In managing claims, we focus on the key cost components. With workers' compensation claims, that means early intervention and employing effective medical and disability cost containment strategies.
Working alongside our claim specialists are Nurse Case Managers. These individuals are Registered Nurses with claims knowledge who work with the involved parties to ensure the medical and disability management components of the claim are being handled effectively.
Medical costs account for more than 50% of all workers' compensation insurance costs, which is why America First Insurance utilizes Medical Management Programs designed to reduce medical costs on these claims.
Our managed care program is available in several jurisdictions. The program coordinates medical care for an injured employee and allows the employer to have more control over the employee's choice of medical providers. The focus of the program is to review and manage medical care on a proactive basis. In many jurisdictions, the program also includes a return to work component.
Medical Bill Review
All medical bills are reviewed to ensure that the medical care provided is related to the loss and injury. Our automated process also ensures that the charges correlate to applicable state fee schedules or usual and customary rates. We also review for duplicate billing and other errors and then administer preferred provider discounts when applicable.
Preferred Provider Organizations (PPOs) and Specialized Services Networks
We have established preferred vendor relationships in order to achieve negotiated discounts for key medical services required in workers' compensation claims. Our PPO networks include most major hospitals in a given area, as well as physicians, occupational health and industrial clinics, and surgical centers. They also include specialized services such as durable medical equipment, diagnostic services, medical transportation, home health services, and physical therapy services.
By using our Pharmacy Program, your employees can have their workers' compensation prescriptions filled through our network pharmacies. Unrelated medications are screened and excluded from coverage. A pharmacy card allows employees to obtain their prescriptions without having to make an out of pocket payment for them. The prescription costs are billed directly to us at a discounted rate.
Prescription costs are the fastest growing expense in workers' compensation claims. Our pharmacy program includes a First Fill® that will allow you to control expenses from the onset of a claim. Read Progressive Medical First Fill Rx Summary for more information.
For easy-to-understand information about medical conditions and medications, you can visit the Merck On-line Medical Library or the Rx Facts – Independent Drug Information Service for assistance.
Return to Work (RTW)
Our program takes into consideration the severity of the injury, the physical demands of the worker's job, and the opportunity for light or modified duty employment. We emphasize early and regularly occurring communication with the involved parties regarding the RTW process to ensure a timely and safe return to work.
Sometimes it is not possible for the injured worker to return to work for his or her prior employer or in the prior occupation. In these situations, our disability management program may include utilization of Vocational Rehabilitation and alternative Return to Work processes.
State-Specific Cost Containment Programs
Workers' Compensation statutes and regulations vary by state. Some states include provisions designed to help employers mitigate their risk potential and/or claim exposures. The provisions can include third party liability and/or apportionment statutes. Second/special injury funds allow for the transfer of claim payments to the state based upon specific criteria or other programs that allow an employer to seek reimbursement from the state. Some states have provisions for policy deductibles and/or employer-funded claim payments intended to help employers reduce and control their experience modification, thereby potentially reducing their insurance premium costs. Other states allow employers to establish a panel of medical providers from which their injured employees must seek treatment.
Workers' Compensation Fraud
Workers' compensation fraud can occur even if the initial accident or injury/illness is legitimate. Misrepresentation of the facts of a claim is just one type of fraud. We look at the three potential sources of fraudulent activity:
- Claimant Fraud can occur when an employee submits a false claim, alleging an accident or injury occurred that never happened or is a pre-existing medical condition. It can also happen if the employee attempts to remain out of work longer than is medically necessary or to secure lost wage benefits while working elsewhere.
- Medical Provider Fraud can occur when a provider deliberately overtreats a claimant or submits charges for services that were not rendered. The provider may also attempt to "up-code" charging for a higher-priced service than the one that was provided.
- Premium Fraud can occur when employers submit incorrect payroll information, misclassify workers, pay workers "under the table," or call them independent or subcontractors for the purposes of securing lower insurance premiums.
Because of its impact on insurance costs, workers' compensation fraud should be a concern for all business owners. Read Tips for Business Owners - Red Flag Indicators in Workers' Compensation Claims to assist you in evaluating whether or not claimant fraud may exist. If you suspect insurance fraud is occurring, notify your claims specialist immediately or call our 24-hour Fraud Hotline at 1-877-528-0461.