Claims Management - ESM Solutions, Inc.

Report
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:
•
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•
•
•
•
•
•
•
•
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: www.executivesm.com
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
Work Comp Policy
written
WC service needed –
ESM introduced
REFERRAL
Broker completes
“Referral Form”
sends to ESM
ESM / Broker/ Client
develop a POA for
client
SERVICE
ESM Service plan
initiated
Carrier/Broker/Client
maintain presence in
service stream
OBJECTIVES
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
•
•
•
•
http://www.executivesm.com/education/
Check out our 90 second trailer!
http://youtu.be/4uMtTY-QSUE
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!
http://youtu.be/d5x6qJTOycQ
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
Insured
ReturnTo-Work
Safety
• Report
• Summary of risk
• SWOT analysis of Safety & Work Comp program
• Recommendations
• Acceptable or unacceptable risk
• Roadmap for risk management improvement
http://www.executivesm.com/products/risk-assestment-kit/
Claims
Management
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) 9th element required for
Construction industry
• 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: Provide Do-It-Yourself compliance based train-thetrainer programs
•
Includes training schedule, attendance forms, learner’s guide,
PowerPoint Training, quizzes and answers
• Private or co-branding available
http://www.executivesm.com/products/iipp-kit/
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
Program Introduction
Complete IIPP
Evaluation
Questionnaire
Customer
Engagement
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)
Phase 1 – IIPP Review
Review client’s
current IIPP
Identify missing
Cal-OSHA
compliance
requirements
Analyze
supporting
documentation
Prepare
revised IIPP
Outline
Coordinate with client
regarding questions, or
additional information needed
Phase 2 – IIPP Revision
Revise and
reformat
IIPP
Ensure IIPP meets
Cal-OSHA
standards
Revise / develop
custom checklists
for implementation
and compliance
Phase 3 – IIPP Roll out
Collaborate on revised program
Provide revised
IIPP, action items
and Bi-monthly
safety training
modules to client
Client
Multiple drafts may be required
Ensure procedures reflect
organizational practices
Adopt
revised IIPP
Provide IIPP training
to Supervisors /
Managers
Provide
bi-monthly
safety training to
employees
Safety training modules include:
PPT Presentation, Learner’s Guide,
Quiz and Answers
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
• http://www.executivesm.com/portfolio/safetymanagement/
Return-To-Work
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
http://www.executivesm.com/portfolio/returntowork/
Return-To-Work Implementation
Phase 1
Foundation
Phase 2
Assessment
Phase 3
Launch
Write a management
plan and policy
statement
Review and Revise
Job Descriptions
Coordinate
communication
Build a support team
and assign roles and
responsibilities
Identify Temporary
Alternative Duties
(TADs)
Train supervisors and
managers
Establish process
and procedures
Document physical
requirements
Evaluate
Business Benefit
Launch RTW program
to all employees
ROI
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 Roles
and
Responsibilities
Establish
Process and
Procedures
Planning
Checklist
Assign RTW Coordinator
Phase 2 - Assessment
Review & Revise
Job Descriptions
to include
Essential Functions
Identify
Temporary
Alternative
Document
Physical
Requirements
Duties (TADs)
Phase 3 - Launch
Coordinate with Employee
Coordinate
Communication
Coordinate with Medical
Provider
Coordinate with Claims
Administrator
Roll out to all
Employees
Train
Supervisors
/Managers
Flyer
PPT
Letter to 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:
http://www.executivesm.com/portfolio/claimsmanagement/
Claims Management Reporting &
Oversight Process
Carrier
processes claim
Claims Management
MO claim
processed,
closed in 90 days
Claim is
classified as MO
or IND
IND claim:
3 point contact,
provide benefits
Begin RTW coordination
with medical provider
and client
Begin RTW coordination
with medical provider
and client
Disputed Claims
Claim is delayed
and investigated
for 90 day
compensability
determination
Monitors Carrier for
investigation process
and strategizes
decision
Determination is
made to accept or
deny
ESM
Strategize best
practices for
resolution
Client
Monitor strategy for
effectiveness and
accountability
Carrier
ESM
analyze at
90 days for
potential
problems
If ACCEPTED, manage claim
to conclusion
If DENIED and UNDISPUTED
Close in 30 days
If DENIED and DISPUTED
Develop litigation strategy
for resolution
Large Loss Claims ( >$25,000 )
Develop a POA for
resolution
Continue 30 day
ongoing
oversight and
direction
Monitor settlement and
any future medical award
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:
• WCCA, WCCP, CPDM, ARM, AIM, SIP, PMP, CSP
• 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
www.executivesm.com

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