Why nurse case management?

Nurse case managers act as social workers, patient advocate, and serve as a liaison between patients, claims personnel, and healthcare providers.  But why?  What good is this to employers?  Well, if an employer has adopted a workers comp advocacy approach, the nurse case manager serves to reduce time off of work by reducing the gaps in the medical care provided.  Most are actual nurses and have a social work background.  Their social work experience helps to retrieve the claimant from post-injury depression or simple uncertainty.  As a nurse they can help to communicate the injured workers needs and concerns to his medical, eliminating pauses in treatment that can increase time off work and increase the probability of litigation.

The days of aggressive claim handling processes is nearing an end.  Common sense and failed experience, has proven that a workers comp advocacy approach coupled with a quality nurse case management team return employees to work.  That means huge savings down the line!

Victory      bmanley assoc logo

Our affiliate Manley & Associates has experienced nurse case managers in all 50 states, including California, that will get employees back to work or help to manage the most complex of claims.  Here’s the link!  https://manleyandassociates.com/service/case-management/

Making the pitch to settle future medical care!

Just as we preach that successful claims examining is all about client care and customer service, making the offer to settle out future medical care is all about salesmanship!  Every office that I’ve visited over the last fourteen years has used a generic letter to the injured worker or his/her representative stating the following: ” Please let me know if you would like to settle out your future medical claim.” or to the attorney “Please advise me of your best settlement offer so we may begin to discuss settlement.”  Both notes gift the power and leverage of settling the claim to the injured worker or his attorney.   The power references an assertive position not a subordinate position.  The leverage refers to the evidence and items of negotiating weight that the examiner holds.  A subordinate position gives away any control or influence the examiner may have to negotiate a great settlement.  In the majority of cases, the adjuster receives a response from applicant counsel outlining an outrageous settlement scenario.

In order to improve the conversion rate from failed offers to winning offers, examiners need change from a feeble approach and develop a little salesmanship in order to make a winning settlement pitch!  Their offer needs to illustrate their leverage points in the claim and the positive scenario that settling the claim will create. Basic sales!  You see everybody wants something.  Once you find out what the other side wants or needs, you have leverage.  One will play to those leverage points in order to influence an accepted offer.

So we go from, “Dear Mr. Savodnich,  I am interested in settling out your future medical claim.  Please let me know if you would like to proceed.  I’d like to offer you $75,000.”  to “Hello Mr. Savodnich, I’m Joe Adjuster and I’ve been administering your future medical claim.  I hope that you are well.  I note that, the frequency of your medical treatment has dropped drastically, which I hope means that you have been well.  As your medical treatment frequency has diminished, I believe that you are in a position to control your own medical treatment.  I would like to discuss transferring your case control and future medical monies to you.  Our expert medical cost projection company, BMA West, has projected that you will need $65,000 in order to cover your medical expenses through the rest of your life.  I’d like to offer you an incentive of $10,000 in order to complete your case with us and transfer your future medical care monies to you.  If you worry that you may not have enough to last into the future, we can also discuss placing your future medical care monies with a life insurance company, where it will safely grow interest throughout the future.”  The leverage is that Mr. Savodnich is not treating frequently and is more than likely dislikes the utilization review process and the poor medical treatment at the occupational clinic.  He’d be happier handling his own medical treatment.  The letter also introduces the idea of placing his monies in an annuity (structured settlement).

For the most part generic form letters won’t bring results, but developing salesmanship can improve claim team results!  If you have questions feel free to contact us at

(949) 830-2027 or glortiz@bmawest-msa.com .  #workerscompemployerschool #claimsexcellence #bmawest-msa.com

Risk manager with a purpose!

I had the pleasure of getting to know a risk manager yesterday, albeit via telephone.  Angel Guerra-Chagolla is a native Californian and graduate of Cal State San Bernardino.  The reason I was so impressed, was that she exuded leadership.  In today’s business world, it’s a rare thing to run into a true leader.  Most folks in the corporate world become lost in their own search for corporate success – corporate climbing.  However, instead of claims and insurance, the first subject we discussed were the upcoming Female Empowerment Seminars she’s created and her hopes of guiding more women forward toward careers in risk management and other related fields.  I had never noticed before, but women in risk management are few in number.  The majority of risk management professionals are male and while there are many women in the insurance claim field and human resources, their inclusion in the risk management profession has lagged.  She wants to change that!

Ms. Guerra-Chagolla will be hosting the Sisters in Business Female Empowerment Seminar on September 27, 2018 at the Dave & Buster’s Event Center in the Ontario Mills Mall from 10 a.m. to 3 p.m.  Attendance is free and lunch is included. Female Empowerment 1

A second seminar is scheduled for October 4, 2018 from 10 a.m. to 3 p.m. at Trader Vic’s in Emeryville, CA.  Both fliers are included here!Female Empowerment 2

We wish Ms. Guerra-Chagolla well in her endeavors!

Three character traits of a top TPA claims examiner!

Sometimes, I’m amazed at what little thought goes into selecting a claims examiner to work on your claims.  However, the most frightening thing to me is that many self-insured employers don’t consider that they’ve put their $5 million dollar security deposit and millions of dollars of reserves in the hands of  individuals who have limited education; are reactive by nature and have little financial education.  More frustrating, is when an employer refuses to consider the issue.  This the main reason we’ve been talking with employers about workers comp claims program oversight!

In any case, here are our thoughts on the three character traits every claims examiner should have:

  1. Friendly, empathetic communicative manner.  Saves the employer thousands of dollars in litigated claims, because a sympathetic/empathetic ear can steer an injured worker away from legal representation!
  2. Financial education.  Whether in college or other learning institution, an examiner needs to monetize the risk of a claim throughout the life of the claim.
  3. Proactive attitude.  By nature, the claims practice of every TPA and insurance carrier is reactive.  If it were proactive, they wouldn’t make any money, but that’s another story.  A proactive approach means that the examiner isn’t waiting to move on claims when their diary comes due.  The wait time creates impatience in injured workers and they seek the sympathetic ear of an attorney.

Our Workers Comp Employer School and WC Claims Oversight service addresses these issues and more.  Feel free to call or write us at (949) 830-2027 or glortiz@bmawest-msa.com

Why workers comp claims oversight can work for you!

Workers comp oversight is one of the most effective tools for reducing your overall workers comp losses!  Solving your work comp challenges and reducing monetary losses should be a high priority on the company agenda.  Today, more than ever, oversight and advocacy needs to be implemented in order to curtail losses.  In California, a Division of Workers Compensation study, showed a 7% rise in medical costs in indemnity claims.  There could be a number of explanations for this, but one ting that must be considered is the drop in experience and expertise of the claims examiners entrusted with handling your millions of dollars of claim reserves.  This drop in expertise can only be explained as an after effect of insurance third-party administrators and “expert” service provider’s greed.  By seeking out equity investors, these organizations must commit to a healthy return on investment for their equity investors.  That means they need to cut costs somewhere and that’s usually the talent.  This is just something for you to consider.  It’s also a call to self-insured employers to begin a proactive approach to their claims program.  Claims Oversight and work comp advocacy can turn a work comp program around!   Our Workers Comp Advocacy and Claims oversight program provides some of the following services at more than half the cost of hiring another employee to do the job:

  • Establish goals & objectives for the employer claim program
  • Review of loss runs
  • Review of expert provider panels
  • Return to work design and coordination.
  • Oversight of insurance company’s reserving logic, decision logic, and claims closure.
  • 90 day written reports on all claims and telephonic review meetings with the employer.
  • Coordination of AOE/COE claim investigations as soon as they occur.
  • Evidence & subrogation identification and collection
  • Witness identification and interview (bilingual Eng/Span)
  • Interventions and resolution of issue with administrator or vendors
  • Claim review attendance
  • Monitor & assess high dollar resolutions on large excess complex claims.
  • Ongoing consultation and advocacy work on legacy files.

Workers comp claim oversight of your third-party administrator or carrier can help to reduce your X mod, reduce outstanding reserves, limit claim life and save on growing losses.  The great thing about this program is that it’s so affordable!

Our program employs the best workers comp claims and risk experts in the country with an average of 20 years’ experience!  Our team is committed to changing your workers comp outcomes!

Call me with questions and to schedule a time to take control of your workers comp program!  (949) 830-2027 or write glortiz@bmawest-msa.com

Proactive work comp claims settlement can save millions in long term costs! It’s well worth the try!

Implementing a proactive workers compensation claims settlement program, cities, counties and public entities can save millions in long term costs.

Question 1 – What do the following cities have in common?
• Atlanta
• Los Angeles
• Santa Monica
• Philadelphia
• Pittsburgh, PA
• Berkley, CA
• Marion County
• San Bernardino, CA

Question 2 – What do these two public entities have in common?
• Pittsburgh, PA
• Marion County

The answer to question number one is that these public entities are/were all suffering from the gross increases in workers compensation costs that threaten their very existence.  The answer to question number two is very simple.  These two entities took a proactive approach to reducing their workers compensation claims losses.  While a few of these entities took the time and expense to audit their claims administration program, the most obvious course of action was overlooked – settle the claims.

Too many answers and not enough focus
A few entities on the list believed that enhancing their loss control procedures would help to alleviate their troubles.  Another was focused on fraud.  All audits did identify the same departments as creating the bulk of the claims – police, fire and public works.  The most frequent and costly were the police and fire departments. The audits also identified issues with claims administration, training and labor unions.  While these entities are correct in their findings, it’s a combination of all of these that create the multi-million dollar losses that threaten these and all public entities throughout the country.

Many contributing factors
There are other issues that directly impact claims costs such as the growing girth of aging
American workers, a decline in professional claims handling education and best practices, collective bargaining agreements and a lack of effective Early Return to Work (ERTW) programs.  However, from a fiscal perspective, which is really what matters, the growing inventory of future medical and long term litigated claims are the culprits.  The fact that the police and fire departments file an excessive number of claims is symptomatic of the employment culture.

Taking a proactive approach to claims
Pittsburgh and Marion County both recognized that in order to repair or preserve their entities and the tax dollars supplied by the people of their respective jurisdictions, they needed to cut long term costs such as medical and legal and reduce their reserve exposure.  The only way to do this is by settling claims.  In Pittsburgh, a massive audit into the finances of the city showed that 21% of workers comp payments in 2003 went to former employees injured over 20 prior.  The restructuring plan devised for the City of Pittsburgh, entitled the Act 47 Recovery Plan, included the implementation of a workers comp claims settlement program.  By settling out claims, the city would save millions in long term costs and reserves.  The story was similar in Marion County, where reserves were reduced the following year by $2 million dollars.  The realization being that legacy claims (cases over five years old) cases get worse with time and significant dollars can
be saved over time by ridding the claims inventory of the old dog files.  It’s simply a numbers game. Forget the nature of the claim and focus on the numbers.  If a claim can be settled for less than the total exposure, in spite of the issues of the claim, then a lump sum settlement should be pursued.  Doing so can save thousands, if not, millions in
taxpayer dollars, medical expenses, legal fees and excess insurance costs.  The effect of
proactive claims approaches such as this reverberates throughout a city, county or school district.  There is a positive trickle-down effect for the public entity, and the taxpayers it serves.  It’s a good business decision.

We’ve had the pleasure of working with public entities for the past thirteen years and have helped them close hundreds of claims by targeting certain claim types, valuating them and moving them into a settlement position.  The use of structured settlement solutions have saved these same entities hundreds of thousands of additional dollars.  A future medical claim settlement project should be no more complicated than that.  Always remember that an injured employee would much rather have medical control over their injury, rather than waiting for his/her claim to come up again on an adjuster’s diary.  Proactive is the word!

What has equity investment done to workers comp insurance?

Risk & Insurance magazine reported on the 2014 National Workers Comp & Disability Conference and a panel discussion called, Buying in to Workers’ Comp.  In the article Hunter Philbrick, managing director of  Hellman & Friedman, is quoted as follows:

“I think you will continue to see significant activity in the workers’ compensation space,” said Hunter Philbrick, managing director of Hellman & Friedman, whose firm (along with Stone Point Capital) acquired Sedgwick Claims Management Services in 2010 and sold it to Kohlberg Kravis Roberts & Co. earlier this year.

P/E firms get a bad reputation for ripping apart companies, he said. “That’s a very small minority and not really true of any of our firms up here.”

Philbrick was joined on the panel by Jeffrey McKinney, managing principal of Odyssey Investment Partners, which acquired majority interest in York Risk Services in 2010, and acquired and later sold One Call Care Management; and Camilo Horvilleur, principal of H.I.G. Capital, which acquired PMSI Group in 2008, selling it in October 2013, after which it merged with Progressive Medical and became Helios.

Of course the attendees at the panel were impressed.  After all, their interest was likely to gain equity investment, use the vacuum cleaner sales model to sell their products or services in order to generate the appearance of growth for the equity investor, whose sole intention it is to sell the company for a huge profit.  But has equity investment improved the workers comp environment or has it created an ambivalence in purpose and loyalty?  Who would have thought that nurse case management services could be sold using the vacuum cleaner sales model?  For those of you who don’t know the vacuum cleaner sales model refers to the sale of a product or service by a company using a large sales force and supporting it with a contracted or very small support group.  That’s how companies make money mass producing products and services – through volume sales.  Other than the volume sales, has equity investment of workers comp companies and service providers improved our “industry”?  Take a look around.  It hasn’t created more jobs, in fact, the industry has contracted.  More importantly, have employers, the folks we have a fiduciary responsibility to, gained anything from this type of  insurance model?  Have employees recovered and returned to work in greater numbers?  Have all these volume sellers, instead, created a regular feeding ground of sales and profit that will suffer if litigation were to fall significantly, TTD periods reduced and employees were to return to work in greater numbers?  It’s hard to see when one is in the midst of the storm and much easier to assess the damage or improvement from a different perspective.  However, a look from a different vantage point may provide some answers.