Published originally on February 6, 2017 on WorkComp Wire
An employer that inherited legacy claims in an acquisition initiated an aggressive settlement program that produced $6.5 million savings on 43 MSAs during a 10-month period.
Yes, the settlement initiatives produce excellent outcomes for old dog claims. But the lesson here is that these so-called new tricks are available throughout claims handling. Adopting a settlement mindset from day-one can prevent claims from spiraling out of control and becoming old dogs. Think of the medical and indemnity cost savings as well as litigation costs that can be saved as a result of settling these claims short of attorney referral.
Remember these two new tricks:
- Proper medical documentation of a file results in better claims handling. If medical treatment records are missing from the file, prescription history is absent or inconsistent with the medical records, or medical care is left open ended, it is difficult to assess the appropriateness of ongoing and future medical care.
- Pharmaceutical intervention does not need to wait. A claim must be consistently evaluated for the appropriateness of recommended and ongoing prescription medication use. The addition of opioids weeks into the claim is a red flag. Do not wait until on the brink of settlement negotiations to intervene on prescription medications use, do it now.
Clinical and legal partners must drive a successful outcome for employer and employee. Every stakeholder (nurse case manager, adjuster, pharmacy benefit manager, defense attorney, or physician) should watch for red flags and intervene themselves or relay issues to the claims handler to determine the necessary action plan to right the ship before the claim gets more difficult to control.
When pursuing a settlement initiative involving complex, “old-dog” claims, savvy payers price out future medical exposure, identify cost drivers, and decide which claims to settle right away and which warrant intervention. The smart payers also learn from these old dog claims and put best practices in place to address cost drivers early on in claims handling. What is the impact of pursuing such a claim strategy? Here are the results from an employer who converted an old-dog settlement initiative into a standard for new claims handling:
- 29% reduction in open claims after one-year
- 43% reduction in open claim after three years
- 14% reduction in total costs after one-year
- 26% reduction in total costs after three years
- 40% reduction in attorney referrals after three years
- 25% reduction in pharmacy costs after three years
- 55% reduction in CMS-approved MSA amounts after three years
It’s never too early or too late for clinical intervention on a claim with the purpose of driving a successful resolution to the claim. While old dogs can be taught new tricks, the best strategy is to incorporate settlement initiative protocols into claims handling best practices.
About Dan Anders
Daniel M. Anders, Esq., MSCC is the Chief Compliance Officer for Tower MSA Partners. A certified Medicare Set-Aside Consultant and attorney, he oversees the Medicare Secondary Payer (MSP) compliance program. Mr. Anders is responsible for ensuring the integrity and quality of the MSA program and other services and products and he provides education and consultation to Tower MSA clients on all aspects of MSP compliance.
Mr. Anders is the former Senior Vice-President of MSP Compliance for ExamWorks Clinical Solutions and he has extensive litigation experience from his prior position with the Chicago law firm of Wiedner & McAuliffe. He holds a Juris Doctor from Chicago-Kent College of Law and a Bachelor of Arts degree from Loyola University Chicago.
Contact Mr. Anders at 847.946.2880 or [email protected]
About Tower MSA Partners
Tower MSA Partners is a national provider of Medicare Secondary Payer services, including Section 111 Reporting and Conditional Payments along with Medicare Set-Aside preparation, submission and oversight. Its proprietary MSP Automation Technology Suite drives MSP compliance best practices and provides end-to-end visibility into each activity. Tower’s other services include pre-MSA Triage, physician peer reviews, MSA administration, medical cost projections, and life care plans. With more than 50 years combined experience in pharmacy, legal oversight and medical care, Tower proactively stages claims and works collaboratively with clients to identify issues and intervene to modify outcomes. Tower remains involved in the claims, through final resolution, MSA and/or other settlement. This model enables Tower’s clients to provide better care to injured workers, reduce claim and MSA costs, and obtain CMS acceptance of the MSA. For more information, visit www.towermsa.com and subscribe to Tower’s www.mspcomplianceblog.com.
