Author: WorkCompAcademy

Insurance fraud is on the rise That’s the consensus of a majority of respondents to a 2013 survey commissioned by FICO. With just a few exceptions, most survey respondents expect most categories of personal lines to experience an increase in fraud losses of 10% to 20% or more in 2012 versus the prior year. A majority of those surveyed, more than 60%, attribute the continued rise in fraud, more than any other factor, to sustained economic hardship in America.

Some 57% of respondents anticipate an increase in personal property fraud by individual policy holders. Around 58% said the same for personal auto insurance fraud, and 69% expect a rise in workers’ compensation fraud.

Only around 11% of respondents view criminal gangs as the number-one factor driving insurance fraud increases. Yet 61% expect to see an increase in auto insurance fraud perpetrated by organized rings, and 55% believe the same for workers’ compensation fraud. This underscores a growing need for solutions that enable insurers to identify organized criminal activity. Some 30% of respondents report that they are already using link analysis in their efforts to detect fraud today, applying predictive analytics to find patterns among different claims that suggest organized activity.

When asked to identify their major priorities in the fight against fraud (from a list of 12 choices), 52.2% cited the detection of fraud in a claim before it is paid, and 39.6% cited adopting or upgrading their fraud analytics capabilities. These two top priorities go hand in hand –predictive analytics offer the most effective and efficient solution for accurately detecting fraud early in the claims process, enabling carriers to sharply limit their losses due to payments against fraudulent claims. About 45% of the survey respondents said they are using predictive analytics for fraud detection in their operations today, compared to around 29% using rules-based systems in an attempt to stop known types of fraud. This is a strong indication that analytics-powered solutions are becoming more widespread, although there is still plenty of room for adoption in the industry. Besides being more efficient and yielding fewer false positives compared to stand-alone, rules-based systems, analytics have the advantage of being able to adapt quickly to new and emerging fraud schemes beyond those already known.

Around 54% of the respondents surveyed employ anti-fraud teams, either centralized or dedicated to specific lines of business. However, only 20% cited the hiring of additional special investigative unit personnel among their major priorities. This suggests that many of the insurers surveyed continue to face headcount constraints, and need to figure out ways that smaller teams can work larger caseloads.

A new study published in the JAMA Internal Medicine and summarized by Reuters Health says that more than one in ten patients being treated in intensive care units (ICUs) was at some point receiving what doctors deemed to be futile care. In those cases, critical care doctors believed people would never survive outside an ICU or that the burdens of their care “grossly outweighed” any benefits. And, researchers found, treating each of those patients cost about $4,000 every day.

“Many physicians find that the provision of futile care is not only contradictory to their professional responsibility, but harmful to patients,” Dr. Neil Wenger, director of the UCLA Healthcare Ethics Center at the David Geffen School of Medicine, and senior author of the study, said. “The biggest issue, more important than the cost issue, is the use of highly advanced medical care that was designed to rescue people that instead gets used to prolong the dying process,” such as ventilators and medicines that raise blood pressure, he told Reuters Health.

For their study, Wenger and his colleagues first convened a group of 13 doctors who worked in critical care to agree on a definition of futile treatment. Categories included care for patients who were permanently unconscious or for whom death was imminent, or treatment that could not achieve the patient’s goals.

Then, the researchers surveyed the attending critical care specialist in five ICUs every day for three months about each of that doctor’s patients to find out how many were receiving futile care under the focus group’s definition. During the study period, 36 doctors assessed 1,136 patients, with an average of six assessments per patient. Of those patients, 123 – or 11 percent – were determined to be receiving futile treatment, and another 98 (8.6 percent) were perceived as receiving probably futile treatment.

Eighty-four of those receiving futile care died before discharge, and another 20 died within six months of their ICU stay, the researchers reported in JAMA Internal Medicine. The rest were left in “severely compromised” states, with many kept alive by machines. Wenger and his team calculated hospital costs for futile care were about $4,000 per day, adding up to $2.6 million of treatment provided unnecessarily.

Dr. Michael Niederman, chair of the department of medicine at Winthrop-University Hospital in Mineola, New York, said how often futile care is provided is likely to vary between ICUs. “It’s very difficult to come up with a definition of futile care,” he told Reuters Health. “I think there are many things we do where over time we realize we’re unable to help the patient.”

Niederman, who has studied futile care but wasn’t involved in the new research, said along with the costs of providing intensive care that is unlikely to help, there may be times when such treatment hurts other patients as well. For example, many very sick patients in the ICU are on antibiotics, even if they don’t currently have an infection. One study he cited showed one quarter of them developed multi-drug resistant bacteria – which could then be spread to other patients on the unit.

Of course, the researchers said, doctors are not making treatment decisions on their own, and families may have different opinions on what constitutes futile care, or when the benefits of treatment outweigh the burdens. “Many times family members have a sense of guilt and responsibility to their loved ones that they want everything done, and I think many times they don’t understand what it means to do everything,” Niederman said.

“The implied discussion here is, do we have the resources in this country to give people care whenever they want it regardless of whether we think the care has benefit?” he said. “That’s a very difficult discussion.” Wenger said for him, the study highlights the importance of having conversations with patients about their end-of-life care while they are still able to participate in those talks. “It’s a very complex process making decisions for very ill patients who are on the brink of death,” he said. “The main message is that early discussions and advance planning are absolutely critical.”

The Division of Workers’ Compensation’s (DWC) invites claims administrators, attorneys, and others to attend this online web training on the Qualified Medical Evaluator (QME) panel request process in order to obtain tips on how to successfully submit represented panel QME requests and to gain tools to make panel requests easier and more efficient leading to a shorter wait time to receive panels. The course will also help avoid common errors in incomplete or inappropriate requests.

The DWC says that up to 90% of represented panel QME requests are improperly submitted since SB 863 changes were implemented.

The course “The QME Process: How to Successfully Request a Represented Panel ” will take place online on Thursday, September. 19 from 2:00 to  3:00 PM. Pre-registration is not required for this free webinar meeting; however ports available for the training are limited. Attendees are encouraged to gather in groups to participate in this online training. The technical specifications for accessing the webinar are posted on the DWC website.

Please note, in order to save time before the meeting, check your system to make sure it is ready to use Microsoft Office Live Meeting. The audio option is not available when you choose the web access option for the webinar program. Instead, launch the Microsoft Live Meeting Client (requires software download). The software download takes approximately 15 to 20 minutes. We recommend that you login approximately 5 minutes before the meeting.

Months of heavy lobbying by the National Football League and other professional sports team owners paid off when lawmakers gave final passage to a bill to limit most workers’ compensation claims by out-of-state professional athletes.

The bill, AB 1309 by Assemblyman Henry T. Perea (D-Fresno), cleared the Assembly on a 66-3 vote and was sent to Gov. Jerry Brown. The governor is expected to sign the bill into law, Perea’s office said.

The Los Angeles Times says that last week, the measure received an overwhelming endorsement in the state Senate with a 34-2 vote. Perea’s proposal, which was opposed by the NFL Players’ Assn. and the AFL-CIO, would close a provision in California law that allowed players from out of state to file workers’ compensation claims for so-called cumulative trauma, including head injuries that manifested themselves years after their careers had ended.

Many of those players may have participated in just a handful of games in California over the course of their careers.

During the bill’s eight-month transit through the Legislature, team owners argued that California had become a de facto forum for claims filed against football, baseball, basketball, hockey and soccer franchises and their insurance companies.

Players unions countered that the employers don’t want to be responsible for their former workers’ head injuries and other ailments.

Former athletes have filed more than 4,400 claims involving head and brain injuries since 2006. This bill would not affect pending claims. Provisions that initially would have had a retroactive effect were removed by a September 5 amendment to the bill. The bill now contains language in paragraph 3600.5 (h) tat says “the amendments made to this section by the act adding this subdivision apply to all claims for benefits pursuant to this division filed on or after September 15 2013.” The previous version of the bill had provisions that would have applied retroactively to all pending claims not yet adjudicated. Thus thousands of these claims already in the system will continue to move forward.

Pundits say that Governor Brown will sign this bill into law. The governor has until Oct. 13 to sign or veto the bill.

Edward Frazier, a peace officer with the Department of Corrections, had a presumptive (L.C. 3212.1 0) industrial heart trouble with diagnosed hypertensive heart disease accompanied by mild left ventricular hypertrophy.

The AME, Dr. Ng, provided an analysis that in his opinion that under the American Medical Association Guides to the Evaluation of Permanent Impairment, Fifth Edition,Table 4-2, (Criteria for Rating Permanent Impairment Due To Hypertensive Cardiovascular Disease AMA 5lh edition) would require a finding that he has a 30% Whole Person Impairment. l

However, the AME was of the opinion that this WPI while appropriate is not an accurate representation of the injured worker’s impairment. Doctor Ng referred to the new AMA Guides 6th Edition as a “standard text or recent research data” to support his conclusion that 30%WPI was too high. He concluded the writers of this recent publication decided that the 30% WPI was too high for asymptomatic mild ventricular hypertrophy. The 6th edition he states shows that for a gentleman with the same mild left ventricular hypertrophy an impairment of 23% WPI is recommended. He concludes that the authors of the AMA guides sixth edition have recognized the accuracy problem (in the 5th edition) and reduced the whole person impairment to a rating of 24% for left ventricular hypertrophy. By inference it is his clinical judgment this lower WPI is more accurate.

In conclusion the AME chose 24% as the most accurate description of this injured workers impairment. This percentage was a combination of his consideration of the analysis of the writers of the AMA 6th edition, his clinical judgment as well as his analogizing with the Coumadin paragraph 9.6C of the AMA 5th edition which has a lower impairment for asymptomatic conditions with serious health risks.

The 24% impairment after the formal rating resulted in a permanent partial disability of 44% which was awarded by the WCJ.

The WCAB denied reconsideration in the panel decision of Edward Frazier v State of California, CDCR – Correctional Training Facility.