Of course, medical treatment and pharmacy costs – particularly driven by potential narcotic over-prescription and abuse – continue to be a high priority issue. Employers are seeking innovative ways to manage these costs across the workers compensation and group health space.

On the treatment side, employers are interested in making sure injured employees have access to those medical providers most likely to deliver the best outcomes cost-effectively. They are keenly interested in measuring provider performance based on outcomes rather than costs, recognizing that quality care up front often means lower claim costs down the road.

NU: What are some of the ways in which Helmsman has evolved in serving its clients' needs? Have you seen any newer types of client requests that you might not have in years past?

DM: While the goal of our customer service is constant – to continually make it easier for employers to better control workers compensation claim costs – technology has evolved how we achieve that strategy.

This is most clearly seen in two areas: data analysis and communication.

Today, technology allows sophisticated data analysis that creates the tools needed to better manage workers compensation costs. Data helps quickly identify problematic claims – such as an injured worker receiving narcotic prescriptions from multiple medical providers – and build the resources that get those claims back on track, such as networks of providers more likely to produce better outcomes cost-effectively.

Technology has also sped the flow of deeper claims information. A single online claims management system enables all parties – employer, broker, claims manager, medical director, nurse case manager, adjustor, et cetera – to quickly share information on a specific claim or entire set of claims. Faster, more detailed information to a wider range of stakeholders helps produce better outcomes and lower total claim costs.

NU: How much of a role does predictive modeling play in Helmsman's work?

DM: Predictive modeling has been an important part of our claims management philosophy for more than a decade.

We analyze data to find actionable information that helps employers better manage the total cost of workers compensation, from taking action on a specific case to developing tools that help impact all claims, such as our provider networks. In working toward this goal, we are fortunate to be able to leverage the vast array of data available to us as the third party administrator subsidiary of Liberty Mutual Insurance.

The most critical aspect of any predictive modeling program is how data is turned into actionable information and shared at the right time with claims staff.

We have focused on broad-based models that help identify claims that are at risk, as well as decision-point models that provide real-time decision support on specific issues. Models can identify claims in need of medical support, fraud investigation or even claims with compensability issues within the first 10 days after report of claim.

Once identified, we support our claims staff with both tools and experienced professionals dedicated to guiding them on alerted claims.

NU: What are some of the loss-control protocols that Helmsman employs to combat workers comp fraud?

DM: Helmsman's Special Investigations Unit (SIU) partners with all internal and external stakeholders in the detection, investigation, and prevention of commercial insurance fraud.

Our claims staff is trained to identify suspicious – or “red-flag” – indicators. Over 50 SIU personnel provide expert analysis and perform investigative tasks to help ensure that claims handlers reach fair decisions. The SIU investigator staff is made up of seasoned claims professionals and individuals with law enforcement backgrounds.

We have various predictive models and business rules that run on our workers compensation claims to identify potential fraud. Those are reviewed by our triage team to determine if an investigation should occur. The triage team and modeling team work together regularly to continuously refine and improve the models and business rules.

Additionally, claims has created a social media team that does more than simply respond to referrals for investigations. The team takes a systematic approach to social media investigations by employing a vetted process that proactively seeks publicly available, non-private information and makes it available to our case handlers for use in determining whether the information supports the injury or conflicts with the injury and/or disability.

To address provider fraud, we have an analytic team that supports our Complex Fraud Investigators. This team is able to analyze our workers compensation medical data to identify concerning trends related to provider treatment and/or billing.

NU: Which states do you find particularly challenging to operate in, when it comes to administering workers comp claims, and what are some of the solutions you've developed to that end?

DM: New York and Illinois are two states that provide significant workers compensation challenges to risk managers, TPAs and insurers.

In New York, medical inflation is a key cost driver. A recently proposed medical fee schedule based on Medicare – together with pain management guidelines – will hopefully help in controlling workers compensation claim costs in the state.

Growth in the New York State Workers Compensation Fund remains a concern. In order to create a more robust private workers compensation market in the state, buyers, brokers, agents, TPAs and insurers are working with regulators to get more price flexibility.

In Illinois, the state now allows employers, TPAs and insurers to use accepted medical networks to treat injured workers. Such networks help control claim costs by producing better outcomes cost-effectively.

Prior to the recent law, the state did not have a workers compensation fee schedule. All medical costs were charged at “usual and customary” levels, which tend to be higher than through a workers compensation medical network.