Article

Using Data Analytics to Optimize Insurance Claims Management

… and operational databases is a critical challenge. Today’s overabundance of data can be an asset. However, without the professional expertise to turn this disparate data into actionable … that exists, to identify untapped opportunities leading to claims management effciencies and an effective overall cost-containment strategy. If we want to capitalize on the data available to … the challenges one company is experiencing over the industry. As a result, the company saw an 18 percent improvement by implementing our recommended changes. The company saw an 18 percent …
Article

StateWatch Summer 2017

… The Department of Labor suspended an … available to the public, in a move OSHA has said would “nudge” employers to focus on safety. An OSHA spokeswoman quoted in a   Washington Post   article the delay   was implemented to … treatment guideline last year  to no longer cover arthroscopic debridement and lavage of an arthritic knee. The issue of arthroscopic knee surgery may be gaining importance as the … has approved a generic version of Roxicodone tablets. Oxycodone hydrochloride is an   immediate-release opioid analgesic   indicated to manage pain severe enough to require an …
Article

StateWatch Summer 2017

… The Department of Labor suspended an … available to the public, in a move OSHA has said would “nudge” employers to focus on safety. An OSHA spokeswoman quoted in a   Washington Post   article the delay   was implemented to … treatment guideline last year  to no longer cover arthroscopic debridement and lavage of an arthritic knee. The issue of arthroscopic knee surgery may be gaining importance as the … has approved a generic version of Roxicodone tablets. Oxycodone hydrochloride is an   immediate-release opioid analgesic   indicated to manage pain severe enough to require an …
Podcast

Why Opioid Trends Are Changing in Workers’ Comp

… : If we look at our top five opioid medications by cost, we see a list that includes oxycodone, hydrocodone, and … drug trends, report and highlights that we come out with. So, oxycodone products held the top spots for cost in 2022. In particular, OxyContin, which is a controlled‑release or … pain conditions or nerve-related pain conditions. That’s one of the reasons we might use an antidepressant, for example, that also targets those same neurotransmitters when we’re looking …
Article

Claims Automation: Separating Fact From Fiction

… Claims automation. Touchless estimating. Straight-through processing (STP). These topics are top of mind for auto insurers looking to improve efficiency, reduce settlement time and enhance … door to STP, there is still work to be done to deliver on the promise of a no-touch claim. As an industry, we are just beginning to reconcile initial expectations with the current state of … Just a few years ago, AI was at the top of the technology trends list, giving the auto insurance sector high hopes in its ability to …
Podcast

Work Comp Guidelines for COVID-19

… clinical guidelines manager at Genex Services, informs us of her team’s development of such an important guidance tool. … sources. On Jan. 8, I received a health advisory for the first time from the CDC regarding an outbreak of pneumonia, at that time of unknown etiology, in Wuhan, China. So, by Jan. 17, the … on this particular virus in texts at this point. But, once we got a draft ready, we have an internal team of physician advisors, including our Genex medical director, who provides …
News Release

August 2022 Utilization Review Compliance Update

… Utilization Review program: KAR 803 25:195E and KAR 803 35:195 Proposed. KAR 803 25:195E is an emergency rule in effect as of April 15, 2022. KAR 803 35:195 Proposed is the same as the … employer, carrier, insurance carrier, self-insurer, or any person acting on behalf of or as an agent of the self-insured employer, carrier, insurance carrier, or self-insurer " … summaries of the number of utilization reviews conducted, utilization reviews resulting in an approval, and utilization reviews resulting in a denial. ( …
Article

How COVID-19 Presumption Laws Might Affect the Workers' Compensation Industry

… Regardless of the jurisdiction, though, the expansion of presumption laws to include an infectious disease such as COVID-19 will affect the workers’ compensation industry . By how … A presumption law describes the conditions where an injury to a certain worker is presumed to have happened on the job and should be compensated. … employer. For example, LexisNexis states , “N.Y. Work. Comp. Law § 21(1) provides that once an employee has shown the employer-employee relationship exists and that there was a causal …
Article

Using Integrated Solutions to Help Improve The Workers Compensation Claim Process

… From the moment an injury occurs, to the day an injured worker returns to work, the journey a workers’ compensation claim may take is complex, … to better communication—communication between people and communication between systems. When an insurer has a robust claims management system fully integrated with managed care, pharmacy … it more difficult for adjusters to monitor every aspect of their claims. Yet, the tools at an adjuster’s disposal are becoming increasingly more sophisticated. Data analytics and clinical …
Article

StateWatch Winter 2015

… Commission adopted a revised Physician Fee Schedule that will increase reimbursements by an average of 4.5%. The change became effective Oct. 1. The National Council on Compensation Insurance estimates the changes will result in an overall increase in system costs of 1.1%. … online QME panel request process for claims where the injured worker is represented by an attorney. Effective Oct. 1, all represented initial panel requests must be submitted through …
Podcast

When Life Gets in the Way of RTW

… Mariellen, let’s start with this scenario: an injured employee is not meeting his return-to-work goals. His claims management team is … go to school, take a test, ride a rollercoaster, give a presentation, go on a date, care for an elderly parent, go on vacation, and the list goes on. Stress is inevitable but although the … According to the World Health Organization, “Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can …
News Release

Enlyte Celebrates Eight Winners of the 10th Annual Heart of Case Management Award

… providing education and emotional support, while expediting authorizations, scheduling with top specialists and coordinating transportation. With her persistence, the employee reached MMI, … change of physician who confirmed the employee’s pain was not related to the original injury, an outcome that not only protected the integrity of the claim but also saved significant costs by … RN, MSN, CCM, Nominated by Sentry Duncombe earned recognition from Sentry for helping an injured employee who had significant reservations about workers’ compensation and was …
Article

State-Mandated Formulary Implementation: Four Key Considerations

… formulary wave is poised to continue in 2019. In just the first month of the year, an additional three states published draft or final formulary rules ( New York , Montana and … similar, every state can develop specific rules that are unique to its jurisdiction. Texas was an early adopter and showed early positive results, setting the stage for other states to adopt … with draft legislation where they solicit public input for review of the legislation. This is an excellent time to make any recommendations that you believe will produce the best outcomes for …
News Release

Bosch and Mitchell Introduce New Target System for Static ADAS Calibration

… by the accompanying MD-500 wireless tablet and its positioning software that features an intuitive user interface designed to reduce errors and improve calibration efficiency. This …
Podcast

Using Risk Prediction Technology to Move Claims Forward

… changed in the life of the claim, things started to go sideways, and the individual claimed an additional body part; or it went from a med‑only claim to a lost‑time claim. At that point, … compensation claim, who they contact, where to get information from. And, that's why it's such an important tool as part of the implementation of a new program. … within one business day of receiving that first report of injury or that claim through an electronic data interface that we have with our clients. And with that early intervention, …
Virtual Event

Beyond Opioids: Current Alternatives for Pain Management [Podcast]

… there are also psychological and social components that need to be considered when treating an injured worker. He says that previous understandings were that no one should be in any pain, … that we still do not know enough about medical marijuana to know for certain that it will be an effective alternative to opioids. Although anecdotes suggest that the drug is effective at … type of pain, even though they have been approved mainly for neuropathic pain. This has led to an increase in the prescribing of Lyrica in the workers’ compensation industry, which has …
Podcast

What is a Pharmacy Nurse Champion?

… Is the pharmacy nurse champion an additional professional added to a case, or is this role wrapped up in a nurse case manager's … if there's not already a TCM or a field case management nurse assigned, they're going to take an active role in being the PBM nurse champion for that. But the big differentiator is the PBM … of the total work comp spend was related to prescription drugs. And opioids accounted for an average of 25 percent of that pharmacy spend. So there needed to be some things put into place …
Podcast

Restoring Lives: How Heart of Case Management Award Winners Make a Difference

… in the hospital setting doing utilization review and discharge planning, but as far as having an actual defined role as a case manager in a hospital, that didn’t exist at the time. It was … a really, really, long time [laughs]. When I first became a nurse, I worked in acute care on an orthopedic and neuro floor, which I really liked and, throughout my career, I kept with trauma … said, “I need to be able to get back to that pasture and take care of this. I’m just going to buy a John Deere riding mower and get on it if you can’t figure out a way for me to get back …
Article

StateWatch: Spring 2019

… released an advisory  urging more people to carry naloxone and to know how to use it. According to a new … report, an employee injured on the job may be hesitant to file a workers’ comp claim, deciding to have … (SEED), an initiative led by the U.S. Department of Labor’s Office of Disability Employment Policy. The … and/or are at risk of developing work disabilities, whether on or off the job. The toolkit is an outgrowth of the 2016 Work Matters Report, a workforce development framework for people with …
Article

StateWatch: Spring 2019

… released an advisory  urging more people to carry naloxone and to know how to use it. According to a new … report, an employee injured on the job may be hesitant to file a workers’ comp claim, deciding to have … (SEED), an initiative led by the U.S. Department of Labor’s Office of Disability Employment Policy. The … and/or are at risk of developing work disabilities, whether on or off the job. The toolkit is an outgrowth of the 2016 Work Matters Report, a workforce development framework for people with …
Podcast

The Other Drug Issue - When Addiction is a Pre-Work Injury Problem

… Let’s get an idea of the scope of this problem. Is pre-injury drug addiction and alcoholism something that … And if an injured worker doesn't reveal his addiction, or doesn't admit to having one, what are some … and I have seen this many times when I worked in inpatient and outpatient rehab. They have an illness, and they're trying to live with this illness, so they have become very creative in …
News Release

September 2022 Utilization Review Compliance Update

… about any of the information presented, please do not hesitate to contact your client account manager. Or you may reach out to a member of the Genex UR Compliance team whose … “Utilization Review Physician” term; This means an actively Tennessee-licensed doctor of medicine, doctor of osteopathy, doctor of chiropractic, … “Claims adjuster” or “adjuster” means a representative of an adjusting entity who investigates workers’ compensation claims for the purposes of making …
Podcast

Purveyors of Hope: Case Management Award Winners Help Injured Employees Defy Odds

… I started in a nurse role at a correctional facility. And then I identified the need for an opiate recovery program. And, in identifying that need, I created a program for inmates to … inmates in Tennessee. I really felt like I wanted more contact with injured employees. And so, an opportunity arose for me to move into case management at Genex. … it. I actually had a friend of a friend's husband speak with my husband and informed me about an opening with Genex and that's how I applied and got into this role. …
Article

StateWatch Winter 2016

… economics briefing. Because medical expenses rose last year, utilization fell resulting in an overall decrease in severity, NCCI concluded. The … economics briefing also provides forecasts for economic factors expected to have an impact on workers’ compensation. It uses Moody’s Analytics and U.S. Department of Labor data … quota in the Federal Register on Oct. 5. The controlled substance quota is designed to ensure an ample supply of controlled substances are available to meet medical need, while limiting the …
Podcast

The PAID Act is Coming to Medicare—Are You Ready?

…   In December 2020, an act was signed into law, which will change the way some reporting entities coordinate Medicare … the Provide Accurate Information Directly Act and it was enacted back on Dec. 11, 2020. It’s an act that is a means to help nongroup health plans such as workers’ compensation, insurance … may not know, Section 111 is the Mandatory Insurer Reporting. So, carriers and insurers have an obligation to report all of their open claims to Medicare so that Medicare can coordinate …
Podcast

Selecting the Right MSA and Regs to Know for 2025

… : So, most people who request an MSA request what we deem to be a standard MSA. And so, for us, a standard MSA is on we prepare that aligns with what CMS deems necessary if they’re going to be reviewing an MSA. A standard MSA contains two years’ worth of medical records that have been reviewed by … log, a pharmacy log and, if there’s any court orders, denials that are reducing a condition or an injury on the claim.  We want to have all that information. So, typically when people send us …
Article

Out-of-Network Dispensing Channels and Their Unique Challenges

… controls aren't in place. Our out-of-network pharmacy spend and utilization continues to be an area of focus for comp for that reason, especially because by the time the payer or the … Yeah. Physician dispensing as most of us probably listening in has long been an area of concern for workers' compensation first, because it may circumvent some of those … for dermatological agents were paid to physician dispensers than to pharmacies. So certainly an area we want to be monitoring and be mindful of. …
Article

2020 in Hindsight: Clinical Trends and Predictions

… Countless treatments have been studied (and are still being studied) to determine if there is an effective treatment for COVID-19. While studies and vaccines are still in progress, some drugs … list of those covered under a presumption law, the COVID-19 pandemic will likely leave an enduring mark on our industry. Listen to our experts’ predictions on how COVID-19 is changing … 18% since the beginning of stay-at-home orders compared to the same period pre-stay-at-home. An analysis from the White House drug policy office reported that drug fatalities increased more …