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