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National Council of Self-Insurers 2013 Annual Meeting

National Council of Self-Insurers 2013 Annual Meeting. Lawrence E. DellaVedova, President of DDP Group, Inc., “A Claims Consulting Company”. Test. If you are a paving worker and you strike a bowling ball and cause eye damage-are you covered under WC?

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National Council of Self-Insurers 2013 Annual Meeting

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  1. National Council of Self-Insurers2013 Annual Meeting Lawrence E. DellaVedova, President of DDP Group, Inc., “A Claims Consulting Company”

  2. Test • If you are a paving worker and you strike a bowling ball and cause eye damage-are you covered under WC? • If you work at home, trip over your dog and injure yourself, are you covered? • If you die of a heart attack while holding a termination letter are you covered? • If you get stuck in a cafeteria booth while at an appreciation dinner and break your leg while trying to get out, are you covered?

  3. Test • If you are a liquor store employee who was robbed can you have PTSD and recover WC? • If you spend 31 years listening to complaints over the phone are you a WC benefit receiver for hearing loss? • If you are a sheep herder, drink heavily and are shot after an argument late at night can you be a WC recipient. • If you are a truck driver, and cough, causing an accident, can you injuries be covered by WC?

  4. SUMMARY OF TOPICS TO BE DISCUSSED TODAY TRENDS IMPACT ON AUDITS NOW AND IN THE FUTURE

  5. AUDIT TYPE • EXCESS INSURANCE • REINSURANCE STATE • AUDITS OF SELF ADMINISTERED CLAIM DEPTS • AUDIT OF TPA’S

  6. OWNERSHIP OF THE CLAIM THE FOCUS WAS SOLELY ON THE ADJUSTER FOCUS HAS SHIFTED TO INCLUDE VENDORS AND SPECIALISTS

  7. SOCIETAL CHANGES PHARMACY/MEDICAL COSTS SKYROCKETING USE OF PAPER AND THE POSTAL SERVICE DECLINE

  8. INDUSTRY CHANGES CLAIM COUNTS ARE DOWN SEVERITY IS TRENDING UP AGING WORK FORCE VENDOR CONSOLIDATION

  9. SEGMENTS OF AN AUDIT • Communications • Process • Reserves • Medical • Supervision • Documentation

  10. NATIONAL TRENDS • Obesity • Telecommuters • Mental Injuries • Erosion of protections • Medical Set Aside Confusions • Illegal or Legal Aliens

  11. SPECIFIC TRENDS WE SEE AT AUDIT • Not taking Comorbidities into account • Neglect or lack of control of medical • No in depth drug reviews • Lack of documentation and information

  12. GENERAL AREAS THAT CONTINUE TO AFFECT CHANGE • TECHNOLOGY • SOCIETY • STATUTORY

  13. TECHNOLOGY 60% OF MEDICAL PERSONNEL ARE USING SOME SORT OF TABLET THERE ARE 20,000 APPS FOR MEDICAL INFORMATION 98 MILLION PEOPLE IN THIS COUNTRY HAVE A CELL PHONE OR SMART PHONE

  14. TECHNOLOGY CLAIM SYSTEM IMPROVEMENTS DASHBOARDS, SCORECARDS, BENCHMARKING APPS THAT TRACK INJURY PATTERNS FROM AUTO IMPACTS

  15. STATUTORY CHANGES • LAW CHANGES • States require continuing education to keep up on changing laws • ADJUSTER LICENSING • 34 states now require licensing • MEDICARE SET ASIDES FOR • SETTLEMENTS

  16. MORE EMPHASIS… • TRAINING • VENDORS • INTERNAL CHANGES • VENDOR VETTING • HIDDEN COSTS IN PRICING (VENDOR OVERIDE)

  17. AUDITORS’ PROCESS DEVELOPMENTS WE ARE SEEING AS A RESULT OF THE CHANGING CLAIM HANDLING DYNAMICS What we are doing: • Examining vendors closely Not only work being done, but quality and cost Review coordination of efforts between adjuster and vendor • Examining specialists Are they necessary? Do they have a proven track record? • Scrutinizing supervisors and managers Discuss office hierarchy, procedures, training Review claim files for evidence of effective oversight, communication, authority, and claim guidance

  18. AUDIT TRENDS DEVELOPMENTS WE ARE SEEING AS A RESULT OF THE CHANGING CLAIM HANDLING DYNAMICS Adjusters: • Complacency and frustration • Lack of proper documentation (scanned documents) • Not factoring in co-morbidities when reserving, planning What Management Can Do: • Oversight to ensure ongoing proper training according to all levels of experience • Roundtable discussions regarding use of vendors and computer programs • Open door policy to encourage daily communication • Question & answer sessions on a regular basis to address claim issues and adjuster concerns

  19. AREAS OF IMPORTANCE FOR MANAGEMENT • “BRAIN DRAIN” OF CLAIMS FOLKS • Reduced to processors vs. managers? • TRAINING • Statutorily required • Ongoing for adjuster development, promotion • DATA ANALYSIS • Claim info is readily available • Proper use of all claim tools by staff • Quality and effectiveness of vendors & programs

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