On-the-job injuries are all too common in some businesses. In assisted living centers, employees must lift, bend, and twist in their efforts to help the elderly residents perform their daily activities. This takes a toll on the backs of employees, even those trained in how to safely work with the elderly and infirm. Regency Pacific, a group of assisted living homes in the Pacific Northwest, while exceptional in other ways, is no exception to that rule.
When an employee is hurt on the job, responsible employers like Regency Pacific want to make sure the injured person can come back to work as soon as possible and that they are fairly compensated while they are injured. Workers’ compensation insurance is the answer. While workers’ comp programs vary from state to state, they are all designed to meet both of those goals.
Regency Pacific, located in Oregon, is careful to follow the workers’ compensation rules for the state. But heavy lifting often leads to back injuries, and back injuries lead to claims against the company’s private workers’ comp insurance policy. It started to look like Regency would be dropped from its insurance company and be unable to obtain workers’ comp insurance from any other company.
That would leave no option but to buy into the high-risk pool established by the state of Oregon. “If the claims were too high, we wouldn’t be able to buy insurance,” says Janice Bottemiller, NHA, who is regional vice president of Operations for Regency. “Companies don’t want to cover you if your claims are too high.”
Whether Regency could find a private insurer to cover workers’ compensation, or whether it would have to enter the state pool, there is no doubt it would be expensive. Regency needed more than an insurance product; it needed guidance. It hired Propel Insurance (www.propelinsurance.com), a Pacific Northwest broker, to provide consulting services. Ken Jackson is one of Propel’s experts in workers’ compensation.
Triage System Separates Claim Types
Over the last decade or so, Jackson says workers’ comp insurers began to apply some strategies that healthcare experts will recognize. “They have begun to streamline their services by tiering their claims services,” he explains. “They are bringing more automation to the processes and systems. In general, the people who handle the routine claims may be less experienced, relying more on systems. It’s kind of a triage system.”
Increasing automation and decreasing the personal touch sounds good on paper. But in practice, Jackson says some claims just require more attention. “Workers’ compensation claims can take on a life of their own,” he says. “Some claims that occur may last for years. Sometimes a claim that’s not very serious can become a problem.
“For example, a claim might develop into something different and need to be moved to another adjuster’s area of responsibility. When a handoff like that occurs, you likely have to recreate how you got there. Sometimes the system the carrier is using is the driver, and it may not give the employer and the employee the best result.
“So what we wanted to do was kind of go back to the good old days where the case managers would really follow the flow of the client’s claim, from the onset of the injury to final resolution.”
“High-touch” is the phrase used in the healthcare arena, and it certainly applies here. Propel’s Comp 360 program brings in registered nurses (RNs) who specialize in workers’ compensation, and they act as case managers for the more complex claims.
“A lot of carriers used to have field nurses for interactions between the employer, the doctor, and the adjuster,” Jackson continues. “Now, they often interact over the phone. You can do a lot over the phone, but when an RN goes into the doctor’s office and schedules an appointment to talk about the nuts and bolts of the case, you get a better result.”
How? Jackson illustrates: “In workers’ compensation, in some states you can just go to your regular family doctor. An employee might go and tell the doctor that his shoulder still hurts, but the company wants him to go back to work. He doesn’t want to do it because he thinks it’s going to hurt his shoulder. The doctor will probably authorize, say, 4 extra weeks of time loss.
“The insurance company and the employer may be trying to get the doctor to see that there are light-duty things [the employee] can do without hurting his shoulder. But when an RN shows up in the office, and says ‘Here is the physical evaluation of the capacities of this person, and here’s the light-duty job,’ it’s a different story. They speak the same language.”
Proper Job Descriptions Critical
More is involved than simply providing a liaison between the physician and the insurance carrier. The nurse/case managers also help companies examine their jobs. This is an important step toward containing the costs of workers’ comp. First, current jobs are evaluated to make sure their requirements are accurate. Jackson says, “Say you have an employee, Jane, who is working on the manufacturing floor. She is released at the conclusion of her claim with the restriction that she cannot lift more than 25 pounds (lb) on occasion.
“At the time of her injury, her job analysis said she might be required to lift 30 lb on occasion. The company may say that she won’t ever have to lift 30 lb, but that’s what the job analysis said. A thorough job analysis with a nurse/case manager should make sure the job analysis is accurate. They’ll ask a lot of questions, help the employer take a look at the jobs, and tighten up those descriptions.
“Under Oregon law, the scenario we just discussed could have huge consequences,” Jackson says. “A disability factor is applied to any award someone gets for their injury. So even though the employer assures Jane she won’t have to lift 30 lb, if her job analysis says she might, the state would apply this factor to her award. So if her award had been $5,000, it might be $35,000 once the disability factor is applied. It’s a huge exposure.
“Often, the job analyses are done by department managers who have a lot of other things to do. If you’re a department head, and somebody in HR asks you to work up job analyses for the 12 positions in your department—how much standing, how much pulling, how much lifting—‘and by the way, I need these today,’ you’re not going to think much about the project. But it’s a very important exercise, and you need to give it some attention.”
Nurse/case managers are also able to help define light-duty jobs. “They’ll take a look at your whole process. They might notice that you say you have light-duty jobs, but you haven’t really defined them. When the employer has the ability to offer light-duty, modified work, they’re going to get a better result for the worker and better results on the claims costs,” says Jackson.
“What you really need is a listing of all the available light-duty tasks within your operation and across departments. [For example] if Joe was injured out on the manufacturing floor, returning him to a light-duty or modified job there might not be possible. He might need to go to the warehouse. So you need to know what tasks are available in the warehouse. A good workers’ compensation broker will help the employer set that up.”