2016 Spring Newsletter - Alabama Self Insurer`s Association (ASIA)

APRIL 2016
VOLUME 1
How the Best PPO Networks
Help Employers with Medical
Cost Containment
ASIA Objectives
ASIA is committed to a workers’ compensation
program that:
Written by: Sarah Cox, Director of Provider Relations, and
Dr. Michael Miller, E xecutive Director
AlaMed Workers’ Compensation Network
Birmingham, Alabama
• Adequately compensates the
employee with a work-related injury
• Recognizes fair limitations on
employer responsibility
• Provides for an appropriate
distribution of the compensation dollar
• Reduces litigation
• Is dedicated to eliminating abuses within the
system
• Operates within the bounds of
reasonable and necessary regulations
ASIA Summer
Conference
August 7-9, 2016
Hilton Sandestin Beach Golf Resort & Spa
Destin, Florida
ASIA Winter Workshop
2017 • To Be Determined
Birmingham, Alabama
INSIDE THIS ISSUE:
A Word from the President. . . . . . . . . . 2
Carlisle Raises Funds
for Penelope House . . . . . . . . . . . . . . . . 3
Calendar of Events. . . . . . . . . . . . . . . . . 3
National Council Update . . . . . . . . . . . 8
New Members. . . . . . . . . . . . . . . . . . . . . 9
Traumatic Brain Injuries
in Work Comp . . . . . . . . . . . . . . . . . . . 11
I
n the workers’ compensation community, Third Party Administrators (TPAs)
often offer the services of a Preferred Provider Organization (PPO) network
in order to assist self-insured employers, funds, and associations with their
medical cost containment. However, not all PPOs are created equal. While
each PPO does have a list of providers, not every PPO has the same coverage
area or the same standards for providers in their network. PPOs do help to
reduce employer costs, but the real benefit is in getting an injured employee
back to work as safely and as quickly as possible through the use of excellent
providers who are available and who have the training and expertise to facilitate
the injured employee’s recovery—and the best PPOs play a significant role in
helping return patients to work. Let us explain some of the different functions you should expect from your
workers’ compensation PPO here in Alabama:
1. Screening. Your PPO should check with its providers and staff
members to make sure they understand workers’ compensation and
how care for a workers’ compensation patient should be delivered.
For instance, does the provider understand the difference between
what medical services qualify as First-Aid and what medical services
are OSHA recordable? Another good measure of a PPO network is
whether or not they monitor the Alabama Board of Medical Examiners
to check for physicians who have had disciplinary actions taken against
their license. 2. Training. If a provider feels they may not understand as much as they
would like or if they don’t know anything at all, your PPO should offer
to help assist and train providers on the different aspects of workers’
CONTINUED ON PAGE 4
— Page 1 —
Alabama Self-Insurers
Association
OFFICERS
President
Connie Cox, Drummond Company, Inc.
Vice President
Anna Scott, AAA Cooper Transportation
Secretary
Randal H. Ward, CAE, Automotive
Aftermarket Fund
Past President
Doug Kitchens, Wiley Sanders Truck Lines, Inc.
Executive Director
Charles F. Carr, Carr Allison
DIRECTORS
Chris Alexander, Blue Cross Blue Shield
Rick Brown, CAE, Alabama Retail Comp
Stewart Civils, Vulcan Materials Company
Toi Corbett, Alabama Power
Connie Cox, Drummond Company, Inc.
Carol Davis, Mercedes Benz US International
Charles Hough, Alabama Self Insurers
Guaranty Association
Allane Hybart, Infirmary Health System
Don Jones, AGC Construction Industry Services, Inc.
Boyd Kelly, ForestFund
Doug Kitchens, Wiley Sanders Truck Lines, Inc.
Marion McQueen, Director Emeritus, Program Director
Anna Scott, AAA Cooper Transportation
John Smitherman, Brentwood Services Administrators,
Inc.
Randal Ward, Automotive Aftermarket Association
Steve Yount, AmTrust North America
The Alabama Self-Insurers Association
is professionally managed by
Group Management Services, LLC
Larry A. Vinson, CAE, President
The Alabama Self-Insurer is a quarterly publication
of the Alabama Self-Insurers Association:
Post Office Box 240757 • Montgomery, AL 36124-0757
(800) 366-3439 • Fax (334) 272-7128
E-mail: asia@gmsal.com
www.asiaal.org
A Word from the President...
Connie Cox
Once again, it seems like we just
finished up an ASIA conference.
Although I’m always proud of
our programs, I have to say that
this past Winter Workshop had
some truly outstanding speakers.
However, I have to admit that I’m
trying hard to “unsee” the video
clip in Charles Carr’s presentation.
To date, my efforts have been
unsuccessful and I’m struggling
with flashbacks to the moment in
the video when that man jumped
in front of an 18 wheeler traveling
down the interstate.
Putting my potential PTSD issue aside for the moment, I want to use
this space to focus on the HR Breakout sessions that we are planning
for the Summer Conference. The ASIA Directors and the Program
Committee constantly rack their brains to bring material to the
membership that is educational, timely and cutting edge. As more and
more laws and regulations affect the employment relationship, it is no
longer possible to look at worker’s compensation issues in a vacuum.
Every action taken in a worker’s compensation case DIRECTLY
AFFECTS one or more other aspects of the employment relationship.
As such, everyone involved in worker’s compensation needs to be
cognizant of the ripple effect that it has on other employment benefits.
For the past two years, the ASIA Summer Conference has included an
HR Breakout session as part of its educational program. Attendees to
the HR Breakout sessions gave us high marks for these presentations.
However, most of the attendees were HR professionals with self-insured
employers. Speaking as a lawyer for one of those employers, it also
makes sense for my company’s worker’s compensation “team” (TPA’s,
case nurses, physical therapists, medical providers and, yes, even my
“outhouse” worker’s compensation lawyers) to be well versed in various
employment laws to help us quickly identify and resolve employment
related issues. Do HR policies and employment laws directly affect the
handling of a particular worker’s compensation claim and are these issues
in the scope of your contract with the employer? Probably not. Is it good
business to help your client spot future problems to reduce your client’s
overall liability? Absolutely. Developing a working knowledge of how
a worker’s compensations claim can affect the voluminous employment
laws, regulations and other HR policies is a valuable resource that you
can bring to your clients.
With all of that being said, I hope that you will take the time to attend at
least one of the HR breakout sessions at this summer’s conference. I look
forward to seeing everyone in August!
— Page 2 —
The Carlisle Companies’ 2015 Fund Raising efforts recently
culminated in a $20,000 donation to Penelope House.
Throughout the year, the Carlisle staff held raffles, bake sales and other events to benefit Penelope House. By the end of
the year, the staff had raised $10,000, with the help of key corporate partners. Donnie and Deborah Carlisle matched the
amount raised and a check for $20,000 was presented to Tonie Ann Torans, Executive Director of Penelope House.
At the presentation Donnie stated he was very proud of the staff and grateful for the company’s corporate partners. “It
takes many stars to form a galaxy. Look at what we have accomplished by coming together as one,” stated Donnie.
The Carlisle Companies proudly support Penelope House, whose mission is “to provide safety, protection and support
to the victims of Domestic Violence and their children through the provision of shelter, advocacy and individual and
community education.”
ASIA Calendar of Events
TO BE DETERMINED
ASIA Winter Workshop • 2017
To Be Determined • Birmingham, AL
AUGUST 7-9, 2016ASIA Summer Conference
Hilton Sandestin Beach Golf Resort & Spa • Destin, FL
— Page 3 —
compensation in Alabama. This can include basic
information to in-depth workers’ compensation law,
OSHA standards, staff training on how to submit
claims and communicating with the payer, etc.
3. Recruiting. Check with your PPO to ensure they
have coverage that suits your needs in the areas
of convenience to the patient’s home or work and
provider expertise. If you have a need of a provider
in an under-served area, your PPO network should
be willing to recruit providers as quickly as possible
to ensure your injured employee’s needs are met.
4. Listing. When it comes to PPO networks and
their databases, how are the providers listed? Are
providers listed by the primary specialty and/or
sub-specialty? Having a provider’s specialty and/or
sub-specialty listed means the adjuster or case manager assigned to your patients will be able to more
— Page 4 —
effectively and efficiently choose the right providers
to get your injured employee back to work. If for
some reason an injured worker is not satisfied with
their provider and their adjuster needs to provide
a panel of providers for the patient to choose, it is
important to choose a provider that would be the
best-suited to oversee care for the patient. 5. Monitoring. An important aspect of a PPO
network is to maintain the correct fee schedules
so the payers can pay claims correctly and within
the guidelines set forth by the State of Alabama
Department of Labor. The DOL updates their fee
schedules for hospitals and facilities on a quarterly
basis so monitoring the DOL for these fee schedule updates and making the payers aware of the
changes helps to maintain a payment adjudication
system on a real-time basis.
6. Resolving. In the case of a dispute between a provider and a payer, the most proactive PPO network
can play a vital role in resolving the dispute quickly.
Your PPO network will know the provider’s contract and will have the latest fee schedule updates,
making them a well-informed mediator between
the two parties and reducing the dispute resolution
to a matter of days rather than a week or longer. 7. Connecting. When a provider needs the services
of an outside vendor, for example, a clinical or
diagnostic laboratory for drug testing, their PPO
network should be able to assist them with a recommendation of a high quality in-network vendor. This ensures that the vendor is preferred by their
payers and can also help deliver the requested
services with a reasonable pricing structure—all the
while building and strengthening the relationship
between the PPO and the provider by providing
quality vendors when they are needed. Sarah Cox
A native of Guntersville, Alabama, Sarah Adkison Cox is
a graduate of Auburn University with a degree in Health
Services Administration. After working in a medical business office setting for two years and obtaining her CPC,
Sarah accepted the position of Director of Provider Relations with the AlaMed Workers’ Compensation Preferred
Provider Organization. In her role at AlaMed, Sarah works
to develop long-term relationships with new and existing providers, payors and adjusters, and she also works to
market a provider’s services to help generate more workers’
compensation referrals for the provider. In her free time
Sarah enjoys spending time with her husband, family and
friends, playing piano and guitar, traveling, and reading.
8. Coordinating. The best PPO networks can help
to coordinate the care of an injured worker. One
aspect of an excellent PPO is listing a Workers’
Compensation Coordinator for each practice in its
database. A Workers’ Compensation Coordinator is a direct point of contact within the provider’s
office who works with the adjusters directly in the
coordination of care for the injured worker. This
includes collecting intake information, sending
any requested information, and ensuring effective
and efficient communication between all parties
involved, just to name a few. However, the role of
the Workers’ Compensation Coordinator can be as
broad or as narrow as it needs to be, and more than
one can be assigned for a provider. When it comes time to choose a TPA, these eight points
covered in this article can help to ensure that all of your
needs as an employer are met. Choosing a TPA with the
best PPO network for your workers’ compensation injuries
is important because not all PPO networks are the same,
and the best PPO networks can provide services beyond
general coverage and discounts.
Knowledge you can
count on for
on-the-job injuries
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For appointments call (205) 930-8905
or toll-free (800) 625-5183
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— Page 5 —
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— Page 6 —
ASIA Speaks Up!
Earlier this spring, your ASIA leadership voted to contribute
$5,000 to the campaign of ASIA member Jim Patterson in his
bid to win a seat on the Mobile County Circuit bench. We are
thrilled to report that Jim was successful in defeating his Republican opposition. He has no Democratic opposition, so he will be
sworn in after the general election this fall. Jim is a member of
the Vernis and Bowling firm.
Jim is an AV Rated “Preeminent” civil defense attorney. He has
practiced law in Mobile County for 15 years, and has handled
just about every type of civil case. He is also licensed in Florida,
and Mississippi, and has done appellate work in Alabama and
Florida. He served his country as a United States Naval Aviator
-- retiring from active duty in 1998. While on active duty, he
served primarily as a helicopter attack pilot, a nuclear weapons
delivery pilot, a nuclear weapons training and safety officer, and
in many other sensitive capacities. He was also a Command
Security Manager, and held above a Top Secret Clearance.
He deployed on five long cruises on various Atlantic fleet aircraft
carriers during his career, starting with his first cruise during
the TWA hostage crisis in 1985, and ending with his last cruise
during the aftermath of the Bosnian war in 1997. He also went
on many more deployments of lesser duration.
Congratulations Jim Patterson. ASIA and COMP PAC are
proud to support conservative candidates who can make a difference on our courts while helping to sustain Alabama’s worker’s
compensation laws.
Count on Carr Allison.
Check out our Blawg!
For regular legislative and
case law updates, check out
www.alabamaworkerscompblawg.com
Your
business
partner
every step
of the way.
No representation is made that the quality of the
legal services to be performed is greater than the
quality of legal services performed by other lawyers.
ALABAMA | FLORIDA | MISSISSIPPI | TENNESSEE | 2 0 5 - 8 2 2 - 2 0 0 6
— Page 7 —
www.carrallison.com
National Council Update
Dear NCSI State Self-Insurer Association Members, Here’s the latest roundup
of issues cresting in the world of workers’ compensation ….
OK OPT-OUT FOUND UNCONSTITUTIONAL BY
OKLAHOMA WC COMMISSION
As noted in our quick news last Friday, the Oklahoma
Workers’ Compensation Commission has ruled unanimously that Sections 203 and 209 of the Oklahoma
Employee Injury Benefit Act (OEIBA) are unconstitutional. These are the provisions that allow employers
an option to “opt-out” of the long-standing workers’
compensation system. The case is Vasquez v. Dillard’s
Department Stores. The Commission ruled that those sections: constitute
an unconstitutional special law that treats Oklahoma
workers differently; deny due process and equal protection of the laws for all Oklahoma injured workers;
and they deny access to justice as guaranteed by the
Oklahoma Constitution. Of course, this decision is
likely to be appealed.
As promised, Here are links to the decision, plus:
ARAWC’s press release regarding the case; ProPublica/
NPR’s weighing in; and a Florida Deputy Chief Judge’s
thoughts on the option/”opt-out.”
Florida Deputy Chief Judge David Langham’s Thoughts
on Vasquez v. Dillard’s
Order of the Oklahoma WC Commission in Vasquez v.
Dillard’s
FEDERALIZATION OF WORKERS’ COMPENSATION
https://www.iaiabc.org/images/iaiabc/Vasquez_
Commission_Order_160217107.pdf
Association for Responsible Alternatives to WC Press
Release on the OK case
http://arawc.org/wp-content/uploads/2016/02/ARAWCStatement.pdf
ProPublica/NPR Weighs in on Vasquez v. Dillard’s
https://www.propublica.org/article/corporate-campaignto-ditch-workers-comp-stalls
http://www.workerscompensation.com/
compnewsnetwork/workers-comp-blogwire/23420oklahoma-opt-out-statute-unconstitutional.html
NATIONAL CONVERSATION ON WORKERS’
COMPENSATION
A few weeks ago, we sent along a thought-provoking
column by NCSI Annual Meeting keynote speaker Bob
Wilson of WorkersCompensation.com regarding the
need for a national conversation on workers’ compensation. It now appears that may become a reality. Florida’s Deputy Chief Judge David Langham has
apparently initiated such a conversation. The National
Council is keeping a close eye on this interesting development.
http://www.workerscompensation.com/compnewsnetwork/from-bobs-cluttered-desk/23385-update-a-national-conversation-on-workers-compensation-is-on.html
Having just returned from presenting to the Associated General Contractors’ Self-Insurance Funds annual Informational Exchange (on the topic of potential
federalization of workers’ comp), I’ve come across this
interesting take by Karen C. Yotis, Esq., in the LexisNexis Workers’ Compensation eNewsletter. Hat tip to
Mark Walls of Safety National for sharing.
http://www.lexisnexis.com/legalnewsroom/workerscompensation/b/recent-cases-news-trends-developments/archive/2016/02/19/federalization-of-workerscomp-politics-opt-outs-and-survival-of-the-state-basedstatus-quo.aspx
— Page 8 —
CMS ISSUES RFP FOR NEW MSA CONTRACTOR
As they have periodically over the years, the Centers
for Medicare & Medicare Services (CMS) issued an
RFP for a new Medicare Set Aside contractor, to review
MSAs submitted for review. It’s unclear what this will
mean relative to delays with the current provider, or
what it will mean relative to a transition at the conclusion of the current contract.
http://www.workerscompensation.com/compnews
network/workers-comp-blogwire/23417-cms-issues-rfpfor-new-msa-contractor-wcrc.html
In the meantime, the National Council continues
to work with UWC for Strategic Services to push for
the Medicare Secondary Payer reforms that will help
streamline, provide some safe harbor, and allow for the
pre-payment of Medicare/Medicaid liabilities (rather
than having to submit an MSA.) We’ll keep you apprised of any progress made by Congress in adopting
this proposal, but we have a good shot.
NEW MEMBERS
Please welcome the following firms as new
members to the National Council:
Aplin & Ringsmuth, LLC
(Waukesha, WI)
Care Bridge International, LLC
(Sarasota, FL)
CBCS
(Dubuque, IA)
Dane Street, LLC
(Palm Beach Gardens, FL)
Hawk Private Investigations, Inc.
(Marietta, GA)
Impartial
(Lake Oswego, OR)
J. P. Investigative Group, Inc.
(Charlotte, NC)
Meridian Health Services Network, LLC
(Highlands Ranch, CO)
Millenium Risk Managers
NATIONAL COUNCIL ANNUAL MEETING
Registration materials are available for the NCSI
Annual Meeting, being held May 22-25, 2016 at
the Wyndham Riverwalk Hotel in San Antonio, TX. You can find registration, hotel, the agenda, and
sponsorship information at the NCSI website at www.
natcouncil.com/meet.html on the right hand side of
the page.
Handling Workers’ Compensation
Defense for Self Insured Companies
throughout the State of Alabama.
Visit us at www.FishNelson.com
or call us today at (205) 332-3430.
No representation is made that the quality of the
legal services to be performed is greater than the
quality of legal services performed by other lawyers.
— Page 9 —
Introducing Better Injury
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able to assess the employee and triage to the
appropriate level of care. The employee gains
immediate access to a health professional, and the
employer benefits from reduction in claims and costs.
FIELD CASE MANAGEMENT
D & D Case Managers work aggressively to manage
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CATASTROPHIC CASE MANAGEMENT
Cases are defined as catastrophic or major, based
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LEGAL NURSE CONSULTING
A legal nurse consultant (LNC) is a registered nurse
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— Page 10 —
Traumatic Brain Injuries in Work Comp
By Ivan Castro, MD
Medical Director, HomeCare Connect
W
ith the increase in workers compensation injuries,
traumatic brain injury (TBI) is noted as the
leading cause of long lasting disability, coma and
death. The Center for Disease Control and Prevention
(CDC) estimates that there were approximately 2.5 million
cases and 50,000 deaths associated with TBI in 2010.
TBI occurs as a result of head trauma from an external or
penetrating force leading to structural and/or psychological
brain disruption. Depending on the type of brain injury,
the recovery process can take years, and in some instances,
the injured worker may never recover motor or cognitive
ability. Timely treatment is of the essence and any delays
in medical treatment can result in costly, long and extensive
forms of rehabilitation.
According to the CDC in 2013, falls are the leading cause
of TBIs, accounting for approximately 35.2 percent. The
second leading cause of TBIs are motor vehicle accidents,
accounting for 17.3 percent. Due to the nature of many
of auto accidents, they result in the highest percentage of
TBI-related deaths according to the CDC. Other forms of
TBI-related accidents according to the CDC include forms
of being struck in the head, running into stationary objects,
violence, inappropriate use of firearms, and assaults. Per the
CDC (2012), men have a higher incidence of TBI; noted at
59 percent.
The specific degree of a TBI (mild, moderate, severe
and catastrophic) is characterized by the severity of the
symptoms caused by the insult and/or injury. When an
injured worker presents to the Emergency Room with
decreased responsiveness, their Glasgow Coma Scale
(GCS) is measured to assess their neurological state and
level of consciousness after head injury by measuring
the conscious state of a person. Symptoms of TBI may
include headache, dizziness, fatigue, blurry vision, shortterm memory loss, difficulty focusing, ringing in the ears,
depression, poor impulse control, and behavioral changes.
The majority of TBI symptoms
subside within a few days to
weeks from date of injury.
Approximately 15 percent of
TBI patients do not recover
within the first year of their
injury. Most mild TBI injuries
are often misdiagnosed as they are not capable of being
detected on CT or MRI scans and go undetected for a
long period of time. Moderate to severe TBI injuries may
require surgery to reverse any signs of trauma- induced
brain damage while preventing any further injury to the
brain.
Depending on the severity of the injury and the permanent
damage associated, the injured worker can become
debilitated and unable to perform day-to-day functions
at home and/or work. Appropriate treatment of a TBI
may be extremely costly and complicated, encompassing
diagnostic testing, medications, possible surgery, durable
medical equipment, rehabilitation, and/or home/vehicle
modifications. The recovery process can be life long
and affect the injured worker’s physical, cognitive, and
vocational and social well-being, resulting in adjustments
and accommodations at home and/or work. Injured workers
who have moderate to severe TBI may receive individually
focused tailored rehabilitation programs consisting of,
but not limited to, physical, occupational and speech
therapy, social support and psychological and psychiatric
treatment. Brain injuries typically mean significant lifestyle
adjustments for injured workers and their families.
The cost of treating a injured worker with TBI can vary
based on the extent of the injury. The National Institute
for Neurological Disorders and Stroke conducted a study
in 1989 and found that found that the lifetime cost of
treatment for a single person with a TBI was more than
$4 million. According to the CDC in 2010, the estimated
— Page 11 —
economic costs of TBI was $76.3 billion, with $11.5 billion
attributed to medical costs and $64.8 billion attributed to
indirect costs of TBI, such as lost productivity. An injured
worker can be in the hospital for a few days to a few weeks,
where charges can range from $4,200 to $9,000 per day
and if they are home receiving round-the-clock nursing
care charges can range from $1,920 to $2,900 per day.
More and more injured workers are going home to receive
their care because of the familiarity of their homes and
being around their family support system. Injured workers
thrive in their own surroundings.
Patient education about TBI is key, and the sooner the
injured worker is treated for a TBI, the quicker he/
she begins the recovery process, and the less costly the
claim becomes in the long run. The goal of transitioning
injured workers to home is assist in safely functioning as
independently as possible where they are comfortable and
familiar. Home health services help provide TBI injured
workers with the right support, where they can learn to
adjust, and ultimately lead fulfilling lives. No one brain
injury is the same and it is important to have the most
accurate clinical assessment and level of care to meet the
needs of the injured worker.
St. Vincent's Orthopedics, PC
J. TODD SMITH, M.D.
205-933-7838
— Page 12 —
Our Alabama Blue app helped him
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AlabamaBlue.com/Joe
BCS46217_asia winter newsletter_JOE_2.indd 1
2/29/16 3:28 PM
FLEXIBILITY AND INNOVATION
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1-800-524-0604
john.smitherman@bwood.com
— Page 13 —
The Self-Insurer is a quarterly
publication of the
Alabama Self-Insurers
Association
Post Office Box 240757
Montgomery, AL 36124-0757
(800) 366-3439
Fax (334) 272-7128
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