URMIA Matters

Claim Handling Strategies for Complex Workers’ Compensation Claims

November 18, 2020 URMIA Members Craig McAllister and Julie Groves with Guest Dr. Branco Season 2 Episode 1
URMIA Matters
Claim Handling Strategies for Complex Workers’ Compensation Claims
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URMIA Matters
Claim Handling Strategies for Complex Workers’ Compensation Claims
Nov 18, 2020 Season 2 Episode 1
URMIA Members Craig McAllister and Julie Groves with Guest Dr. Branco

The best claim settlement is one that is reached early and makes both the injured worker and employer happy. Join URMIA guest hosts Julie Groves of Wake Forest University and Craig McAllister of the University of Miami as they talk with Dr. Fernando Branco, chief medical officer at Midwest Employers Casualty.  Dr. Branco provides a fascinating medical insider's view of best practices that will help risk managers achieve better outcomes with workers’ compensation claims.

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Show Notes Transcript

The best claim settlement is one that is reached early and makes both the injured worker and employer happy. Join URMIA guest hosts Julie Groves of Wake Forest University and Craig McAllister of the University of Miami as they talk with Dr. Fernando Branco, chief medical officer at Midwest Employers Casualty.  Dr. Branco provides a fascinating medical insider's view of best practices that will help risk managers achieve better outcomes with workers’ compensation claims.

Show Notes [member login required]

Jenny: Welcome back to another episode of URMIA matters. Today you’re in for a treat! We have guest hosts Julie Groves from Wake Forest University and Craig McAllister from University of Miami. Take it away, guys. 

Julie: Hi everyone, welcome to URMIA Matters. I'm Julie Groves, the Director of Risk Services at Wake Forest University and I'll be a guest host today along with Craig McAllister. Hi Craig!

Craig: Hi, Julie. I’m Craig McAllister. I’m the Executive Director of Risk Management for the University of Miami in Coral Gables, Florida. The two of us were recently reelected to a second/third year term on the URMIA board and appeared in a podcast together. There was such a positive reception we were asked to co-host this podcast.

Julie: So the subject of today's podcast is claim handling strategies for complex workers compensation claims. This topic was actually a proposed presentation for our 2020 annual conference, but because of our compressed virtual format we had to reduce the number of overall presentations and it ultimately wasn't selected but we appreciate the opportunity to discuss this topic today on our podcast.

Craig: Julie and I both have workers compensation in our responsibilities and we're looking forward to hearing more about the strategies today. I’d like to welcome Dr. Fernando Branco with Midwest Employers Casualty. Thanks for being with us today. Please tell us a bit about yourself. 

Dr. Branco: Hello everybody, thank you Craig and Julie for the invitation and the privilege of being here to talk to this great audience. My name is Fernando Branco, I’m a Physical Medicine Rehabilitation Specialist. I graduated quite a while ago in 1986 and I've been a PMR doctor after my residency and I did work with a lot of the catastrophic patients that we’ll discuss today. They are what we originally called catastrophic spinal cord injury patients but I also work for a long time with pain cases that I also consider catastrophic pain cases and we'll talk about those also. And because I started after a couple decades of clinical work I start focusing on pain cases and as you guys know 20 years ago, if not more than 25 years ago we start having this very strange opioid epidemic and I realized that if I was going to treat pain I need it to not only be board certified in pain, that I became and eventually because a lot of the patients had addiction I felt the need to also become an addictionologist. I’m triple board-certified and I work with patients with addiction and catastrophic injuries in my background. I can give you my overall feelings about that. I work in clinical practice until close to six years ago and I have been working with Midwest Employers Casualty for probably a decade before that they were sending patients to me. I was the medical director of a functional restoration program and I got to know the company, and the rest is history. They, we discussed and I joined them six years ago to help them, exactly on this how to handle not only catastrophic, standard catastrophic cases but also the pain catastrophic cases.

Julie: So tell us just before we start our discussion when you graduated from med school did you think you would ever end up at an insurance company?

Dr. Branco: No, you never think that way of course. Julie: I never thought I’d end up with insurance so I’m just always fascinated at people’s past to get there.

Dr. Branco: I think it has something to do with me because when I went from the clinical for so many years, literally almost 30 years of clinical work, it was a, how are you going to be able to handle it, and to a certain degree I felt that was a normal progression because all of my experience, my clinical experience, I think being the chief medical officer of the success carrier that deals with literally hundreds of these cases, I can help lead these cases in the best direction for the patients and for the insurance of course because in the end that’s something that I’m going to try to be as… that the best outcomes of the claim and most of the time if not almost 100% of the time means a good outcome or in settlement or less expenses for the insurance. It sounds a little strange but I’ll try to go over why Midwest has that philosophy, that’s why I joined them. I probably wouldn’t have joined if I didn’t feel like they have something that fits with my philosophy. That means I didn’t feel like I felt like I was growing my role to instead of just dealing with my local, I was able to influence countrywide and all those difficult cases using all those background that I built for so many decades.


Julie: Great, that’s very helpful. So, let me ask you to give us your thoughts on how to best implement a settlement strategy that results in a successful financial outcome for the employer, while still ensuring that the employee receives the best care. 


Dr. Branco: Of course. I think one of the important things, there’s two different main, what I consider catastrophic cases but there is the, what we call the classic catastrophic case. That is a spinal cord injury patient, tetraplegic, paraplegic or you have burns, extensive burns or an amputation or a brain injury, be a stroke or most formally in workers comp a traumatic brain injury that’s called TBI. Those are the classical cases and I think most immediately at least on insurance is that this is going to be expensive no matter what. No matter what we do. Interesting enough, what Midwest has done, what I have worked myself from clinical, what I’ve been doing there, it makes a huge difference how much we invest early on a catastrophic case with the right personnel, the right treatment and implement those treatments correctly, even sometimes they will be a little more expensive to start out. This is in the classic catastrophic case, I think you invest more in the beginning then you invest less later on. Different enough, I think there are two different cases that are… There's also what we call at Midwest they’re called migratory claims, what I call catastrophic pain cases. Those are the cases that you have somebody to lift a box and has a back pain and 10 years later files a million dollars and the patient is as disabled as a spinal cord injury patient or a brain injury patient. Those are what I call the catastrophic pain cases. Those in general, they’re much harder to intervene than the clear classical catastrophic case. Those migratory cases, how we deal with them is with what I call the onion, peeling of the onion. You have to start, because normally by the time they get at least to us because we’re an excess carrier we don’t get those patients until normally they’re quite complex already. We have to peel this onion and then slowly direct these cases, not necessarily to approve every possible treatment. I think something that is very important is not approving all treatments is not the best for the claim, and this is not as an insurance chief medical officer, as a physician I definitely never felt that way because you need to have the right treatment, and that's why it is important to 

have advice and the understanding of all these conditions and have a team to really understand and say if somebody just jumps and lets say recommends a spinal cord stimulator for low back pain, you immediately have to be concerned, that’s a case of this catastrophic pain case. That means there are different approaches to both of them but in general the investment in a standard catastrophic case is initial investment with a good team and the best centers of excellence that we call, and best follow up. We’ll talk a little bit about nurse case managers and how important they are. And also have integration because insurance, there’s several layers in here. One of the most important is the third-party administrator, and we work with 400 TPAs and that means intended with this very large group of people, and different TPAs have different experience. Some have quite a bit of experience with catastrophic, others don’t. And I think in some ways we interact with all this and try to give our, because we built quite a select and very experience-kept unit at Midwest and not only we cover Midwest, but we also cover a lot of our Berkeley sister companies. We do consultation. That’s the initial different types of cases that we have.  What should we do because in Indiana we do want to settle. Lets say that the goal is settlement because the goal is..Settlement really makes everybody happy. This idea that people have that patients don't want to settle or they won’t be happy if they settle, that’s really not true. As a clinician, I had literally hundreds of patients that settle and they couldn’t be happier when they settle. Of course the big tricky piece is how do we settle that everybody’s happy, of course. There’s so many things in there but one of the most important things is if the claimant or the patient, if I’m saying the patient I’m meaning the claimant. I’m still a physician in my mind obviously. So it’s hard to just say claimant. If the patient is happy and he understands that, he feels that his treatment is appropriate and that he feels in control of his life, even if he is tetraplegic, people still can feel comfortable and understand that they will be provided and continue to have support. That means that is the interesting piece to getting there, and I think one big mistake in terms of the settlement is more than one. One big one is not address these things and then the case after a year or a year and a half of a major catastrophic case, this is all we need to settle, we need to settle, we need to get this off the blocks. If you really did invest on having this person, address all their medical wishes, have the right medical equipment at home, the right support that they need, you’re going to settle .. It’s gonna cost you millions and more because the lawyer for sure is going to say look, you’re going to have to provide all these things for life, but if these things are addressed in advance or early on the case in the case of a standard classical catastrophic case, you’re not going to have those. The difference for example, if you do a good treatment…let's say somebody who can use their legs and if you do a good treatment and this patient most likely will be independent for all activities and probably have an adapted car and have a completely independent life and most likely will go back to work, and even tetraplegics might go back to work, otherwise if the right treatment is not done, that person in a year is going to have all sorts of pressure, all sorts of how he needs all sorts of home health care and house and issues of that matter and one of the worst things you want to settle is, there is like home health care for life. And I think one important thing to remember also is that it’s a great thing, but at the same time is something that’s taxing on insurance companies is that for most of the catastrophic diagnosis the life expectancy has increased tremendously for all sorts of reasons, good medical treatment. A spinal cord injury, when I started as a PM&R in the mid-80s, the lifespan was no more than 15-20 years for a paraplegic. Today you almost get close to a normal lifetime. Then you need to keep in mind , because when you do the settlement, you’re going to have to keep in mind that the lifetimes are different, this person will develop different complications. The more you avoid the complications and get this person in a stable medical place, the better. And that, for me, is the most important piece in terms of then achieving the settlement because then everybody will be happy. 


Craig: Dr. Branco, can you tell us some of the key items necessary in developing an effective process for managing these complex workers compensation claims? 


Dr. Branco: Thank you, yes Craig thank you. One key piece, so let’s say, I’m going to give an example, say you guys, one of your employees just got run over a car and has a brain injury, maybe a possible spinal cord injury, they’ve just been transferred to University of Miami Hospital and they are in the trauma center, and what should you do right there? First thing: don’t feel like… The first thing that sometimes it scares people that are not used to dealing with cat cases. There’s no way we’re going to do anything, but now he’s in ICU what’s the point, just let things go and we’ll check on this later. My first recommendation on that case is immediately, if it is a catastrophic case, if it’s not a catastrophic case you can have a normal standard nurse case manager. Let’s say you have a catastrophic case, a major brain injury, this person’s intubated, possible spinal cord, I would say you have to engage a catastrophic nurse case manager on site. Of course let’s not worry or think about COVID right now, because hopefully this will eventually pass and we have a more normal because right now it’s very difficult to get all this hands on, but the idea is you need a nurse that’s going to go to that hospital literally on the first or second day of injury and start interacting with the nurses and interacting with the doctors, collecting medical information because that is one of the key pieces, the more information you have, the better, and you’re not going to worry about what’s happening two months later. Sometimes in insurance we have a tendency to think nothing is an emergency in insurance, but in this case it is because this is a catastrophic case, it can go in the wrong direction very early and very badly, and in this case for example if I knew that this person was transferred to the University of Miami not because I work there but I know that the University of Miami has a very high standards of care, but that’s not, doesn’t happen with every patient that we get. Sometimes will be some country hospital that never dealt with a patient with spinal cord injury, then right away you’re going to have to be very aware of thinking- is this patient maybe needs to be transferred somewhere else? A lot of times the hospitals are not going to transfer even if they can’t take care of the patient, they just keep them in there, just part of the process, others will. That means you need to understand that the level of care needs a level of treatment at the level of the University of Miami or John Hopkins or other centers of trauma in the country that can deal with that initial piece. That means you can’t wait two months for that, that’s that initial piece. In that regard it wouldn’t hurt to have a medical director to be able to look at this, I look at all of the cat cases, every single one of them as soon as they start and we see problems, issues in these cases, and we follow with a nurse. That means if we start noticing something, that it's been 2-3 weeks and the patient is somewhat medically stable but I don’t see any rehabilitation, then you might have to intervene somewhere. That means you can have, if you have a medical director, or if you have access of somebody that can help, a lot of times the nurse case managers are more than capable of doing this. A good cat nurse that has a lot of experience will be able to intervene very easily. These nurses are amazing. There is a lot of them, not of great quantity but they are all over the country, a lot of them can be, if you don't have on your staff somebody you can use them as a freelancer. This is one of the first pieces that I think, get a nurse case manager there, obtain as much medical information as you can and make sure that the treatment is adequate for the diagnosis of that patient. Definitely very important patient. Another piece that the nurse case managers, it’s extremely important, is starting to do exactly what a nurse case manager is supposed to do, manage. And not just manage medically, but to start interacting with the family, because on this case the family will be extremely important for the discharge, how the patient will handle, you need to start seeing the psychosocial situation. One thing is to have a patient that is going to go back to a ranch house that is adapted to and is doing great, but most patients that are going back to maybe a double wide that has 10 steps or 2 steps. Those things you need to start thinking, not two months later. You need to start thinking right away and start evaluating, not necessarily modeling or anything like that, but you need to start discussing this, talking, and creating this connection, the nurse case manager with the family. Because this is going to be very important because everything you do influences what we discussed in the beginning, the settlement. Because when people feel that they have been supported and they have been given what they need and that doesn’t mean to have, to get everything they want, let’s make it very clear, it means they feel that they are receiving the treatment and support. That can be very complicated because when you have a case like this, not only are you going to have a patient that has major psychological issues, catastrophic injuries will do that. You have the family trying to deal with this catastrophic injury, and then on top of that you need to deal with the whole baggage of whatever the family had, because you’re going to have families that are very pathological in nature or psychiatric diagnosis already, they’re already fighting with each other before, who knows what's in there. All that needs to be looked into. The things that you really get, its amazing how these nurse case managers end up being completely involved on this and being extremely helpful in how to lead this. Of course, in very rare occasions, you’re going to have a nurse case manager that will get too involved. I haven’t seen that literally in probably 10 years if not more. It’s a very rare situation because the nurse case manager gets so attached to the family and end up becoming not as objective as they should, and you always need to keep that in mind. If you notice that then you need to address it. The nurse case manager should not become a buddy. I’ve had patients that they’ll say oh we go for breakfast every week, and that's going a little beyond. The relationship has to be intense, has to be trust, a lot of trust, but it should be professional. But I don’t think this is a major issue, just something to keep in mind in the background. If you ever see that most cat nurses are extremely professional and if you ever need anything you can reach out to us because we know them all over the country. We have a huge pool all over the country that we utilize because we need onsite case managers. We have, at Midwest,  we have a catastrophic unit that we have two full-time, very experienced catastrophic nurses, and they supervise these cases, but they don’t go on the ground. They once in a while visit some centers of excellence like Craig or Shepard are considered one of the best or Shirley Ryan, Chicago those are the top notch rehab places in the country, but in general the onsite we have is a very large pool. This important thing, this connection between everybody and of course if there is a there is a lawyer involved sometimes that needs to be and engaged and one thing to remember is that most patients don't engage lawyers if they feel that their needs are being taken care or they feel like they're being hurt. I'm not saying that's the case always but it’s very common not to have a lawyer if they feel comfortable and they feel like things are going the right direction. Even if it is a catastrophic because I think people are very intelligent in that sense. They realize this is a very bad problem and they’re doing everything they can. You can’t heal and do miraculous things, heal immediately, there is a whole process and I think most people understand. A lot of times they, what they call lawyer up, or become more litigious because they are not happy. That means again you are helping in the process of settlement and it, with this initial.. one interesting thing is the moment the nurse case manager goes into there and sometimes this patient will be in the hospital for sometimes a month, two months, three months because they’re very complicated, they might have lots of surgeries and different issues that will keep them going in and out of ICU or being intubated, and it’s interesting because I’ve seen a lot of times people say okay we’ll worry about the discharge when it’s time to discharge. That’s a problem because you need to start planning the discharge literally on the first week. Where are you on the country, let’s say University of Miami. I’m saying this because I have a background with the University of Miami. The University of Miami has a rehab center right there. That means that you don’t have to think about okay spinal cord injury, they have a center there that is CARF approved blah blah blah. That means we’re okay in there. But that’s not the case in most places. You’re going to have to think about it, and if you have a case that is extremely complicated, let’s say event-dependent patient that probably the University of Miami wouldn’t be able to handle in the rehab, we probably would have to send it to Shepard, and it happens, one that is very complex. Because they have event rehab units that’s the only one I know that is structured that way, maybe other places, not that I’m aware, we’re constantly checking. That means that, those are reasons why you send, but if it was, for example, in a rural area or in the states that there’s full states that don’t have a single rehab unit that’s capable of dealing with this case. You’re probably going to have to send this patient far away and then you have to have this collection of centers of excellence, there are not that many, if you’re going to move them, then move them to some of the best. That I would say would be Shepard, Shirley Ryan, Shepard’s in Georgia, Shirley Ryan’s in Chicago and Craig that’s outstanding is in Colorado and we have Madonna also that’s in Nebraska. These are all high, top-notch rehab centers. There’s others of course that can be, but those are the only that I specific dealing with these catastrophic cases as the co, all the equipments needed, the best technologies to get the best out of these patients. You also need to think when you send to a rehab center, is this place able to really deal with all the specialties because some places are very good at spinal cord injury, but others are not so good. You need to be specialized in each of these specialties because burn victims are treated completely different from a brain injury victim, the same way with amputations. You need to have an amazing layout and prosthetic department that’s going to be top-notch, otherwise there’s no reason to send a patient there. Those have to be kept in mind, and for you to have all this information. In general it’s a good idea to have a team of people that are used to this. If you’re not, there are ways of course to outsource this need, there are vendors that we’re not going to get into names in here that can be utilized to do that, but if you want to build something in house that’s okay too if you are a large enough of an employer there’s nothing wrong to at least have some experience, but if you need more help of course there’s always somebody that can help. Of course we can help. I think this is one important thing, we discussed about the home situation, very important, make sure that you get the best durable medical equipment, but that does not mean the most expensive. You guys know that there is a tendency to, let’s say you have an amputee and the next thing you know they want the most expensive bioelectric prosthetic that’s probably going to cost you $200,000, or a spinal cord injury patient that wants rewalk, you guys have probably seen those orthotics that the spinal cord injury patients actually walk. It’s fascinating, it’s wonderful, it’s the future but a little detail, rewalk only works with very few patients. You have to be very athletic, young, no other medical complications, and unfortunately what you have happening is some patients will see that or people come to them and say oh why don’t you get a rewalk, it’s okay. It’s not that simple and I think that idea, giving all the treatment doesn’t mean that’s the best for the patient. In reality, good sense treatment is the best. What is appropriate should be given and we shouldn’t worry about necessarily how much it costs in the beginning, but not treatment that’s not necessary or things that won’t be used. I saw, as a physician, I remember having lots of workers comp patients and sometimes there will be all sorts of demands and I had patients that had full heated pools, indoor pools installed in their houses that they never went into, and there’s absolutely no reason for that, because it’s not helpful, and it’s not going to add anything to that person. They’re not even going to use it. I remember this one kind of becomes like a joke because she kept coming to see me every few months to say my lifter is still broken, my powerlift is still broken, my insurance doesn’t want to pay to fix it. And I said why don’t you just pay to fix it, and then eventually they will pay you, and he goes no! But it’s been two years, just take care of it, what’s so bad to just fix the lift, but anyway that’s how you can have this mentality that you deserve everything. People need what they need for the best outcome, and the best outcome will be the best for the patient, it will be the best for the insurance, and the best for the settlement. One last thing that I will say that is very important as you approach this is that after the acute in care hospital, you go to acute care, sometimes you go to post-acute, that’s another few months, depends on what's the situation at home or your needs in terms of rehab, sometimes it takes a few months to get there. When you finally, if you are discharged home, some people are not discharged home, if you are dischargeable, you need to make sure that nurse case manager’s still there because she or he will be able to make sure that this patient follows with follow ups and do the treatments that are necessary because it’s quite common that these patients will do extremely well in very good hospitals, and if they go home and then everything falls apart. You guys know you have seen this before and that’s not a good thing because you’re probably not going to be settling these cases immediately after they are discharged from post-acute. It happens sometimes, but most times it will be like a year into the disability, and you want to make sure that this patient is doing well at that point. 


Julie: That was very helpful. I just wanted to know if you could share some metrics with us that you believe define success. 


Dr. Branco: Yes, I think the most important thing, behind a catastrophic, classic catastrophic or a pain catastrophic case, the most important outcome is function, always function. In pain cases, never pain because to be pain free, it’s not, it’s probably not realistic to 90% of the world population because we all have an ache and pain. Of course, it’s not the same as somebody who has excruciating pain, not decreasing pain, but the idea of being pain free, it’s not realistic. What is realistic is to have the best function you can, that be classical catastrophic case or a catastrophic pain case. That means, what can you do, how independent are you, because function and independence are extremely important, and that’s definitely the most important metric that you can determine for the claimant, how, what can they do when they leave there. The difference of having somebody that finishes a rehabilitation and is actually employable.  I like to say sometimes people like to say return to work, return to work. Yeah, return to work is very good. There is so many factors that influence return to work. I think it’s best to say is the person employable, yes they are employable and they could return to work, but there is reason why people don’t go back to work, but they need to be at that point because that will influence, of course, your settlement wages in that area. With the function you’re going to decrease what, if this person is functional and independent, you’re not going to need assistants, you’re not going to need more visits to doctors. They will be able to do things and have a much better psychiatric status or psychological not psychiatric because psychiatric means that you have some form of disease, not everybody does, but psychological status will be in a better place, and all that will decrease what kind of settlement you’re gonna have and the future expenses that you can have. Let’s say you can’t close, in some states you can’t close, can’t settle, that means that there will be influence. That’s one piece is the function that you need to make sure. Another way is to see how, where you are going in terms of the future medical care. Are we going into this endless visits with, or physical therapists or, that needs to be established very early and very clear where you want to go because if you don’t clarify that, we’re never going to be able to get a settlement number that’s needed.


Craig: Dr. Branco, do you have any additional thoughts or comments that our listeners may want to know?


Dr. Branco: I think that, if I could, just keep in mind, I think I repeated this so many times, but I think the idea that catastrophic cases, that be a catastrophic pain cases or classical catastrophic cases, is something that we should intervene because they’re a disaster anyway and they are going to be expensive and we’re never going to be able to settle, and that’s really not true because we settle all the time and it happens all the time. It’s not easy to settle, but you can settle, and the reasons you can is if you follow the steps and I’m not being …. In here when a claimant gets the best treatment in appropriate time, not necessarily all the treatment, but the appropriate treatment in the right time, they will probably be much better to accept a settlement very early and they will have a much better life quality, and in the end everybody wins. I think that should be our goal really, that everybody wins because I’ve never seen in my experience working with a lot of different lawyers and TPAs, I’ve never seen an employer in a TPA that didn’t want their employer to be better. Never heard of that. Never seen it. What happens is, though, weird things because they start being bombarded by crazy treatments or going to absurd places that do treatments that don’t help and then they do the same thing over and over, or they don’t treat the patients, then the patients start becoming angry. What a very interesting thing, comparing a workers comp patient with another workers comp patient, in general the workers comp patient, they have much more of the sense that they’re always against me or something, and that was something that I dealt, as a physician, with all the time and I had to just say really? Is that how you feel? I remember patients being sent to me, my function restoration program, and they will come to me and say ah the insurance is terrible, it’s terrible! A terrible insurance company, and I say really? They’re sending you to me, I’m a very expensive program, they’re investing a ton of money to make your life better and then sometimes they look at me and say, oh you’re right, you’re right, and I thinks it’s the perception that I’m trying to mention. It’s important to maintain the correct perception because there isn't such a thing as an employer that want their employees to be in a bad place, it’s just, I’ve never seen one. Never seen it. 


Craig: I fully agree with you on that. In the end you want to take care of your own and make sure that your people, you know if they’ve been injured, are in a good spot. So, thank you. This was very informative and again we’d like to thank you for being our guest.


Julie: Thank you so much. 


Craig: And this wraps another episode of URMIAmatters 


Dr. Branco: Have a good day guys!