Месечни архиви: December 2015

Smooth Sailing for Most California Workers’ Comp Cases Drugs a Problem

Smooth Sailing for Most California Workers’ Comp Cases Drugs a Problem

More than eight-in-10 workers’ compensation cases in California were taken care of without a hitch, and an overwhelming majority of those cases sent to review were ultimately upheld, according to a new study detailing the outcomes of millions of cases in the first half of 2015.

The study from the California Workers’ Compensation Institute released Wednesday shows that 15.3 percent of the workers’ comp medical services requested for authorization – also known as RFA – from an injured worker’s physician for a specific course of medical treatment underwent utilization review for medical necessity.

That means that nearly 85 percent of medical services examined in the study were paid for without being requested in RFAs and undergoing UR.

“That demonstrates that a very large majority of care is expedited and is paid for in very quick and routine way,” CWCI President Alex Swedlow said.

Following California workers’ comp reforms enacted in 2002-2004 and again 2012, the process of approving payment for medical care for injured workers has changed dramatically – most notably through the adoption of an evidence-based medicine medical treatment utilization schedule and the addition of independent medical review to resolve medical necessity disputes, the study notes.

Leading up to an IMR the approval process includes a series of checks and balances to reconcile an RFA from an injured worker’s physician for a specific course of medical treatment with the Medical Treatment Utilization Schedule that defines the medical standard of care for workers’ comp in California.

A study breaks down independent medical review decisions in California's workers' comp system. Source: California Workers' Compensation Institute

A study breaks down independent medical review decisions in California’s workers’ comp system in the first half of 2015.
Source: California Workers’ Compensation Institute

Components of medical review and dispute resolution can include review of medical reports and bills by claims adjusters, bill reviewers, nurses and utilization review physicians. When requested, the process includes an IMR from physicians.

In the first half of 2015, IMR physicians upheld 89.1 percent of the UR denials and modifications, while 10.9 percent were overturned, which is consistent with the 91 percent “uphold rate” noted in CWCI’s analysis of 2014 IMR outcomes, the group’s study states.

Just over 4 percent of the 5.6 million California workers’ comp medical services reviewed in the study were modified or denied through the UR process, making them eligible for IMR if the injured worker chose to dispute the UR decision.

Of those denials and modifications that were appealed, less than 11 percent were overturned by the IMR physician, which translates to an estimated approval rate for all California workers’ comp medical services of between 95.7 percent and 96.2 percent, according to the study.

It wasn’t all good news. The study shows that the top 10 percent of all physicians involved in these IMR disputes were identified in more than 80 percent of all IMR letters, and less than 100 physicians, which comprised the top 1 percent, were named in four-in-10 IMR decision letters.

Additionally, nearly half of IMR decisions rendered between in the first half of 2015 involved disputes over prescription drugs, with one-third involving requests for opioids and 11 percent involving compounded drug requests, the study shows.

“It’s a huge part of this,” Swedlow said. “The proportion of drugs in IMR has increased.”

According to him, 42 percent of IMR cases involved drugs in 2014, and that figure rose to 49 percent to for the first half of the year.

Swedlow expressed hopes for a fix that’s on its way.

Assembly Bill 1124 signed in September by Gov. Jerry Brown instructs the Division of Workers’ Compensation to implement a closed drug formulary by July 2017. The bill, introduced by Assemblyman Henry Perea, D-Fresno, would establish an evidence-based prescription drug formulary for the state’s workers’ comp system.

A CWCI study released last year shows that a closed drug formulary could save California between $124 million to $420 million.

Addressing whether the workers’ comp system is better off after passage in 2012 of the state’s massive reform law, Senate Bill 863, Swedlow offered: “That’s a complicated question. It is upholding the standard of care to a very high degree.”

While an increase in IMR volume may have added costs to the system, a 5 percent decrease in medical costs has been observed, he said.

That 5 percent reduction comes from several provisions in SB 863, including a fee schedule, a more effective review process and addressing duplicate costs in surgical hardware, according to Swedlow.

“Right now there is evidence that many elements of SB 863 are working as the Legislature intended,” he said.


California Workers’ Comp IMR Working: Study, Government
Small Number Causing California Worker’s Comp Review Excess
Report: Workers’ Comp Reform Saving California’s System $770M Annually
WCIRB: Los Angeles Workers’ Comp Claims Outlier in California
Another Report Shows California Workers’ Comp Reforms Working
California Governor Signs Workers’ Comp Formulary Bill

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Vermont Health Connect Promises Fixes After Critical Review

Vermont Health Connect Promises Fixes After Critical Review

Although Vermont Gov. Peter Shumlin recently proclaimed the Vermont Health Connect a “totally different ballgame” in comparison to last year’s performance, a House committee on Monday heard of several unresolved problems affecting the insurance exchange.

“There’s a heck of a lot that’s not fixed yet,” said Rep. Anne Donahue, R-Northfield, a member of the House Health Care Committee. “It’s a long, long way from saying `Victory! The system’s working now.”’

Cassandra Gekas, operations director for Vermont Health Connect, said staff members are working on a problem in which hundreds of people who paid their monthly premiums on time were canceled for nonpayment. Apparently, the cancellations were related to a five- to seven-day period it takes for the system to process end of the month payments.

Gekas and Lori Collins, deputy commissioner of the Department of Vermont Health Access, also responded to critical audits — one by state Auditor Doug Hoffer’s office and another by the national accounting and consulting firm Grant Thornton.

Collins said Grant Thornton looked at calendar year 2014 and many of the problems it cited had been resolved since the review period ended 11 months ago.

“Fortunately … we are in a far different place than we were when Grant Thornton conducted this audit,” she said.

The Grant Thornton review faulted the state program for not having detailed, written procedures in place for many of its functions — something Gekas acknowledged Vermont Health Connect was still working on.

Hoffer’s audit found that as of Oct. 30, the system had 121 “outstanding security weaknesses” of which three were high risk and 63 were moderate risk. But Gekas said the numbers fall “well within” the range deemed acceptable by the federal agency that oversees the exchanges.

Hoffer also found Collins’ department gave contractors the go-ahead to do work without following the state’s usual procedure for doing so. Gekas said the state was under pressure to get the system fully up and running, but she also promised to adhere to the policy in the future.

Vermont Health Connect was plagued with technical glitches and security problems after its launch Oct. 1, 2013. Shumlin announced last winter that the system had to automate by this fall its “change-of-circumstance” function, in which consumers report job changes, marriages and other life events that affect health insurance. The function was automated, prompting the governor’s laudatory comments in mid-November.

Failing to get enrollments and changes automated likely would have increased pressure on Vermont to scrap the state exchange and join the federal one, something administration officials resisted. Administration Secretary Justin Johnson testified Monday that switching to the federal exchange would have brought hefty new costs and disruptions.


Copyright 2015 Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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Blankenship Jury Still Deadlocked in West Virginia Mine Blast Case

Blankenship Jury Still Deadlocked in West Virginia Mine Blast Case

Jurors at former Massey Energy Co. Chief Donald Blankenship’s criminal trial ended their eighth day of deliberations after telling the judge they remain deadlocked on charges the coal executive plotted to ignore safety rules before a 2010 mine explosion that killed 29.

U.S. District Judge Irene Berger gave jurors special instructions designed to encourage them to set aside differences and reach a verdict. She told them to continue deliberations and consider the possibility of reaching a unanimous verdict on one or two of the three counts. Jurors ended the day without a verdict and will return Wednesday.

“You have a duty to reach a verdict,” Berger told jurors earlier on Tuesday, while also saying that they must not compromise their “conscience, scruples or personal beliefs.”

The trial in Charleston, West Virginia, caps a five-year effort by the U.S. to hold Blankenship accountable for safety violations at the Upper Big Branch mine, the site of the worst U.S. mining disaster in more than 30 years.

Blankenship is accused of conspiracy, making false statements to regulators and securities fraud for trying to prop up Massey’s stock price in the wake of the blast. Jurors have deliberated for about 40 hours over eight days.

The case is U.S. v. Blankenship, 14-cr-00244, U.S. District Court, Southern District of West Virginia (Charleston).


Mine Worker Talks Safety Shortcuts in Blankenship Trial
Blankenship Case in Limbo in West Virginia as Jurors Struggle to Reach Verdict
Blankenship Pleads Not Guilty to Charges Linked to Massey Mine Explosion
Defense Rests in West Virginia Mine Blast Trial, Blankenship Stays Mum
Trial Update: Ex-Massey CEO Blankenship Downplayed Black-Lung Threat to Miners
Massey Ex-CEO Blankenship Faces Criminal Charges Over 2010 Mine Explosion Copyright 2015 Bloomberg.

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Allianz Launches Motorsports Unit in North America

Allianz Launches Motorsports Unit in North America

Allianz Group’s specialist corporate insurer Allianz Global Corporate & Specialty (AGCS) is launching a dedicated motorsports unit in North America to be led by David Cloward, Global Product leader for Live Entertainment, effective January 1, 2016.

National Program Management will be led by Kelly Iwan, Entertainment executive underwriter for AGCS.  This new division will offer coverage designed exclusively for racing facilities, events, teams, sponsors and sanctioning bodies.

Under the global AGCS Entertainment umbrella, this launch will begin in the U.S., followed by expansion into Canada and Europe in the coming years.

AGCS has aligned with Alive Risk as its managing general agent (MGA).  Specializing in motorsports, Alive Risk has underwriting, risk management and claims expertise of racing facilities, events and teams.  Alive Risk is a division of All Risks, Ltd., the largest independently held broker in the U.S.

The global AGCS Entertainment arm was formed in January of 2015 after the integration of the commercial insurance business of the Fireman’s Fund (FFIC) into AGCS.

In the U.S., motorsports draw an annual attendance estimated at more than 15 million. As these events are heavily promoted and designed to maximize entertainment value, they involve a variety of supporting engagements, including secondary races, qualifying time trials, auto launch parties, celebrity driver appearances and related broadcast and media activity.

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Ironshore Launches Hybrid Product for Fine Art Losses from Political Risks

Ironshore Launches Hybrid Product for Fine Art Losses from Political Risks

Ironshore International has introduced a hybrid insurance product to protect against loss or damage of works of art in the care custody and control of Museums and Exhibition organizers, as well as personal fine art valuables and collections.

Ironshore’s new product offering combines the resources of its Fine Arts & General Specie and Political Risk underwriting teams.  Coverage provides protection against loss from confiscation and seizure of fine art holdings while on loan to, on display or housed at commercial art institutions resulting from political acts, underwritten as a stand-alone policy or add-on endorsement basis.  Customized alignment of Ironshore’s specialty classes of business also offers policy protection for high net worth individuals subject to loss resulting from the seizure of personal fine art belongings by state-owned entities.

“Museums and fine art exhibitors face potential  loss scenarios in foreign regions not only due to economic turmoil and political uncertainty, but also different cultural tastes, historic or religious viewpoints thereby threatening the security of valuable fine art assets,” said Richard Northcott, director of High Value Cargo.

The growth of global personal wealth in emerging markets has led to increased demand for luxury goods and heightened activity in individual and family fine art investment. According to Ironshore’s Director of Political Risk, Charles MacKay, the new product has been designed for clients that are discerning art investors residing in volatile jurisdictions, “who face unprecedented vulnerabilities in an array of political risk scenarios.”

Ironshore’s High Value Cargo unit offers customized coverage programs for Fine Art & General Specie Risk for museums, galleries, exhibitions, corporate and private collections and auction houses.  Ironshore Political Risk provides structured policy protection for international risks for domestic or cross-border exposure to government action and political events in emerging markets.

Coverage is offered by Ironshore’s Pembroke Managing Agency Ltd., through its Lloyd’s Syndicate 4000 based in London.

Ironshore provides broker-sourced specialty property & casualty insurance coverages for varying risks located throughout the world.  Select specialty coverages are underwritten at Lloyd’s through Ironshore’s Pembroke Syndicate 4000.

Source: Ironshore International

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