Disability Insurance Specialists will be represented on two panels at ICA's annual conference held this year in Austin, TX from October 3 - 6, 2010.
Tom Loftus will be joining Michael Coupland of BMI to give a presentation on Effective Interviewing of disability claimants. Tom will also be presenting on Life Waiver of Premium claims with representatives from Principal Financial and Swiss Re.
Follow Tom (@dispecialist) on Twitter from the link on the main page here for updates from the conference. For more information on the ICA, visit www.claim.org
Monday, September 13, 2010
Monday, May 10, 2010
Social Media - Ignore It At Your Own Peril (Video)
I recently attended the Midwest Claims Conference in Lake Geneva, WI. During the session on Social Media presented by Kevin D'Aprile (@kdaprile on Twitter) he showed an interesting and informative video I thought our readers might enjoy. See the video here: Social Media
Tuesday, March 16, 2010
Details, Details...Effective Interviewing for Disability Claims
Good claims decisions demand a complete understanding of all of the facts of a case. Small details, which may seem insignificant on their own, may play a big role when combined with all of the facts related to a claim. Accordingly, it is essential for the claims professional to treat the information gathering process much like an investigator processing a crime scene; gathering details while not contaminating potential or future evidence.
We don’t know what will be important as our evaluation continues. Therefore, it is crucial to gather information while reserving judgment for later. Similarly, as the picture comes together, we may need to revisit several sources of information. For this reason, developing a measure of trust and an open line of communication serves you well. Making contact in a way that is convenient for your source keeps communication lines open.
Information sources related to a claim may be plentiful, however the vast majority of pertinent details may be obtained through three sources:
• The Claimant
• The Employer
• The Medical Provider
For the purposes of this article, we will concentrate on effectively obtaining information from these three sources.
The Claimant
The primary source for information related to the claim is the claimant. It is important to have direct contact at the earliest possible opportunity to be sure he or she understands the coverage, his or her role in the claims process, the information that is required, and the anticipated timeframe for a decision (or more importantly, the soonest a claim may be paid). Information requested from the claimant during the call should be sent in writing as a reminder, and to document the request and conversation.
Being upfront and establishing the groundwork goes a long way in building a healthy rapport. This makes future conversations more effective and generates better information because the claimant is more willing to talk to someone who listens and understands their situation.
For far too long, there has been a notion of competition between the claimant and the claim examiner. Statistically, however, the vast majority of claims are approved. The examiner should bear this in mind when speaking with the claimant and exude an attitude of working with the claimant towards reaching a favorable determination. When asked a common question such as, "Do you see any problems with the claim," it is a good approach for the claim examiner to respond that if an issue arises, the claimant will be contacted first. We find that claimants are more at ease if they know they will have an opportunity to get involved if there is a possibility of an unfavorable. This approach puts the claimant and the examiner together working as a team towards a common goal.
In the end, the facts and policy provisions will yield the decision. Therefore, when we find information that appears contrary to the claim, we should dispassionately share that with the claimant, rather than taking a "Gotcha!" approach. Infrequently we do uncover fraud and proceed accordingly, but many times there are explanations you would not have considered that fully explain the outlying information. In this case, a follow up request can be sent to the claimant (or other source identified) to document why the previous information was incorrect or irrelevant. On the other hand, if the claimant does not have any new information to share and a denial is the appropriate next step, they are more likely to accept the denial without appeal at this point.
If proper rapport was established and follow up communications were made throughout the claims process, there should be no surprises for the claimant when a decision is made. In our experience of conducting audits for various claim operations, there has been a direct correlation between the level of communication and the volume of appeals encountered on a given block of claims.
The Employer
Contacting the employer is often a very different experience from contacting the claimant whose only job (aside from trying to get healthy) is working with the insurance company to get his or her claim paid. The employer contact is likely a very busy person with multiple responsibilities. In addition to this, privacy rules, state guidelines and company policies and procedures may inhibit a full response.
Accordingly, in most cases it makes sense to approach the employer in the completely opposite manner than the claimant. First, send a written request for the information you want to cover and then follow up with a call to review the pre-planned questions and gather any additional details available at that time.
Once the validity of the claim is established, the examiner should focus on seeking the earliest safe date for a return to work. The best place to start this process is with the employer. It is important to understand the policies, procedures, and overall mindset of the employer with regard to returning employees to work. Important information to know includes:
• How long will the job be held open?
• Can the position be accommodated for the claimant’s limitations/restrictions?
• Are alternate "light duty" positions available?
• How long will light duty work be provided?
With this information, the examiner can assess where the employee falls within the parameters of the real work environment. Some employers fully understand the value of returning employees to work through accommodations or alternate positions and others only see this as more work in their already overburdened schedule. Knowing which type of employer you are dealing with is important.
It helps to have some statistical information available regarding the ROI of returning disabled employees to work, but realize that changing the culture of an employer is typically a larger job than can be accomplished by one claim person working on one employee’s claim. Typically, culture consultation is best reserved for a more macro evaluation with the carrier’s (or TPA’s) account rep and the employer’s senior management either at the outset of the relationship or during annual reviews. For the claim examiner, it is better to deal with the reality of the situation at hand and attempt to achieve the best possible outcome within that set of circumstances.
The Medical Provider
As with the employer, the medical provider should be contacted in a manner deferring to their convenience. A medical office typically has a set schedule when the provider conducts patient examinations, completes chart documentation, and makes contact with insurance carriers, pharmacies or other outside sources. Accordingly, the initial contact with the physician’s office should be to make an appointment to speak with the provider. Once the appointment is set, it’s best to fax a list of questions or topics in to the provider’s attention at least 24 hours in advance of the contact. If possible, a brief call should be made to the provider’s office to request that a member of the staff verify that the fax was received and ensure the provider is aware that it is in the file for review prior to the call.
Remember that in most cases, the provider is the patient’s advocate and understands the claimant far better than we can through a paper review of the file. Accordingly, while we may have opinions about recovery, care and treatment formed from our knowledge of the file and our own medical staff’s review, it is important to remain objective and be deferential to the opinion of the treating provider. The best approach is to simply hold the provider accountable for his or her opinion and seek an explanation for how that opinion was formed. In the end, the provider will either offer more details to aide in understanding the claimed loss, or it will be clear that the opinion is just that and an objective basis was not evident. In this case, the next steps are typically to arrange an independent medical examination.
The overall process of gathering information via telephone interview involves as much time and effort in the pre-planning stage as it does for the actual interview event. This can be frustrating but the time spent is well worth it if we can achieve a meaningful result and can save a lot of added work that results from making decisions with insufficient information.
Understanding and adapting to the different concerns and perspectives of the claimant, the employer and the physician increases the possibility of an effective and successful audit.
by: Charlie Putnam & Tom Loftus
We don’t know what will be important as our evaluation continues. Therefore, it is crucial to gather information while reserving judgment for later. Similarly, as the picture comes together, we may need to revisit several sources of information. For this reason, developing a measure of trust and an open line of communication serves you well. Making contact in a way that is convenient for your source keeps communication lines open.
Information sources related to a claim may be plentiful, however the vast majority of pertinent details may be obtained through three sources:
• The Claimant
• The Employer
• The Medical Provider
For the purposes of this article, we will concentrate on effectively obtaining information from these three sources.
The Claimant
The primary source for information related to the claim is the claimant. It is important to have direct contact at the earliest possible opportunity to be sure he or she understands the coverage, his or her role in the claims process, the information that is required, and the anticipated timeframe for a decision (or more importantly, the soonest a claim may be paid). Information requested from the claimant during the call should be sent in writing as a reminder, and to document the request and conversation.
Being upfront and establishing the groundwork goes a long way in building a healthy rapport. This makes future conversations more effective and generates better information because the claimant is more willing to talk to someone who listens and understands their situation.
For far too long, there has been a notion of competition between the claimant and the claim examiner. Statistically, however, the vast majority of claims are approved. The examiner should bear this in mind when speaking with the claimant and exude an attitude of working with the claimant towards reaching a favorable determination. When asked a common question such as, "Do you see any problems with the claim," it is a good approach for the claim examiner to respond that if an issue arises, the claimant will be contacted first. We find that claimants are more at ease if they know they will have an opportunity to get involved if there is a possibility of an unfavorable. This approach puts the claimant and the examiner together working as a team towards a common goal.
In the end, the facts and policy provisions will yield the decision. Therefore, when we find information that appears contrary to the claim, we should dispassionately share that with the claimant, rather than taking a "Gotcha!" approach. Infrequently we do uncover fraud and proceed accordingly, but many times there are explanations you would not have considered that fully explain the outlying information. In this case, a follow up request can be sent to the claimant (or other source identified) to document why the previous information was incorrect or irrelevant. On the other hand, if the claimant does not have any new information to share and a denial is the appropriate next step, they are more likely to accept the denial without appeal at this point.
If proper rapport was established and follow up communications were made throughout the claims process, there should be no surprises for the claimant when a decision is made. In our experience of conducting audits for various claim operations, there has been a direct correlation between the level of communication and the volume of appeals encountered on a given block of claims.
The Employer
Contacting the employer is often a very different experience from contacting the claimant whose only job (aside from trying to get healthy) is working with the insurance company to get his or her claim paid. The employer contact is likely a very busy person with multiple responsibilities. In addition to this, privacy rules, state guidelines and company policies and procedures may inhibit a full response.
Accordingly, in most cases it makes sense to approach the employer in the completely opposite manner than the claimant. First, send a written request for the information you want to cover and then follow up with a call to review the pre-planned questions and gather any additional details available at that time.
Once the validity of the claim is established, the examiner should focus on seeking the earliest safe date for a return to work. The best place to start this process is with the employer. It is important to understand the policies, procedures, and overall mindset of the employer with regard to returning employees to work. Important information to know includes:
• How long will the job be held open?
• Can the position be accommodated for the claimant’s limitations/restrictions?
• Are alternate "light duty" positions available?
• How long will light duty work be provided?
With this information, the examiner can assess where the employee falls within the parameters of the real work environment. Some employers fully understand the value of returning employees to work through accommodations or alternate positions and others only see this as more work in their already overburdened schedule. Knowing which type of employer you are dealing with is important.
It helps to have some statistical information available regarding the ROI of returning disabled employees to work, but realize that changing the culture of an employer is typically a larger job than can be accomplished by one claim person working on one employee’s claim. Typically, culture consultation is best reserved for a more macro evaluation with the carrier’s (or TPA’s) account rep and the employer’s senior management either at the outset of the relationship or during annual reviews. For the claim examiner, it is better to deal with the reality of the situation at hand and attempt to achieve the best possible outcome within that set of circumstances.
The Medical Provider
As with the employer, the medical provider should be contacted in a manner deferring to their convenience. A medical office typically has a set schedule when the provider conducts patient examinations, completes chart documentation, and makes contact with insurance carriers, pharmacies or other outside sources. Accordingly, the initial contact with the physician’s office should be to make an appointment to speak with the provider. Once the appointment is set, it’s best to fax a list of questions or topics in to the provider’s attention at least 24 hours in advance of the contact. If possible, a brief call should be made to the provider’s office to request that a member of the staff verify that the fax was received and ensure the provider is aware that it is in the file for review prior to the call.
Remember that in most cases, the provider is the patient’s advocate and understands the claimant far better than we can through a paper review of the file. Accordingly, while we may have opinions about recovery, care and treatment formed from our knowledge of the file and our own medical staff’s review, it is important to remain objective and be deferential to the opinion of the treating provider. The best approach is to simply hold the provider accountable for his or her opinion and seek an explanation for how that opinion was formed. In the end, the provider will either offer more details to aide in understanding the claimed loss, or it will be clear that the opinion is just that and an objective basis was not evident. In this case, the next steps are typically to arrange an independent medical examination.
The overall process of gathering information via telephone interview involves as much time and effort in the pre-planning stage as it does for the actual interview event. This can be frustrating but the time spent is well worth it if we can achieve a meaningful result and can save a lot of added work that results from making decisions with insufficient information.
Understanding and adapting to the different concerns and perspectives of the claimant, the employer and the physician increases the possibility of an effective and successful audit.
by: Charlie Putnam & Tom Loftus
Friday, September 25, 2009
Internet as a Claims Tool
The Internet is an endless source of information, some of which may have value during the course of a disability claim evaluation. It may help to think of the Internet as a giant garage full of items that have been placed there over a long period of time. Some were put there just moments ago and some are gathering dust off in a dark corner that has not seen the light of day in many years. Trying to retrieve a needed item from this garage can be a time-consuming and frustrating venture if you don’t know how or where to look and especially if you are not exactly sure what you are looking for.
In addition to the time constraints outlined above, insurance company legal departments may cringe at the thought of employees “on the web” during company time for fear of viewing or sharing inappropriate information. Nonetheless, given the inherent value we have gained from access to the Internet for the purpose of assisting claim evaluations, we are advocates of finding some agreeable avenue for this access. Also, given the fact that we have uncovered claim fraud through “social media” sites, “hate” sites and “adult” sites; there should be some resource within your company to achieve “unrestricted” access. For the purposes of this article, we are primarily covering free, public records.
With all that said, it is important to have rules and accountability around such a resource and each company will need to develop its own set of parameters. The company may want to designate just one or a small number of people or just one or a small number of computers to this activity.
One of the pitfalls of the novice “surfer” is one interesting piece of information leads to another and another but not to anything concrete or useful. It is easy to get distracted into thinking that useful information is “just around the corner.” The rule of thumb here is that after five or ten minutes, tops, you should be getting more and more specific details related to your particular subject. If that is not happening, it is time to move on.
Anyone who has heard of the Internet is also aware of the famous Google search. This is still a great place to start. We recommend the advanced search or quotes around the search input to narrow the results. We completed a recent claim audit where we found information demonstrating work-related activity for the company’s largest liability claim using a simple Google search and about five minutes of sorting through results.
For more specific examples, see the following items below:
- http://www.ghin.com/lookups/index.html - A website devoted to golf handicaps. If your claimant with a back problem is playing a full round of golf several times a week, you may want to look into this further. Interestingly, dates of play are posted and it is possible to develop a pattern of dates and locations played.
- http://www.bowl.com/ - Bowling Scores – Similar to the golf site above.
- http://usppa.com/ - Pool/billiards website similar to above.
- http://www.betterwhois.com/ - Website ownership. Does it appear that your claimant may have some business activity generated from a website? This site may assist you in verifying the owner of the site and how long it has been in use.
- http://www.archive.org/index.php (a.k.a. “The Wayback Machine”) This has come in handy when a claimant took down a site while we were investigating it. This site allows you to back over the years and view snapshots of what the site looked like over different points of time.
- myspace.com / twitter.com / facebook.com – Most of these social media sites have filters the user can place on them to protect their information however, due to their “social” aspect, many users do not employ the filters. Accordingly, this is information put out for public consumption. Thanks to Twitter, we now have a nation of informants. One of our claimants had a friend put up a blog post (complete with photo of our claimant) about some work activity they were performing together and then “tweet” about it. Since I was running a continual search for the claimant’s name on Twitter, I was automatically notified when it happened.
- http://www.blackbookonline.info/index.html This is an aggregate of available public record databases. Good starting point, created by the author of “The Investigator’s Little Black Book 3.” Examples include verification of a valid SSN, identification of an address as a mail drop vs. residence/business, news searches (including hometown newspapers for local stories that may have impacted your claimant), etc. Most sources are free, some tell you if they have information or not and let you decide if its worth paying for.
- http://www.legacy.com/NS/ - Obituaries Search
It is important to note that the vast majority of information gleaned from the internet should be seen simply as a lead to develop more information. It is helpful to think about it like an annual physical with your doctor. You go in good health but they still check for all sorts of things to “rule out” any problems that merit further evaluation.
Tuesday, July 21, 2009
DMEC 2009
The organizers of the 2009 Disability Management Employer Coalition conference in Portland, OR have done a fantastic job. The conference is chock full of excellent speakers and the attendee base is loaded with experts in the field of absence management. On a side note, the Twitter crowd is small but powerful here with folks like Andrea Olson (@pacifdisability), Kim Greive (@CAHRKim), Carol Harnett (@carolharnett), Steve Cyboran (@SCyboran), and Tamara Greenleaf (@mdguidelines). Follow them all if you are so inclined.
The official start of the conference commenced with an amazing speaker, Kirk Bauer who is the founder of the Wounded Warrior Project and more recently, Disabled Sports USA. Kirk is a veteran who sustained a service-related injury resulting in an above-the-knee amputation. As a fiercely competitive guy, he found himself sidelined for the first time in life. However, rather than succumb to the notions of what he was unable to do, Kirk focused on what might still be possible for him to do. As a result, he found a pathway to recovery and created the road map for other wounded veterans and more recently, any disabled person, to find rehabilitation through sports activity.
"If I can do this, I can do anything" became the motto of Disabled Sports USA. DSUSA has over 20 different sporting activities and 75 teaching events across the country where disabled individuals can participate, free of charge (that's right...free!). DSUSA has found that by engaging in physical activities that may have seemed out of reach, disabled individuals are achieving success in all other areas of their life. For example, a recent study conducted by DSUSA and Harris Interactive revealed that individuals participating in DSUSA were twice as likely to return to work than the general population (68% vs. 33%).
The lesson here?...If you are not currently referring your disabled employees/claimants to DSUSA, you should start immediately. Kirk took what could have been a very negative turn in his life and decided to see it as an opportunity to recognize what his abilities were instead, and discovered some pretty amazing things.
Wednesday, July 15, 2009
DMEC 2009 - Annual Conference, Portland, OR
Will you be at the Disability Management Employer Coalition conference July 19th - 22nd in Portland, OR? As the only non-profit devoted to integrated disability and absence management, the Disability Management Employer Coalition (DMEC) will provide you with tools to save your company money and keep valuable employees at work.
I hope to see you there. Either way, you can follow the conference right here with daily updates from the show! We will be posting information on the material presented and providing insight on who is making news - as it unfolds.
With a line-up of expert panelists scheduled and nearly 500 attendees already registered, it is bound to be a gold mine of information on industry best practices for maximizing employee productivity in a healthy, safe and effective manner. Registrations are still be accepted on site at the "early bird" discount rate in order to allow as many of us as possible to join in while budgets are tight. Nonetheless, if you can't be there in person, participate by adding your comments here and don't forget to follow me on Twitter @DIspecialist.
More to come....
I hope to see you there. Either way, you can follow the conference right here with daily updates from the show! We will be posting information on the material presented and providing insight on who is making news - as it unfolds.
With a line-up of expert panelists scheduled and nearly 500 attendees already registered, it is bound to be a gold mine of information on industry best practices for maximizing employee productivity in a healthy, safe and effective manner. Registrations are still be accepted on site at the "early bird" discount rate in order to allow as many of us as possible to join in while budgets are tight. Nonetheless, if you can't be there in person, participate by adding your comments here and don't forget to follow me on Twitter @DIspecialist.
More to come....
Thursday, June 11, 2009
DMEC - Boston Chapter Meeting - "EXTREME PRODUCTIVITY"
DMEC's Boston Chapter hosted a terrific meeting on June 10th, 2009 at the Liberty Mutual Training Center in Weston, MA. The panel of speakers was led by Carol Harnett, who was joined by Tracie Foster, Dr. Edward Crouch and Dan Arkins.
This presentation was based upon the White Paper produced by the 2008 DMEC (Disability Management Employer Coalition) Think Tank. This is the second White Paper produced by DMEC and follows their successful "Workplace Warrior" project which dealt with best practices in the case of employees involved in military service.
The speakers discussed the perils of "extreme productivity" and the misconception that more work hours necessarily equals more productivity. The publication suggests that stress (caused by overwork) is a driver of reduced profitability, increased healthcare costs and reduced productivity. Clearly, this is not the result desired by an employer. But how do we fix the problem? Well, the presenters did not dare to suggest that they had all of the answers (although they seemed to have a lot of them), but rather stated that they were attempting to start the discussion which they hoped would continue into each employer's workplace.
As a basis for the discussion, the panel reviewed several real case studies of companies, both big and small, who had volunteered to participate in the Think Tank study. Some of the solutions were simple, as in the case of H-E-B Grocery who simply created a message from top management that encouraged employees to take advantage of existing benefits. The culture had become one where it was not expected that you would use all of your vacation days or take any personal time. Senior management was able to create a culture shift to a more healthy level of productivity and claims that they have improved their employee retention by at least 10%.
Plans adopted by other employers focused on increasing communication, such as the "daily huddle." The huddle is a brief, daily meeting designed to encourage communication between employees and typically with their manager. Tracie Foster explained that she decided to try this out with her own group and found it very successful. In Tracie's case, she and her staff have a 10 minute meeting every morning and each member speaks for 90 seconds, covering current roadblocks/hurdles, what other departments they are working with, and how they are benefiting the company. The idea here is the that employees feel engaged and also gain a fresh focus on how they impact the company. A more comprehensive communication model created by USAA was also outlined. USAA's "Personal Best" online tool helps guide employees by asking them to enter information about their own status and then provides them with the cadre of benefits offered by the company that can assist them. The tool also provides coaching resources to assist managers in dealing with their employees.
Lastly, the Think Tank explored the neuroscience of stress. Dr. Crouch outlined the medical reality that increased stress accelerates the loss of neurons in the brain and creates the downward spiral that leads to an actual reduction in productivity. Dr. Crouch talked about the healthy habits used to counter the effects of stress, such as exercise, which decreases depression and actually builds neurons, leading to "healthy, high productivity."
The "bottom line" conclusions were narrowed down to:
- The importance of the manager in modeling and encouraging adherence to corporate practices as well as fostering a healthy work environment
- Communication: Not just "what" is communicated but also "how" it is done can be crucial to employee satisfaction
- Resiliency: There will be ups and downs in employee stress levels, but giving them the tools to enable them to get back on their feet as soon as possible, is crucial.
If you don't think employee satisfaction is very important, just look at Sears' statistics. They found that for every 5% increase in employee satisfaction, their sales increased 1.5% and bottom line profit rose .5%. Apparently happy employees sell lots of appliances.
It was an interesting presentation and for more details, I encourage you to download the full White Paper.
Hope to see you at the DMEC Annual Conference in Portland, OR from July 19-22nd!
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