Insurers and examiners administering workers’ compensation claims face many challenges with claims involving even minor, non-catastrophic injuries. The insurer must fulfill its duty to provide the necessary medical treatment to a claimant injured on a job site while simultaneously managing the rising costs of medical claims and ensuring a minor injury-related claim does not advance into a more catastrophic claim.
Medical claim costs have been steadily increasing over the last several years, according to Verisk Analytics. Many reasons factor in to these rising costs, including advances in medical technology and more complicated issues such as increasingly subjective diagnoses of additional, unrelated medical issues at the time of the workers’ comp incident. Verisk Analytics also highlights growing litigation occurrences and the increasingly complex responsibilities of an insurer’s examiner. As the workers’ comp claims industry becomes more complex, the frequency of claims involving minor injuries developing into more catastrophic injuries may grow if the proper precautions are not taken; these so-called ‘creeping catastrophic claims’ can and should be prevented with the proper claims administration.
The first step in preventing creeping catastrophic claims is to identify instances of these potential cases right away, according to Verisk Analytics. Some workers’ comp claims become unnecessarily complicated or even develop into catastrophic claims due to unwarranted or redundant medical action, overuse of opioid drugs and sometimes even fraud. Even after identifying the early signs of these potential creeping catastrophic claims, proper action must be taken to avoid increased costs and negative outcomes for claimants. Among other suggestions, Verisk Analytics recommends assembling a team and assigning experienced estimators to the claim. This can be difficult for an insurer to do when their examiners are already tasked with many other complex duties and may not have adequate training in areas of medical claims and the pharmaceutical industry or the durable medical equipment, prosthetic and orthotic and medical supply (DMEPOS) industry.
Partnering with a Pharmacy Benefit Manager and Durable Medical Equipment Benefits Manager (PBM/DBM) provides multiple benefits to the insurer and to the examiner. The PBM/DBM provides the examiner with access to an experienced team of industry professionals who recognize the warning signs and best methods for preventing creeping catastrophic claims. Northwood, a leading PBM/DBM located in Michigan, provides its insurers with access to its accredited network of home health care providers which allows the insurer to prevent costs associated with workers’ comp claims from rising even further. Northwood’s experience in the workers’ comp claims sector can assist an insurer with preventing a catastrophic claim from developing out of initially minor claimant injuries. The experience that is gained by partnering with Northwood benefits claimants and can help create a more positive outcome for them as well. For more information or questions on teaming up with Northwood on your workers’ comp claims administration, please contact a representative today at 877-684-9276.
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