Riverside Community College District (RCCD)

Industrial and Non-Industrial Claim RecoveryMichael W. Simmons, MAOM, CSRM

Director, Risk Management

Riverside Community College District

Presentation Agenda

RCCD’S Commitment to its Staff, Faculty, and Students What RCCD Risk Management Believes About Its Service to the Institution

Strategies Deployed by the RCCD RISK Team Risk Management Tactics and Strategies are the Key

RCCD Risk Claims Management – A Case StudyOverview of the Results to Reduce Claims Liability

Questions and Answers

RCCD RISK Philosophy

RCCD Claims Management Team Experience and Expertise How Can RCCD Risk Management Provide the Service Levels Needed to Manage Claims Effectively?

RCCD RISK Expertise

Focus for RCCD RISK

RCCD Strategies

RCCD Results

Questions and Answers

The Risk Management ProcessRisk Has Many Moving Parts. Risk Management Should be Approached Holistically

RCCD Risk Department Claims Management Philosophy

• Every Injured Worker is a Human Being

• Every Injured Worker Will Be Treated with Dignity and Respect

• At the End of the Day, We are a Service Department

• We Perform (1) Early Investigations, (2) Early Evaluations, and (3) Early Resolutions

• Claims with Fraud Indicators are the Exception to the Previous Bullet

• For Industrial Injuries we Prefer to C&R All Issues. Stipulations are Rare Cases.

• Our Claims Management Process is Designed to Achieve the Previous Bullet

• Open Claims Represent a Primary Cost Driver and are Our Priority. We CLOSE Claims

• We Maintain a Rigid Procedural and Timeline Hold on ALL Industrial Injuries

• We Select Our Supporting Partners Based on Their Alignment with Our Philosophy

• We Demystify the Claims Process to Nullify the Employee’s Need for an Advocate

• Creativity in ALL Settlement Scenarios is Welcome and Expected

• The Credit for the Results Goes to Our Team. There are No Individuals Here

• It is Our Goal to Hear Positive Feedback from Our Constituencies

RCCD Risk Management Team Expertise and Experience

Question: What Qualifications Does the RCCD Risk Management Department Have?

Answer: Over 200 Combined Years of Experience in Claims Management and an

Extremely Diverse Claims Management Team with a Variety of Backgrounds.

Team Member Career Focus

Michael W. Simmons, CSRM Private and Public Sector Risk Management / Claims Management

Monica Esqueda, CSRM Private and Public Sector Claims Management

Dr. Sherry Stone Disaster Preparedness and Safety Management

Rachel Shaw Widely Recognized as One of the Best Disability Experts Available

Dan Conley York Risk Services Adjuster with Years of Public Sector Experience

David Kargozar GL and Workers’ Compensation Attorney | Private and Public Sectors

Medcor Triage Nurse Services

California Schools Risk Mgmt Middle Market Insurance JPA with Ample Support Resources

Wellcomp Flexible Medical Provider Network

Various Nurse Case Manager, Medical Specialists, and Private Investigations

PRE-LOSS STEPS

ACCIDENT PREVENTION

Review of ALL Safety Processes

with Focus on Effective Reduction

of Frequency and Severity

Redesign of Ineffective Safety

Processes and Procedures

Establish a Minimum Standard

and Consequences for Failure to

Comply / Perform

Implement a Sense of Safety and

Loss Control Continuity

The Risk Management ProcessWhat Can Does RCCD Set Out to Accomplish?

LOSS MANAGEMENT STEPS

DAMAGE CONTROL

Develop Internal Claims

Management, First-Aid, and

Temporary Alternative Work

Programs to Better Manage

Claims Costs

Focus Efforts on Timely Closure

of ALL Claims

Establish Goals for Claims

Management, RTW, TPA

Performance, Defense Counsel

Effectiveness, etc.

POST-LOSS STEPS

LEARN FROM OPPORTUNITIES

Develop Culture Specific Accident

Investigation Procedures Based

on Our Own Loss History

Start Claims Cost Education

Effort with Faculty, Staff,

Managers, etc.

Include Everyone in the

Development of Safety and Claims

Programs and Educate Them on

Their Importance to the

Successful Reduction of Losses

RCCD Risk Management Claims Liability Mitigation Plan

Modify Current Claims Management Philosophy

Revise the Claims Management Program

Remove ALL Obstacles to the New Program

Identify the Claims Management Team Members and Get Them Onboard

Implement the New Strategies for Claims Management

Apply Consistent Pressure to the Claims Management Flywheel

Carve Out Older Claims and Target for Resolution

Address our Actuarial Concerns and Identify a New Reserve Target

Monitor Claim and Reserve Activity for Positive Trending

Set an Aggressive Goal for Closed Files and Reserves and Achieve the Goals

Acknowledge Positive Results and Support Team Efforts with Recognition

Transition from Claims Management to Accident Frequency Controls

Apply Claims Management Resistance Before and After Claims Occur

Monitor for Applicant Attorney Adjustments and Modify Accordingly

RCCD Interactive Process Cooperative Effort

• Human Resources and Risk Management Work Collaboratively

• Risk Management Involved in Interactive Process for Industrial and Non-industrial

• Risk Evaluates all Non-industrial Scenarios for Industrial Exposures

• Interactive Process is an Opportunity to Facilitate Action to Mitigate Losses

• Consistency and Transparency are the Keys to an Effective Interactive Process

• The Disability Specialist is the Core Element to the Process

• Everything Risk Contributes is Designed to Support the Disability Specialist / HR

• Interactive Process Achieves Medical Separations Timely and Appropriately

• RCCD Aggressively Complies with the Laws Governing the Process

• Employees Rarely Claim a Lack of Understanding and Often Agree with the Outcome

• Bargaining Unit Representatives Have Complimented Our Process

• Not One Case Has Been Litigated in the Last 3 Years

• Helps us Manage Even the Toughest Cases and Most Difficult Personalities

• Should be Part of Every Claims Management Program

RCCD Risk Management Claims Liability Mitigation Plan

Internal Claims Management Team

• Risk Manager

• Claims Coordinator

• District Safety & Emergency Planning Manager

• College Safety Coordinators (in hiring process)

External Claims Management Team

• Dedicated TPA Adjuster

• GL Defense Attorney for Workers’ Compensation Defense

• Triage Nurse Services

• Disability Specialist

• Nurse Case Manager(s)

• JPA Resources

• Medical Specialists

• Private Investigations

Plan in Action – A Case StudyRCCD Case Analysis: Multi-College District with 4,500 Employees

Workers’ Compensation Program Initiatives

Created an Internal Claims Position – Monica Esqueda | Casualty Claims Coordinator

Accessed JPA Claims and Safety Resources

Implemented a Dignified and Respectful Claims Management Environment

Modified TPA Accountability from Active Claim Handling to Directed Claim Handling

Dedicated TPA Adjuster with Client Specific Instructions for Handling Our Claims

Retrained a GL Defense Attorney to Mitigate / Defend Industrial Injury Claims

Deployed a Triage Nurse Service for ALL Newly Reported Injuries

Reinforced Use of the Medical Provider Network

Drafted a Thorough Claims Reporting Process to Demystify Workers’ Compensation

Partnered with Approved Specialists, Disability Expert, Nurse Case Managers, etc.

Targeted ALL Future Med Claims for C&R Settlement to Reduce Future Liability

Refined Conventional Claim Activity (RTW, Early Evaluations and C&R’s, Treatment Approval, etc.)

Proactive Employer Level Investigation (3 and 3 Rule)

Plan in Action – A Case Study2012

130 Open Workers’ Compensation Claims

95% of the Open Pending Actively Litigated

Oldest Claim Date of Loss: 1997

High Rate of Litigation and Attorney Activity

Claim Payment Reserves Underfunded (200%)

Sought Relief Plan to Post $4M in Reserves

Over $6M in Projected Claims Liability

Lag Days Average at 60+ Days

Average Time to Close: 475 Days

Several Serious Injuries Into Excess Layer

Average $182K Per Year in Defense Expenses

Average Cost of Claims: $13,512

General Lack of Trust in Risk Management

2015

23 Open Workers’ Compensation Claims

30% of the Open Pending Actively Litigated

Oldest Claim Date of Loss: 2000*

3 New Litigated Claims in the Last 37 Months

Claim Payment Reserves Overfunded

Returned $3M to the General Fund (2013-2015)

$2.1 in Projected Claims Liability

Lag Days Average Reduced to 7+ Days

Average Time to Close: 170 Days

0 New Excess Layer Claims in the Pending

Average $70K Per Year in Defense Expenses

Average Cost of Claim: $8,473 (-37%)

Monica Receiving “Thank You” Notes

* Only 2 of 23 Open Claims with Pre-2009 Dates of Loss

QUESTIONS