Proactively Identifying and Managing Back Claims May Reduce Costs by 33%

A combination of sophisticated predictive analytics and early, expert medical assessment can significantly reduce the cost and duration of workers’ compensation back claims, according to new research released by York Risk Services Group, a claims management, managed care and risk control services provider.

The study looked at 24 months of back claim data using an approach which York defined as “TeamComp”:

• The average medical paid decreased 29 percent from $7,923 to $5,631.
• The average total paid decreased 33 percent from $14,301 to $9,605.
• Lost days decreased 35 percent from 64 days to 42 days.
• The length of the claim from open to close decreased 35 percent, from 158 days to 103 days.

The full report was published in a whitepaper, “TeamComp Significantly Reduces the Cost and Duration of Back Claims”.

“The key to TeamComp’s success is the way we integrate predictive analytic intelligence and medical expertise into the overall claims management process,” explained Doug Markham, president of Managed Care.

In addition, there is a partnership established among the adjuster, case manager and network provider “to design light duty or modified duty jobs that expedite the injured workers return to work.”

The approach, he said, “automatically alerts a dedicated team of clinical review nurses whenever a claim is flagged by our analytic engine. The review team’s medical expertise allows them to triage the claim and partner with the adjuster to make the best decision about how to manage the claim to a positive outcome. Where it will help drive the claim to a better outcome, the adjuster can also assign a case manager to provide an additional level of medical expertise and guidance.”

Focus on Back Problems

The company chose to focus on back claims because it is “the most frequently reported and treated occupational health injury in workers’ compensation.” According to the report, around 33 percent of workers’ compensation dollars are spent on lower back injuries and almost half of claims associated with back injuries result in lost work time.

“We chose to look at back claims because they are such a significant driver of costs for employers,” says Todd DeStefano, president of York’s Risk Management Practices division.

The report cited key factors that drive up back claim costs, including difficulty in obtaining a reliable diagnosis of the cause and the timing and appropriateness of the treatment injured workers receive during the claim.

If a medical provider doesn’t specialize in occupational injuries or illnesses, it may take more time “to understand the context of the injury and inhibit their ability to determine the best treatment. Lack of familiarity with best practices for treating work-related back injuries can lead providers to apply ineffective treatment,” the report stated.

In fact, research indicates providers may assume that appropriate treatment aligns within their specific discipline. According to the report, “physical therapists prescribe exercises, surgeons recommend surgery, pain management specialists often apply injection therapies and chiropractors rely on chiropractic manipulations.”

The Workers’ Compensation Research Institute (WCRI) conducted research that appears to back this theory. A study of back injury treatments in 16 states led the WCRI to conclude that “the type of care an injured employee received for low back pain was often inconsistent with evidence-based treatment guidelines and that care varied significantly from state to state. The biggest differences occurred in the areas of diagnostic tests/services and pain management injections for low back pain and use of diagnostic tests, approach to pain management and use of surgical intervention in disc cases.”

Keith Rosenblum, senior strategist for Workers’ Compensation Risk Control at Lockton, addressed the value of using evidence-based medicine in a recent white paper.

According to Rosenblum, since 2004 the use of MRIs and CT scans in chronic low back pain claims has increased substantially, leading to increased costs but with no real improvement in treatment outcomes. He suggested medical imaging findings in chronic pain cases are “red herrings” noting that in medicine, “a red herring is a diagnosis made based on poor science or inaccurate criteria. False certainty is created, and the search for the actual problem ends.”

York found that a third provider-related issue involves medical providers who are unfamiliar with workers’ comp injuries and who may be unwilling or unable “to partner with an employer to design light duty or modified duty jobs to expedite return to work.”

Another factor is that injured workers and their employers may emphasize self-care rather than seeking treatment from a provider, the white paper noted. “That can reduce costs initially, but can also prevent appropriate treatment early in the claim that can resolve the injury before it worsens.”