> 00:21:27,115 But that's an option for some injured workers that live in rural areas 338 00:21:27,335 --> 00:21:31,905 and doing everything that we can to limit the disruption to the injured 339 00:21:31,905 --> 00:21:36,135 workers' life while still allowing them to receive the best medical care. 340 00:21:38,145 --> 00:21:40,905 Those are all really good points and I appreciate you guys. 341 00:21:41,685 --> 00:21:43,455 Kind of sharing that with us. 342 00:21:43,485 --> 00:21:47,475 It's just something to think about that maybe, you know, when you're 343 00:21:47,475 --> 00:21:51,645 faced with an injury, you're not really thinking location matters or state 344 00:21:51,645 --> 00:21:53,295 regulations or those types of things. 345 00:21:53,295 --> 00:21:57,195 So it's nice to know kind of how that plays out and what people 346 00:21:57,195 --> 00:21:59,505 can expect in different ways 347 00:21:59,555 --> 00:22:04,505 while we're talking about the cost of these types of claims, you know, we 348 00:22:04,505 --> 00:22:06,545 mentioned that they're usually very high. 349 00:22:06,665 --> 00:22:11,435 These that are multifaceted and, you know, require care from a 350 00:22:11,435 --> 00:22:15,215 team of providers and physical therapy and those types of pieces. 351 00:22:15,695 --> 00:22:17,915 We know medical expenses are on their eyes. 352 00:22:17,915 --> 00:22:18,215 Right. 353 00:22:18,215 --> 00:22:19,685 So, I mean, that's not a surprise. 354 00:22:19,685 --> 00:22:20,525 They always are. 355 00:22:21,065 --> 00:22:25,685 But if you could talk a little bit about, from your perspectives, what 356 00:22:25,685 --> 00:22:32,735 the biggest drivers are that make these types of claims become so expensive. 357 00:22:33,335 --> 00:22:37,530 Well, I would say that the biggest drivers. 358 00:22:38,965 --> 00:22:42,205 Outside of medical treatment, I think there's something that we probably 359 00:22:42,625 --> 00:22:50,275 didn't touch on is like a high risk claim when there is a brain injury, right? 360 00:22:50,365 --> 00:22:53,455 Or if someone gets paralyzed. 361 00:22:53,505 --> 00:22:56,445 Where we talk about those, it's not only are we looking at 362 00:22:56,445 --> 00:23:00,225 treatment in our immediate area, but sometimes we have to send. 363 00:23:00,790 --> 00:23:02,880 Your worker to a center of excellence. 364 00:23:02,880 --> 00:23:06,360 And that could be in Nebraska, it could be in Illinois. 365 00:23:06,780 --> 00:23:11,850 And if their family is located in Missouri or somewhere other than 366 00:23:11,850 --> 00:23:15,180 where the center of excellence is located, then you have another. 367 00:23:16,485 --> 00:23:18,285 Cost driver, right? 368 00:23:18,345 --> 00:23:23,145 And it's not only a financial impact to the company, but it's a financial impact 369 00:23:23,145 --> 00:23:27,775 to the family to have to uproot sometimes and be with your worker while they go 370 00:23:27,775 --> 00:23:29,755 through this extended medical treatment. 371 00:23:29,755 --> 00:23:34,205 Just something else to consider on larger type cases but in a normal 372 00:23:34,205 --> 00:23:38,435 type claim where yes, high risk, but not that high like a brain 373 00:23:38,435 --> 00:23:41,075 injury or someone being paralyzed, 374 00:23:41,155 --> 00:23:43,255 lost time from work can be huge. 375 00:23:43,625 --> 00:23:48,755 The mental component that has been added to large portions of our claim 376 00:23:48,805 --> 00:23:51,295 has been significant since COVID. 377 00:23:51,345 --> 00:23:53,925 That's what I've seen from a claim selling perspective. 378 00:23:53,925 --> 00:23:59,505 We used to have that mental component to a smaller degree, but now post 379 00:23:59,505 --> 00:24:03,585 COVID, it seems as if that mental component has just skyrocketed. 380 00:24:04,260 --> 00:24:07,020 Anytime you have a claim, it's like we're dealing with a mental 381 00:24:07,020 --> 00:24:11,430 component, which definitely extends the cost and the life of a claim. 382 00:24:11,790 --> 00:24:18,760 You know, multiple physical therapy sessions and work conditioning and, oh my 383 00:24:18,760 --> 00:24:22,780 god, prescription medical cost excessive. 384 00:24:23,110 --> 00:24:27,520 So if you compound all of that and then you add in a legal component, that 385 00:24:27,520 --> 00:24:30,460 financial impact grows even more so. 386 00:24:31,975 --> 00:24:34,695 Lady, do you have anything from, a medical treatment 387 00:24:35,295 --> 00:24:36,225 standpoint? 388 00:24:36,275 --> 00:24:39,755 I just wanted to add on to your discussion surrounding the center 389 00:24:39,755 --> 00:24:43,085 of excellence, and although we know it is a higher cost to send 390 00:24:43,085 --> 00:24:45,425 individuals to a center of excellence. 391 00:24:46,235 --> 00:24:50,915 Maybe the term center of excellence is not just thrown around and anyone could 392 00:24:50,915 --> 00:24:53,165 be termed to be a center of excellence. 393 00:24:53,195 --> 00:24:57,955 It is a designation of hospitals, which provide the highest level 394 00:24:57,955 --> 00:24:59,335 of care for these severe injuries. 395 00:24:59,335 --> 00:25:03,115 And I just wanted to say that although we know it does add cost 396 00:25:03,205 --> 00:25:05,995 to these claims, we believe and. 397 00:25:06,745 --> 00:25:10,885 Studies have shown, and our experience has shown that our injured workers 398 00:25:10,885 --> 00:25:14,935 do better when we allow them to have the highest level of care 399 00:25:14,935 --> 00:25:16,345 at the right time in the claim. 400 00:25:16,405 --> 00:25:21,185 And we are seeking those centers of excellence very quickly into the 401 00:25:21,185 --> 00:25:23,225 timeline of these very severe injuries. 402 00:25:23,225 --> 00:25:25,275 So it's so important and it. 403 00:25:25,850 --> 00:25:29,780 Is a financial impact, but it definitely helps these individuals 404 00:25:29,780 --> 00:25:31,820 to do better in many, many cases. 405 00:25:31,820 --> 00:25:35,690 And so again, we're about helping them to achieve the highest level 406 00:25:35,690 --> 00:25:37,010 of outcome that is possible. 407 00:25:37,060 --> 00:25:41,780 I do agree that medical care and lost time are two of the main drivers that 408 00:25:41,780 --> 00:25:47,800 we see on claims medical care associated with surgical fees is an issue for us. 409 00:25:47,800 --> 00:25:51,550 So we're continually looking at assuring that our patients see the 410 00:25:51,550 --> 00:25:55,900 right physicians that we know have the best outcomes for these surgical 411 00:25:55,900 --> 00:26:00,220 situations, and have protocols that help to return this injured worker. 412 00:26:00,970 --> 00:26:05,350 Back to work following evidenced based guidelines, and Shannon 413 00:26:05,350 --> 00:26:08,680 indicated all of the things that go into that recovery include. 414 00:26:09,370 --> 00:26:14,180 Physical therapy, mental health treatments assuring that we're getting them back 415 00:26:14,180 --> 00:26:17,790 and encouraging their, the policy holders to bring the injured workers back, 416 00:26:17,790 --> 00:26:19,440 not waiting till they're at full duty. 417 00:26:19,500 --> 00:26:23,770 We know that injured workers get better when we return them even when their 418 00:26:23,770 --> 00:26:26,650 capabilities are not back to their full. 419 00:26:26,895 --> 00:26:31,455 Uh, job demands, but returning them, uh, with modified duty helps that 420 00:26:31,455 --> 00:26:36,755 injured worker feel re-engaged and important and a part of their work team. 421 00:26:36,755 --> 00:26:41,885 And that's such an added way to shorten the timeline, decrease the costs, and 422 00:26:41,885 --> 00:26:43,445 make the injured workers feel better. 423 00:26:43,695 --> 00:26:49,095 So some great points that Shannon, um, discussed, and those are ways in 424 00:26:49,095 --> 00:26:54,135 which we're engaging to try to help them navigate some of those issues. 425 00:26:55,885 --> 00:27:01,125 Well, speaking of navigating those issues if we were speaking to employers or 426 00:27:01,125 --> 00:27:08,505 policy holders, uh, I wonder if you could talk a little bit about how a costly 427 00:27:08,505 --> 00:27:11,775 claim can impact the business side. 428 00:27:12,075 --> 00:27:17,205 So especially maybe a small or a mid-sized business where. 429 00:27:17,775 --> 00:27:22,635 These types of things might be less common but more impactful in different ways. 430 00:27:23,055 --> 00:27:28,905 And you know, what should an employer need to understand about the long-term 431 00:27:28,905 --> 00:27:34,095 financial effects of one of these high risk, high dollar type claims? 432 00:27:34,575 --> 00:27:34,995 Ooh. 433 00:27:35,985 --> 00:27:40,875 Well, for smaller businesses, one large claim can have a real 434 00:27:40,905 --> 00:27:43,395 impact on their premium, right? 435 00:27:43,495 --> 00:27:46,110 And their possible budgeting for years to come. 436 00:27:46,900 --> 00:27:51,970 Um, it's not just the direct medical or wage cost, it's how 437 00:27:51,970 --> 00:27:54,610 those costs affect their MO. 438 00:27:54,820 --> 00:27:55,240 Right? 439 00:27:55,240 --> 00:27:56,590 And I'm not gonna go into that. 440 00:27:56,590 --> 00:27:58,360 That's not my area of expertise. 441 00:27:58,810 --> 00:28:05,020 But employers should know that investing time, um, I would say in a good safety 442 00:28:05,110 --> 00:28:11,530 practice, right, and staying engaged in the claims handling process really can 443 00:28:11,530 --> 00:28:14,560 reduce long-term impact significantly. 444 00:28:15,205 --> 00:28:18,965 You know, if you look over the history of the claims that we handled when you 445 00:28:18,965 --> 00:28:26,105 see the employer involved it is usually followed by an injured worker, that 446 00:28:26,105 --> 00:28:32,405 wants to heal a return to work faster than an employer not being engaged. 447 00:28:32,405 --> 00:28:35,945 So, I mean, that's what I've seen from a claims handling perspective. 448 00:28:36,425 --> 00:28:37,625 Lindy, what about. 449 00:28:38,480 --> 00:28:39,890 Anything that you've seen? 450 00:28:41,270 --> 00:28:43,670 I don't think I have much more to add, but I think we've talked 451 00:28:43,670 --> 00:28:46,910 about some foundational things and that is communication. 452 00:28:47,300 --> 00:28:48,470 Create a plan. 453 00:28:48,590 --> 00:28:53,240 When someone prior to someone being injured, it's always important for 454 00:28:53,630 --> 00:28:56,720 policy holders to know who, where would they send us injured worker? 455 00:28:56,720 --> 00:29:00,960 If it is not a situation where you need to call 9 1 1, what would be your plan? 456 00:29:00,960 --> 00:29:05,250 What is an in-network appropriate provider in your area and. 457 00:29:05,820 --> 00:29:08,440 Then again, utilizing all of our MEM resources. 458 00:29:08,440 --> 00:29:12,400 We have a safety and risk services team, and we have field service managers that 459 00:29:12,730 --> 00:29:16,870 when a policy holder has questions on what their best practices should be in 460 00:29:16,870 --> 00:29:21,160 their work environment, we have a support team to help you with that because 461 00:29:21,160 --> 00:29:25,360 the number one priority to us would be to prevent a claim from happening. 462 00:29:25,360 --> 00:29:26,770 That's the best thing that could happen. 463 00:29:29,755 --> 00:29:34,315 We have covered so much today, and yet I'm still sure there's 464 00:29:34,315 --> 00:29:35,995 a ton more we could cover. 465 00:29:36,395 --> 00:29:39,995 As our time kind of comes to a close for this discussion, I was wondering 466 00:29:39,995 --> 00:29:45,125 if each of you could share with our listeners the one thing you hope that 467 00:29:45,125 --> 00:29:47,030 they take away from today's episode. 468 00:29:49,895 --> 00:29:50,735 Just one. 469 00:29:53,380 --> 00:29:53,830 One more. 470 00:29:53,950 --> 00:29:58,730 I think the theme that both Lindy and I had as we were discussing the 471 00:29:58,730 --> 00:30:04,455 details of these high risk claims is really communication, right? 472 00:30:04,505 --> 00:30:09,705 If everyone can have open and honest communication, you know, if I had 473 00:30:09,705 --> 00:30:15,405 one thing, but if I had a couple of other things, you know, I think that 474 00:30:15,675 --> 00:30:21,135 really if an employer could really look into their modified duty practices 475 00:30:21,165 --> 00:30:24,915 and assure that when an injury takes place that they can bring that injured 476 00:30:24,915 --> 00:30:30,015 worker back to work, I think that would be absolutely outstanding. 477 00:30:30,065 --> 00:30:32,855 It can add to it and just treating your injured worker 478 00:30:32,855 --> 00:30:35,225 as if they're an individual. 479 00:30:35,555 --> 00:30:36,665 Not a burden. 480 00:30:36,905 --> 00:30:41,585 You know, because things happen and I would say what sets MEM apart 481 00:30:41,585 --> 00:30:44,825 from other carriers is that we care. 482 00:30:45,285 --> 00:30:48,015 You know, Lindy was talking about the center of excellence that we 483 00:30:48,015 --> 00:30:53,985 use that is going to result in better physical outcomes is not. 484 00:30:54,555 --> 00:30:56,715 Always about the financial impact. 485 00:30:56,925 --> 00:31:00,885 But when the financial impact is involved, what we do as an organization is try 486 00:31:00,885 --> 00:31:06,475 to minimize that cost through Lindy's teams or utilizing specialists faster. 487 00:31:06,475 --> 00:31:08,665 So I'm gonna go ahead and turn it over to Lindy. 488 00:31:08,665 --> 00:31:11,275 'cause you see I'm passionate about it and I can keep going, 489 00:31:11,275 --> 00:31:12,265 but I'm gonna stop there. 490 00:31:12,805 --> 00:31:13,915 Um, I'll turn her over to Lindy. 491 00:31:14,455 --> 00:31:14,755 Great. 492 00:31:14,755 --> 00:31:15,115 Thank you. 493 00:31:15,115 --> 00:31:17,485 She keeps stealing my thunder 'cause she's exactly right. 494 00:31:17,485 --> 00:31:21,185 But if I were to say one thing, I would recommend to a policy holder to 495 00:31:21,185 --> 00:31:26,135 stay engaged and rely upon the experts that we have here at MEM to help them 496 00:31:26,385 --> 00:31:31,335 manage the claim between our claims representatives and our excellent, 497 00:31:31,335 --> 00:31:32,985 can't gotta say it one more time. 498 00:31:32,985 --> 00:31:36,675 Our great nurse case management team that helps to manage the 499 00:31:36,725 --> 00:31:38,105 medical side of things, which. 500 00:31:38,170 --> 00:31:42,430 Can be very complex, but having an engaged policy holder that wants to 501 00:31:42,430 --> 00:31:47,760 understand and be a part of the recovery and the successful outcome and return to 502 00:31:47,760 --> 00:31:53,310 function for that injured worker raises the level of success that we will have 503 00:31:53,340 --> 00:31:55,680 in managing a claim and mitigating. 504 00:31:56,030 --> 00:31:59,780 The financial impact and the losses in the long term, and will help that 505 00:31:59,780 --> 00:32:03,680 injure worker back to the highest level of recovery and return to work, which 506 00:32:03,680 --> 00:32:04,895 that's what we're striving to achieve. 507 00:32:07,805 --> 00:32:13,655 Thank you both for joining us and thank you to you and your teams for all that you 508 00:32:13,655 --> 00:32:19,505 do to help support injured workers and our policy holders in achieving those outcomes 509 00:32:19,685 --> 00:32:24,665 and getting everyone back to work as quickly and as successfully as possible. 510 00:32:25,145 --> 00:32:29,795 We know that high risk claims can feel daunting, but with the right 511 00:32:29,795 --> 00:32:34,955 tools, support and communication, employers can navigate them more 512 00:32:34,955 --> 00:32:39,605 confidently and keep their teams and their businesses moving forward.