ASC's External Newsletter Current Issue
When it comes to hiring a third party administrator (TPA) or maintaining a successful business relationship with one, it requires choosing a TPA with the following characteristics: expertise in your industry, an adaptability to adhere to your risk management needs, a high claims staff retention rate, and a robust risk management information system (RMIS). Let’s take a closer look at some of the reasons why many have chosen their TPA and how they get the most from their TPA.
The Business Relationship
At this point, it is likely you have chosen a TPA based on a number of reasons. One of those reasons may be the TPA’s experience in your industry. We have found that clients often prefer their prospective TPA to have prior experience with similar types of accounts in their industry. This association provides a level of trust for the client knowing that the TPA is familiar with the type of injuries and liabilities that occur at this type of workplace.
When it comes to knowing the uniqueness of your industry, it is also important that your TPA understands your business culture and the nature of your business. Understanding your processes begins by having your TPA visit your facilities to learn about your daily work environment from the ground up. For example, TPAs must be willing to work within the client’s culture and organizational framework, which may include the TPA staff working on the client’s holiday schedule, and working onsite as a dedicated resource. More about dedicated claims staff later.
Another uniqueness that a TPA should understand about your business is the diverse cultures of the region where you have exposure. Claims may be handled differently in New York and Florida than in the Midwest. The differences can range from the technical handling to the psychosocial handling of the claim. Each state varies with claim handling requirements while each region can vary with claimant personalities and dialects. Knowing what staff options you have (e.g., bilingual, regional offices, etc.) will help you get the most out of your TPA.
The relationship is everything, which is why TPAs would be wise to first invest their time with everyone involved in the program. Your TPA needs to have an excellent alliance with all vendors (e.g., managed care), brokers, carriers, and the insured to coordinate a collaborative effort for the best possible outcomes. This is where dialogue comes in which forms the basic process for building a mutual understanding of your claims program.
As a way to measure effective dialogue, you should require regular claims reviews for in-depth discussion. Claim reviews are the time where you can cement the relationship with your claim adjuster(s) who provides face to face responsiveness for collective learning and inquiry. Claim adjuster discussion holds considerable assurance as a problem-solving strategy when reviewing open claims. Here is where you can review select claim files to measure proper contact made, reserves calculated, investigations completed, and more.
“Shopping” a TPA
Clients are likely not shopping for a service if they are happy with their current TPA. The long-term relationships that have been built can be more valuable than saving a few thousand dollars. When you consider the time and resources it takes to train a new TPA on the client’s company culture and needs, the “soft “costs from switching can outweigh the savings. For example, what if the new TPA is not as effective at closing claims early? Claims pricing is only one factor, so make certain you receive the best claims service to avoid costly claim outcomes.
Many clients have recognized the value in going beyond the biggest TPAs or the well-known TPAs who have a high search engine status on the Internet. Lesser-known TPAs may offer a specific culture or service package that may be as good as or a better fit for the client. We call this a “boutique” TPA service. Alternatively, clients find familiarity with TPAs based on name recognition and structured claims administration appealing. Either solution, it’s important that you receive the best claims service from the best claims resource available to you.
Now that you have finalized your selection, you may have noted the importance of selecting a TPA who places a high value on its claims staff. Employee satisfaction is one way to determine if your claims team will be engaged and happy serving your claims program. The critical factor with employee satisfaction is that a satisfied claims staff must do the job and make the contributions that the client needs. This begins with choosing a TPA that fosters employee motivation, goal achievement, and positive morale in the workplace.
Here are three aspects of the workplace that successful TPAs implement to keep claim adjusters and support staff happy and reduce turnover rates:
- A recognition program
- A lucrative benefits package
- A manageable caseload
A TPA’s recognition program is a very effective way to keep claim adjusters motivated and satisfied with their work. A monetary reward for meeting or exceeding their measured claims handling goals is one method of appreciation. Another is a support staff bonus based on the success of the TPA as a whole. Satisfied employees provide exceptional service. Exceptional service makes for satisfied clients.
Minimizing stress on claim adjusters through lucrative benefit packages and work/life balance opportunities can also reduce turnover. For example, a TPA that allows its workers to work remotely from home on occasion throughout the week. Another contribution is a generous PTO policy that re-energizes the mind and body.
Manageable claim caseloads are necessary to avoid claims staff burnout. A TPA that regularly monitors and measures claim types, and the time it takes to administer each new claim, can greatly distinguish between truly happy employees and those who are just getting by. Mismanaged claim caseloads by overworked claims staff will lead to poor claim outcomes.
Another operational component to consider is an alternative staffing model. As an option to traditional, designated claim adjusters, you may have chosen a dedicated/exclusive claims staffing model. Dedicated claim adjusters that work onsite or nearby the client make another excellent example of dialogue that generates positive outcomes.
With a dedicated service model, you are encouraged to participate in the hiring process to choose among candidates with the required expertise & professional personality/demeanor best suited to your company’s culture. A TPA that knows how to establish a dedicated claims model for its client can provide claim adjusters who attend regular or impromptu staff meetings, and interact with company/entity department heads regularly. It’s this business relationship that makes the claims team feel like a valued member of your risk management team which results in a very high staff retention rate. Knowing your claim adjuster by name makes for a loyal, long-term relationship.
With positive TPA operations come high employee satisfaction. High staff retention creates familiarity with the claim adjuster and employer that leads to better communication, higher responsiveness, and better overall outcomes.
RMIS Systems That Work
Clients require an intuitive RMIS that operates as a useful research tool for their staff. Proactive RMIS users want more value than just looking up individual claims. The ability of a RMIS system to handle predictive analytics has become very important to clients. In addition, the ability to run scheduled or on-demand claim data reports are a necessity. It is important to know what functions are available and what training will be provided as a resource in order to get the most value out of your TPA.
Getting the most from your TPA comes from first knowing your TPA. Whether you choose your TPA for their loyalty to their employees, their service with integrity, their flexibility of size and service models, or their expertise in your business, the decision should be a rewarding one.
Congratulations to Ms. Lillian Hall, Claim Supervisor in our Plano, Texas dedicated unit client office for a recent recognition from the Plano City Manager, Mr. Bruce Glasscock. An award was presented to Lillian Hall by Senior Claim Analyst, Ms. Elsa Gonzales for Lillian's handling of a sensitive claim.
Gratitude from WC and Leave Administrator, Ms. Janelle Nowicki with ABC Fine Wine & Spirits for Ms. Geri Wines' quick action on a CAT claim handled while on vacation. Geri's quick action averted a crisis for an injury that "could have gone down a different path."
Legislative & Regulatory News
Q3, 2018 Issue:
This article is aimed at discovering the role a good workers’ compensation claim adjuster has surrounding opioid use as a treatment for an injured worker.
It seems that everyone from the President of the United States to state governors and legislators has come to the realization that the opioid epidemic in our country is out of control. Whether it be a crackdown on pharmaceutical manufacturers or medical providers, the story is at the forefront of the nation.
At the front of this battle are claim adjusters who work directly with injured workers, employers, and medical providers; who work diligently and in good faith to rehabilitate our country’s injured laborers. When we think about a crisis with this level of attention, we may not first think about the role of the workers’ compensation claim adjuster as much as the role a doctor or treating facility has with properly treating the injured worker.
As a workers’ compensation third party administrator, you want to have good claim adjusters whose experience and wisdom makes a major difference in this battle; you want good claim adjusters who recognize the value of a productive employee in the workforce. The key word is “productive.”
In workers’ comp, we think of “productive” as someone who returns to work in a full capacity position or into a light-duty job if possible. A return-to-work (RTW) strategy is part of the rehabilitation process just as proper medical advice and prescription treatment are to an injured worker's physical recovery. It is this combined effort that makes the claim adjuster’s role in the opioid epidemic that much more important.
Recognizing The Value of a Productive Employee
A good claim adjuster first makes certain the injured worker receives treatment from a reputable provider. A good claim adjuster establishes a positive rapport with the medical provider alerting the provider to the worker’s injury and employment. In select jurisdictions, the claim adjuster has the ability to offer a selection of providers to choose from upon initial visit. Conversely, in select jurisdictions, the claim adjuster has the ability to change providers upon his or her own professional recommendation to the injured worker as well as upon request of the injured worker at any time during treatment.
A good claim adjuster encourages the injured worker to be productive while taking necessary opioids. A good claim adjuster maintains contact with the injured worker after initial contact to develop a good rapport, putting the injured worker’s best interest in mind first and foremost.
A good claim adjuster works with the employer for RTW and motivates the injured worker to balance work with improvement. An example is making sure the injured worker is taking opioids as needed at night or only at home. This condition may be based on the employer’s requirement not to be on pain medications during work hours or on the commute to and from work for safety reasons (liability).
A good claim adjuster listens to the injured worker to determine if the opioids are helpful or harmful to their overall improvement. In select jurisdictions, the claim adjuster may even assign a nurse to assure the injured worker that he or she is receiving the proper care from the medical provider.
In situations where the claim adjuster may doubt proper opioid use by the injured worker, a good claim adjuster may work alongside a medical provider who orders routine or sometimes random drug screening. The purpose of the screening is to be certain the opioids are being used properly for the injured worker’s benefit and as prescribed. For example, a urine analysis review by a good claim adjuster can be effective as follows:
- It can detect if proper levels of prescribed opioids are in the injured worker's body
- It provides a safety mechanism by which to determine if meds are being mixed
- It detects whether meds are simply being taken at all for the injured worker’s treatment benefit
Experience Makes A Difference
Knowing injury types and severity plus pain meds make a good claim adjuster better prepared for knowing what pain med treatment is or isn’t needed. The wisdom that comes from experience along with collaborating with the right medical personnel, gives the adjuster the knowledge to identify the correct opioid/script type, the proper number of scripts prescribed, an ideal pill count for each prescription, and the dosage (mg) prescribed.
A good claim adjuster is better prepared to question the medical provider or provider practicing manager, request a peer review or independent medical exam (IME), and question if the doctor is suitable to continue treatment for the injured worker. If necessary, the adjuster can take the final step of filing a formal complaint against a medical provider. For example, a medical provider prescribed Oxycodone 80 MG ER #60, Oxycodone 40 MG ER #30, and Morphine SUL 15 MG #60 to an injured worker. The injured worker recognized the power/effect of these combined opioids when taken together and immediately discussed this with his claim adjuster. With the adjuster’s wisdom and pro-action, the injured worker's overuse and potential overdose may have led to the worker's death.
Recognizing an overprescribing doctor alerts a good claim adjuster to seek a number of resources. Resources who may be alerted include:
- Other fellow claim adjusters who administer claims in the same territory (“please consider your choice of medical provider”)
- Possibly the district attorney’s office or DEA through a DA (under circumstances where other good claim adjusters complain repeatedly)
- Select PPO networks who seek reputable pain med doctors
- The injured worker’s employer to know not to seek out that provider for future medical attention
Knowing injury types and severity better prepares the good claim adjuster to recognize any follow-up surgeries or long-term injury that may require continued use of pain medications. For example, corrective surgery that causes further pain, ongoing, long-term treatments for an old injury, and treatment for a secondary injury resulting from the initial injury.
Having good claim adjusters who are well-rounded in identifying injuries, determining injury severity, and understanding the impact that opioids can have in a positive and negative way can help a third party administrator work most effectively for any entity’s injured workers. The good claim adjuster along with a knowledgeable and aware employer can make all the difference towards positive outcomes like return-to-work, quicker recovery, and coordinated care and concern for the injured worker.