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All the program's cost containment features
include: pro-active claims management,
medical management, and aggressive defense
of litigated files. Empire Pacific Risk
Management has contracted with medical
bill review companies and other specialists
to augment cost containment services to
the program participants.
Upon notice of a claim we do a 3-point
contact investigation to confirm facts.
This initial review includes contacting
1) the employee, 2) the employer, and
3) the medical provider. All claims are
reviewed regularly for appropriateness
of care, with an emphasis on prompt resolution
of the medical condition. Ninety percent
of claims are generally found to be compensable
and without complications. For the other
ten percent, where necessary / applicable,
independent medical examinations are obtained
in order to delineate the employer’s
responsibility or to establish that different
care is warranted. Each program contracts
with
Oregon Health Systems (OHS) MCO. If a
claim is “red-flagged” for possible
malingering or fraud, we utilize other
tools and investigation specialists who
can be called in for additional investigative
support.
Return to Work Programs are actively encouraged
and assistance is provided to employers
in setting up appropriate Return to Work
policies. The direct benefit to the employer
is the potential for dramatic savings
of workers’ compensation costs. State
“programs”, such as the Employer
at Injury Program and Preferred Worker
Program, are tapped to procure state monies
for wage subsidies and work place modifications.
Funds from these two programs are paid
directly to the employers.
A primary goal is to avoid litigation.
To this end, we communicate regularly
and effectively in an attempt to leave
no unanswered questions in the injured
employee’s mind. We also encourage
employers to take an active role in communicating
with disabled workers. Self Insured Group
[SIG] programs also encourage employers
to take an active role in communicating
with disabled workers. When an attorney
is sought, the primary areas of litigation
are compensibility and permanent disability.
Every effort is made to monitor and manage
claims that make their way into litigation.
The process is collaborative and employers
regularly participate in deciding legal
strategies.
SIG programs typically raise the bar regarding
health and safety issues. A zero drug
tolerance policy for all participants
of the group is typical and endorsed by
the administrator. Boilerplate drug programs
are provided to program participants and
supported by the claims and loss prevention
staff.
Most cost containment strategies are easily
measured with objective results. Other
results are more subjective and these
results are best measured by their ease
of use, quality of service and the people
who deliver said services.
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