Welcome to the WorkSafe podcast.
Today we're diving into a challenging but important topic, high risk and high
dollar workers' compensation claims.
When a workplace injury turns serious, it's more than just a health concern.
It can have long-term effects on the injured worker, the
employer, and the business itself.
These aren't your typical claims.
They often require a different approach, closer attention, and stronger
communication to help us understand what sets these claims apart and how
employers can manage them effectively.
We're joined by em's, manager of Medical Services, Lindy Baral, and
Claims Operation Manager Shannon Fox.
We'll talk about early warning signs, cost drivers, communication strategies,
and what employer should focus on if they find themselves facing one
of these claims for the first time.
Welcome to the podcast, ladies.
I know you've been with us before in different respects,
so we're glad to have you back.
Thank you for having us back.
Yes, thank you so much.
To get us started off, let's talk about what we mean when we say high
risk or high dollar work comp claims.
You know, it could be a very general term, so I wonder if you could share
with us any common characteristics or red flags that kind of set these
apart from a more typical claim.
Okay.
You know, I would say from a claims handling perspective.
These are the files that we know could have long-term medical
treatment, significant time away from work or even, um, high
potentials of litigation involved.
Um, these are the claims where medical treatment can extend
beyond maximum medical improvement.
And an injured worker could have complications for the
rest of their life possibly.
I think what sets them apart is the complexity.
Multiple medical providers are involved.
Extended recovery surgeries, usually it's definitely more than one or
uncertainty around whether the employee will even return to work at all.
So from a claims perspective, that is what I've seen in the past.
I don't know if, Lindy, if you have anything additional to add to that.
I completely agree.
Those are identifying factors that can prolong the recovery of an
injured worker and, uh, make them a more high dollar or high risk claim.
I think Shannon's team, uh, over in claims operations, the claims representatives
are experts in helping to evaluate when a claim comes, what are the factors that
should, will make this a more challenging claim to manage and create a more
long-term recovery for the injured worker.
So.
That the, they are the experts to evaluate and understand those factors and
determine what additional support that they may require in managing the claim.
Well, Lindy, that was a good point and I, this may be a question for Shannon,
so either one of you feel free to jump in, but I wonder if something is early
on, you know, it's gonna be pretty clear that there's gonna be a lot of providers.
Multiple surgeries, long-term recovery plan, maybe not even a complete
recoveries is possible with some injuries.
So if that happens and it starts to go through our claims processes at MEM.
Are we providing a different type of approach to those claims as
far as do they get more of a team approach, something that, is more
relationship building than say maybe a couple doctor visits type of claim.
And I wondered if you could talk with us a little bit about
how that might look different.
You know, I would say when a claim does arrive and when
we have the initial notice.
That is going to be a high risk or high dollar claims.
We do involve multiple people in our decision making process.
Right.
I know that, um, an example could be, which we see a lot,
falls from high levels, a roof, a high ceiling, things like that.
It could be a traumatic brain injury when someone falls and land on their head.
We've had a lot of those.
When those enter into the organization with factors that are extenuating nurse
case management, they are on top of the claim just making sure that they utilize
their resources effectively because we do have the ability to outsource nurse
case manager on high dollar claims.
Right.
And that's in the hundreds of thousands I'm speaking about.
And we also have all of our departments involved when high dollar claims come in.
So it's not just claims looking at the file.
I have claims I have the technical services unit, I have sometimes executives
get into the file field service managers.
So it is really.
A team approach to assure that we're not missing anything.
And also subrogation may come into play with higher dollar claims just to make
sure all of the professional eyes are on the file and we're open to recommendations
from anyone to assure that we're moving that claim along appropriately.
Hard to add a lot to what Shannon has just indicated there.
I think it is critically important to have experts in each area to help
identify and eliminate any risks or untoward actions that may take place.
So, critical to get all of those individuals involved and, um, have
the nurse case manager assist with facilitating all of the medical care
and help to coordinate all of those external providers, external stakeholders
that become involved with these claims.
Well, the way you all answered it is pretty much what I suspected.
So what I'm taking away from that is when there is a claim that's
classified in these areas and we know is gonna require more.
Our policy holders and even the injured worker can expect a team approach
and ensuring that all of the bases are covered in every way to ensure
the best outcome, make sure nothing's overlooked and all of those things.
So, I was just kind of curious.
I figured it was probably a little bit different from just a typical,
um, maybe somebody had to go to urgent care for something and, and
then they were able to move on.
So I know Shannon mentioned a couple of types of injuries that often result
in high dollar and high complex claims, and she mentioned some falls from
heights, uh, as being a big factor at something we do hear about Often.
It's hard to come through something like that without a lot of problems.
And so, I wondered if maybe the two of you could talk a little bit about.
What types of injuries?
So we know about falls, that's one for sure.
But, and other ones too that maybe we might not think but can tend
to escalate into a higher risk or more high dollar situation.
Hmm.
You know, motor vehicle accidents, they have their own dynamics when,
um, the accident is extensive.
Also I've seen.
Underlying medical conditions like diabetes, I've seen lower extremity
injuries have excessive costs because when you get an injured worker, you get
them how they are, and that's underlying medical conditions such as hypertension,
not just diabetes, heart issues.
So when that comes into play you know, we can have really
extenuating circumstances because.
If an injured worker sustains an injury to their leg or their foot, maybe their
healing time, their treatment time, and all of that will be extended because
of the underlying medical condition.
I can't think of anything additional.
Lindy,
can you think of something?
Well, I think you touched on most of them.
I would, you know, validate that our highest dollar claims are at the falls.
We do occasionally see burns.
Spinal cord injuries that often result from falls, but not always.
Sometimes that is from motor vehicle accidents as well
as traumatic brain injuries.
But, um, I was also going to speak on even in circumstances that are outside of those
most severe diagnoses, and those of course we know will require all hands on deck.
But underlying personal health issues can truly impact the
healing process and ultimately the recovery of an injured worker.
So those are things that the claims experts have to be aware of.
There are times when we have poor health literacy with individuals that just.
Don't completely understand their medical recovery needs.
There are language barriers.
We've also discussed those injured workers that have more than one
physician that really complicates the recovery for an injured worker, even
outside of those higher level, uh, diagnoses that we've talked about.
So, these claims are very complex, and if any of you have had a recent health
issue or a family member or loved one that you've had to assist them with navigating
out in our healthcare environment, it can be extremely challenging.
So, in addition to these really, really severe diagnoses, it's a,
a really a big challenge that our claims team has to all work together
to assure that we're doing all of the right things to guide that injured
worker through the recovery journey.
Well, thank you for those insights.
I think it was very interesting to hear about the different ways that
other factors can play in, aside from just the initial impact or
injury, but other complicating health factors communication barriers,
things like that can also definitely get in the way of some of those.
So it's good to think about that as well.
In some of our previous episodes, we have discussed how
complexity and severity can play.
A significant role in the cost of a claim.
But it can be difficult to identify that something is going to be
complex from the very beginning.
And I say that from an employer's perspective, so we may know
what to look for, you know, as claims professionals, but.
A business owner or a safety manager or, any of those types of folks may
not know what some of those early warning signs, a claim could elevate
to a more complex or costly scenario.
So if we could share some advice with some of our listeners about what to
look for as an early sign from their end, that might be helpful as well.
Wow.
Absolutely.
You know, I would say if an employee is not improving throughout
the medical process, right?
If every time that you talk to them or you call and get an update
about their work status, if they're saying that it's getting worse, even
though treatment has been extensive.
They've been in physical therapy, they may have steroid
injections or something like that.
That could be a red flag if treatment keeps on the path of not improving, right?
Missed medical appointments is huge.
Anytime you have an employee, they keeps saying they cannot attend appointments
because of something happening at home.
That could be a warning sign.
Lack of communication is so important.
That the policy holders stay in touch with the injured
worker throughout this process.
Or if there's confusion about their job duties, right?
If someone returns to work light duty and they're not sure if they should
show up or not, that's a gap in communication, which can cause claims
to linger on and become more costly.
So technically, employers should pay attention to,
what's happening on the file?
What's happening with this injured worker's, mental processes?
Because sometimes employees don't feel supported throughout this whole process.
And if an employee doesn't feel supported by their employer, that's another drawback
which could, lead to more cost on a claim.
You know, that was such a good answer and you've hit on many of the points
that I was going to talk about.
I think fundamentally communication is the key.
And Shannon's staff, again, they are experts in, at the onset of the claim,
assuring that they're taking in all of the appropriate information foundationally.
Understanding what took place and learning about the injured
worker and their role at work and communicating with the policy holder.
All of those things start the claims process off on the right foot.
Then you want to evaluate what is the expected timeframe of
recovery for this individual.
So the claims team works to determine through engaging with evidence-based
platforms, what the expected.
Recovery is for this injured worker with a diagnosis that they
have their age comorbidities.
What type of job that they'll be returning to.
So all of these things we should be communicating with the policy holder
and we'll be communicating with the policy holder to understand what the
expectations are for the injured workers.
So if we have lack of consistency of communication or missed appointments
as Shannon indicated, those are red flags to engage and make sure
that we're understanding why the injured worker is not recovering at
the timeline that would be expected considering all of those factors.
And sometimes that may indicate that the adjuster may engage with another
team member and get them involved in helping them to evaluate the claim and
where the action should move forward in getting that patient back to work.
Well, it sounds like communication is really probably.
The number one key here to ensuring things go as smoothly as possible, or helping
to identify things early on that aren't.
And I wonder if you ever encounter an employer policy holder who you know
is hesitant to be involved, because obviously someone's medical information
is, you know, HIPAA protected in many ways and those types of things
are, are there things that are.
Policy holders should know about what they can and can't ask about or stay in
the loop on or, or those types of things.
That's a very interesting question.
. Because it is work related.
The employer is entitled to obtain that information.
Right.
In all my years of handling claims, I have never encountered an employer
that wanted to cross boundaries, right?
Usually they allow us to share the information with them and they don't
cross a boundary with trying to go too far into underlying personal
medical type treatment, right?
But.
As the policy holder, they do have the ability to access this
information, you know, just to know what is going on with the employee
at every, per every level, right?
Um, so technically I have not encountered that area of concern.
I'm not sure if Lindy has had experiences on the nurse's
side with matters like that.
Right.
Well, from the nurse case manager perspective, they are all registered
nurses who assist in management of workers' compensation injuries.
And there certainly is, a line where we may learn things about an injured
worker and their personal health.
That as a nurse is important in those conversations, but may not impact
the workers' compensation claim.
So those are areas in which we do not share personal health
information that is not related to the claim or does not impact.
The injured worker's recovery, and so it is a matter of professionals.
I agree with Shannon.
It has never been an issue in my many, many years of being a nurse
case manager, but it is important for the nurse to engage with the injured
worker holistically in order to help them through the recovery and maximize
their potential to return to their highest level of functioning, which is
hopefully returning to their full duties.
Well, thank you for kind of walking through that with me.
It sort of came to mind as we were talking and I was curious
about that ever being a barrier.
I know that, , Missouri Employers Mutual, NEM started obviously in
Missouri and we now have a lot of policy holders as we've expanded our
regional presence that have employees in either a state outside of Missouri.
Or in multiple states and.
That brings to light another question that maybe some of our policy
holders might have or listeners.
And that is in regards to work comp regulations being
different within each state.
So each state has its own set of rules and those types of things
that have to be followed from a claims perspective and from a policy
perspective, I was wondering if you could maybe share from your experience.
Any regional differences or state to state type scenarios where you
see that it can impact, the way a claim plays out is geography,
access to care type of industry.
Do those things make a difference?
You know, in rural areas, access to specialty care can
mean longer recovery times.
If you're in a metropolitan area, you tend to have the
availability of more providers.
But then there could be higher costs, right?
You know, even different types of.
Employers and specific jobs.
For example, if you're in an agricultural type area, if you are
a truck driver, driving through different types of areas, that will
change the dynamics of the claim.
So yes, I mean now we are in other states, different states.
Cost is significantly different, I would say, um, primarily in Arkansas.
Medical cost is usually lower there.
However, we're also in Illinois, so treatment costs could be higher there.
So, there are definitely regional differences.
What we try to do is, um, utilize our expertise along with the nurses,
um, to try and figure out the best care for an injured worker.
And when you're in a rural area, you have to drive longer, which can impact.
An injured worker's ability to wanna go to the doctor.
Right.
The more you have to travel, the longer it is, the more reluctant you are to go.
Longer healing times.
Um, we have that even in the state of Missouri, someone's traveling from a
rural area and they have to go to, um, a bigger city can be an area of concern.
So that's just something that we have to work closely with.
The nurses we try to accommodate, but sometimes it's not always possible.
Lindy, did you have anything additional to add to that?
Sure.
I mean, this is such a great question because it is an important factor
and definitely does play a role in how the claims team manages a claim.
So there are states in which we get to direct care.
Shannon's team can determine who the appropriate physicians are, but
there are those in which the injured worker has the option to select care.
We are very fortunate in that we have a very comprehensive medical network
partner that has physicians throughout the nation, not just in our state.
So there are a lot of opportunities there.
However, each state has different rules and regulations regarding
the processing of medical bills, and so there are states that have
fee schedules that are specifically identified to say what the cost to a
workers' compensation carrier can be.
For each level of services provided.
But there are also states in which there are no fee schedules and it is, these
are usual and customary states where the providers can simply determine what
a usual and customary amount should be paid for each of these services.
So those are some challenges, but we work very closely with our medical network
partner, our managed care partner, to assist us in number one, identifying the
best providers for our injured worker.
That's the number one thing.
We wanna make sure that they receive the best level of care
for whatever that injury might be.
Um, and then we hope that we can find a provider in the network, which is
generally very easy to do with the nature of our network being very comprehensive.
But as Shannon indicates in certain areas, there may be a distance to be traveled.
So we engage with other partners to say, are there options?
Looking at virtual opportunities for care at times, which isn't always possible
as you get into treat with specialists.
But that's an option for some injured workers that live in rural areas
and doing everything that we can to limit the disruption to the injured
workers' life while still allowing them to receive the best medical care.
Those are all really good points and I appreciate you guys.
Kind of sharing that with us.
It's just something to think about that maybe, you know, when you're
faced with an injury, you're not really thinking location matters or state
regulations or those types of things.
So it's nice to know kind of how that plays out and what people
can expect in different ways
while we're talking about the cost of these types of claims, you know, we
mentioned that they're usually very high.
These that are multifaceted and, you know, require care from a
team of providers and physical therapy and those types of pieces.
We know medical expenses are on their eyes.
Right.
So, I mean, that's not a surprise.
They always are.
But if you could talk a little bit about, from your perspectives, what
the biggest drivers are that make these types of claims become so expensive.
Well, I would say that the biggest drivers.
Outside of medical treatment, I think there's something that we probably
didn't touch on is like a high risk claim when there is a brain injury, right?
Or if someone gets paralyzed.
Where we talk about those, it's not only are we looking at
treatment in our immediate area, but sometimes we have to send.
Your worker to a center of excellence.
And that could be in Nebraska, it could be in Illinois.
And if their family is located in Missouri or somewhere other than
where the center of excellence is located, then you have another.
Cost driver, right?
And it's not only a financial impact to the company, but it's a financial impact
to the family to have to uproot sometimes and be with your worker while they go
through this extended medical treatment.
Just something else to consider on larger type cases but in a normal
type claim where yes, high risk, but not that high like a brain
injury or someone being paralyzed,
lost time from work can be huge.
The mental component that has been added to large portions of our claim
has been significant since COVID.
That's what I've seen from a claim selling perspective.
We used to have that mental component to a smaller degree, but now post
COVID, it seems as if that mental component has just skyrocketed.
Anytime you have a claim, it's like we're dealing with a mental
component, which definitely extends the cost and the life of a claim.
You know, multiple physical therapy sessions and work conditioning and, oh my
god, prescription medical cost excessive.
So if you compound all of that and then you add in a legal component, that
financial impact grows even more so.
Lady, do you have anything from, a medical treatment
standpoint?
I just wanted to add on to your discussion surrounding the center
of excellence, and although we know it is a higher cost to send
individuals to a center of excellence.
Maybe the term center of excellence is not just thrown around and anyone could
be termed to be a center of excellence.
It is a designation of hospitals, which provide the highest level
of care for these severe injuries.
And I just wanted to say that although we know it does add cost
to these claims, we believe and.
Studies have shown, and our experience has shown that our injured workers
do better when we allow them to have the highest level of care
at the right time in the claim.
And we are seeking those centers of excellence very quickly into the
timeline of these very severe injuries.
So it's so important and it.
Is a financial impact, but it definitely helps these individuals
to do better in many, many cases.
And so again, we're about helping them to achieve the highest level
of outcome that is possible.
I do agree that medical care and lost time are two of the main drivers that
we see on claims medical care associated with surgical fees is an issue for us.
So we're continually looking at assuring that our patients see the
right physicians that we know have the best outcomes for these surgical
situations, and have protocols that help to return this injured worker.
Back to work following evidenced based guidelines, and Shannon
indicated all of the things that go into that recovery include.
Physical therapy, mental health treatments assuring that we're getting them back
and encouraging their, the policy holders to bring the injured workers back,
not waiting till they're at full duty.
We know that injured workers get better when we return them even when their
capabilities are not back to their full.
Uh, job demands, but returning them, uh, with modified duty helps that
injured worker feel re-engaged and important and a part of their work team.
And that's such an added way to shorten the timeline, decrease the costs, and
make the injured workers feel better.
So some great points that Shannon, um, discussed, and those are ways in
which we're engaging to try to help them navigate some of those issues.
Well, speaking of navigating those issues if we were speaking to employers or
policy holders, uh, I wonder if you could talk a little bit about how a costly
claim can impact the business side.
So especially maybe a small or a mid-sized business where.
These types of things might be less common but more impactful in different ways.
And you know, what should an employer need to understand about the long-term
financial effects of one of these high risk, high dollar type claims?
Ooh.
Well, for smaller businesses, one large claim can have a real
impact on their premium, right?
And their possible budgeting for years to come.
Um, it's not just the direct medical or wage cost, it's how
those costs affect their MO.
Right?
And I'm not gonna go into that.
That's not my area of expertise.
But employers should know that investing time, um, I would say in a good safety
practice, right, and staying engaged in the claims handling process really can
reduce long-term impact significantly.
You know, if you look over the history of the claims that we handled when you
see the employer involved it is usually followed by an injured worker, that
wants to heal a return to work faster than an employer not being engaged.
So, I mean, that's what I've seen from a claims handling perspective.
Lindy, what about.
Anything that you've seen?
I don't think I have much more to add, but I think we've talked
about some foundational things and that is communication.
Create a plan.
When someone prior to someone being injured, it's always important for
policy holders to know who, where would they send us injured worker?
If it is not a situation where you need to call 9 1 1, what would be your plan?
What is an in-network appropriate provider in your area and.
Then again, utilizing all of our MEM resources.
We have a safety and risk services team, and we have field service managers that
when a policy holder has questions on what their best practices should be in
their work environment, we have a support team to help you with that because
the number one priority to us would be to prevent a claim from happening.
That's the best thing that could happen.
We have covered so much today, and yet I'm still sure there's
a ton more we could cover.
As our time kind of comes to a close for this discussion, I was wondering
if each of you could share with our listeners the one thing you hope that
they take away from today's episode.
Just one.
One more.
I think the theme that both Lindy and I had as we were discussing the
details of these high risk claims is really communication, right?
If everyone can have open and honest communication, you know, if I had
one thing, but if I had a couple of other things, you know, I think that
really if an employer could really look into their modified duty practices
and assure that when an injury takes place that they can bring that injured
worker back to work, I think that would be absolutely outstanding.
It can add to it and just treating your injured worker
as if they're an individual.
Not a burden.
You know, because things happen and I would say what sets MEM apart
from other carriers is that we care.
You know, Lindy was talking about the center of excellence that we
use that is going to result in better physical outcomes is not.
Always about the financial impact.
But when the financial impact is involved, what we do as an organization is try
to minimize that cost through Lindy's teams or utilizing specialists faster.
So I'm gonna go ahead and turn it over to Lindy.
'cause you see I'm passionate about it and I can keep going,
but I'm gonna stop there.
Um, I'll turn her over to Lindy.
Great.
Thank you.
She keeps stealing my thunder 'cause she's exactly right.
But if I were to say one thing, I would recommend to a policy holder to
stay engaged and rely upon the experts that we have here at MEM to help them
manage the claim between our claims representatives and our excellent,
can't gotta say it one more time.
Our great nurse case management team that helps to manage the
medical side of things, which.
Can be very complex, but having an engaged policy holder that wants to
understand and be a part of the recovery and the successful outcome and return to
function for that injured worker raises the level of success that we will have
in managing a claim and mitigating.
The financial impact and the losses in the long term, and will help that
injure worker back to the highest level of recovery and return to work, which
that's what we're striving to achieve.
Thank you both for joining us and thank you to you and your teams for all that you
do to help support injured workers and our policy holders in achieving those outcomes
and getting everyone back to work as quickly and as successfully as possible.
We know that high risk claims can feel daunting, but with the right
tools, support and communication, employers can navigate them more
confidently and keep their teams and their businesses moving forward.