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Santa’s Workers Comp Claim

Santa Claus Contends with Workers Compensation Claim

Elf claims physical injury and mental stress due to heavy workload.

North Pole — (December 20, 2021) — Saint Nicholas, sometimes known as Kris Kringle but most popularly known as Santa Claus, has had a workers compensation claim filed by one of his elves. It appears the elf suffered from Pre-Holiday Burnout (PHB), caused by the effort required to make gifts for everyone in the world. He also suffered a broken toe when he dropped a toy anvil on his foot. Mr. Claus consented to sit for an interview with a reporter from WILBUR (World Insurance-Leading Business Underwriting Report). The elf, identified only as Ernie, declined to be interviewed. What follows is a transcript of the interview with Mr. Claus, edited for brevity and clarity.

WILBUR: How are you feeling about Ernie’s claim, Mr. Claus?

Santa: Look. I know this is supposed to be the season of giving. But all this claim is giving me is grief and agita.

WILBUR: You have the proper insurance coverage, don’t you?

Santa: Well, yeah. But managing two different claims is a nightmare.

WILBUR: What do you mean?

Santa: Ernie filed one claim for physical injury for the broken toe. That caused him to file another claim for the PHB. Now I have to manage both of them.

WILBUR: What if your claims system tracked claims by incident, recording every claim resulting from that one incident?

Santa: Right. And what if reindeer could fly?

WILBUR: Uh … they can.

Santa: Okay. I forgot. But where do I find an incident-based claims system?

WILBUR: In the cloud.

Santa: You mean with the reindeer?

WILBUR: Not exactly. It’s called Cloud Claims. I’ll get you the information.

Santa: Thank you. But I have to get back to work now. I’m short one elf. Ho, Ho, Ho!

About WILBUR

WILBUR is the world’s foremost insurance authority. If it’s insurance, it’s WILBUR. For more information, please visit www.wilburinsurance.com, email info@wilburinsurance.com, or call 1-800-WILBUR1.

About Santa Claus

Santa Claus is a fat guy in a red suit who flies around the world in a red sleigh on Christmas Eve and brings everybody everything they want. For more information, please write a letter to the North Pole.

Media Contact:
JoAnna Bennett
203-341-2360
joanna@obriencg.com

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the word paid is written in red on a black background

The PAID Act Deadline is Here

Last June, we published a post called, Clean Up Your PAID Act. It laid out the reasons that entities required to comply with the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) of the Centers for Medicare and Medicaid Services (CMS) and its Section 111 reporting requirements would soon be facing new mandates. Those mandates would be coming under the new compliance guidelines of the Provide Accurate Information Directly (PAID) Act. The PAID act was signed into law on December 11, 2020. As promised by CMS, the new law goes into effect on December 11, 2021. That’s Saturday of this week.

The PAID Act enable insurers to better identify claimants’ Medicare plans and to avoid unnecessary litigation. And it prevents the lawsuits that were being filed by Medicare Advantage Plans against insurers for double recovery and for failure to provide primary payment or reimbursement for qualifying charges. But it will require all responsible reporting entities (RREs) to manage additional data from CMS — data they they weren’t required to manage before the PAID Act. More specifically, the PAID Act requires CMS to deliver Medicare Part C (Medicare Advantage Plans) & Part D information to help RREs resolve liens with Medicare. That, however, requires significant changes to Section 111 reporting systems.

That means, beyond your present system’s inability to access the new fields, without changes, many systems won’t be able to process the new CMS query responses at all. That may render your current Section 111 reporting process obsolete. And it will put your CMS compliance at very real risk.

Depending on when your CMS reports are due, you don’t have much time. But with MIR Express™, we do. MIR Express is our secure system for managing your Non-Group Health Plan (NGHP) Medicare reporting. It’ll ensure you’re ready to handle CMS’s changes and to access all the valuable new information you’ll be getting from CMS right away. And we’ll make the transition painless.

If you’re already using MIR Express, you don’t have anything to worry about. And if you’re not already using MIR Express, you still don’t have anything to worry about because you can get it and be using it before your actual reporting deadlines.

We’re ready right now. Please let us know when you are.

December 11 is five days away.

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a bunch of green houses are lined up on a white surface

Property Management Claims … and a Moose

We were flipping through an older issue of Insurance Journal the other day and came across an article with this headline: “The Complicated Risk Exposures of Property Managers and Investors”. We were okay at first, especially when we read this:

Property managers and real estate investors face bedbug exposures, mold behind the dishwasher, tenant and vendor service issues, tenants without insurance, vetting contractors, insurance claims, property inspections, tax authorities, tenant harassment and discrimination claims, and more.

That’s nothing but true, fair, and accurate. But this part freaked us out a little bit:

In most cases, the property manager is responsible for tenant screening and placement of the tenant in the investor’s property, which leads to another potential financial exposure for the property manager … Medical payments, property damage to others, additional living expenses, and contents coverage are not required or reviewed.

The fact that property managers may not be aware of the extent of their exposures is bad enough. But what really freaked us out was the reality that all those claims — whether the property manager saw them coming notwithstanding — will have to be managed.

If you were using Excel, you could record an incident. Then, if you were able to tell what claims resulted from that specific incident, you could put links to those claims in other spreadsheets or documents. That feels like a dicey proposition because it feels like a pretty big if.

When we got to this part of the article, we completely flipped:

Property management firms often assume that by having their investor add the property management firm as an additional insured on the investor’s personal homeowners or commercial multi-family policy they can mitigate all their liability exposures related to the servicing of the individual property … [but] they may be facing uninsured losses due to vacancy clauses, intentional acts or damage by the tenant, and “service animals” that could take down a moose.

The potential liability inherent in vacancy clauses and intentional acts or damage is scary enough. But the idea of heading out to a property inspection and having to face off with a service animal that could take down a moose, is terrifying — especially if the resulting claims have to do with a leg in the service animal’s choppers.

You could trust all that to Excel. Or you could use Cloud Claims. Cloud Claims won’t protect you from a service animal that could take down a moose. And it won’t read your policies for you. But since it connects incidents to claims — and claims to policies — it will protect you from disorganization and inefficiency. And it’ll help you identify patterns, assess risks more effectively, and mitigate them accordingly.

Note to Self: Give service animals a much wider berth.

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restaurant with tables and chairs

Connecting the Dots in Restaurant Claims

Have you ever played Connect the Dots? At first it might seem like a bunch of dots and numbers. But as the dots begin to connect, the image magically appears. Restaurant claims are similar. At first it might seem like a bunch of events and numbers. But eventually general liability, personal injury, liquor liability, product liability (food poisoning, allergic reactions, hepatitis), and fire can all come together and magically reveal the whole picture.

It’s obvious enough that insurers have an obligation to fulfill the promises they make to protect against losses when they sell policies. But who protects your risk managers? How can they ensure they’re properly identifying all of the risks they’re paid to mitigate? How can they do so efficiently and coherently? And how can they connect the dots between claims to identify patterns, to improve their risk selections, and to maximize guest satisfaction?

The Whole Picture

They can start by tracking incidents, rather than claims. Here’s a scenario: One evening, Gladys, a waitress at Ernie’s Chop Joint, trips on her way across the dining room and drops a tray containing a carafe full of water and eight water glasses. The glasses shatter. As the carafe rolls across the floor, water runs into some electric sockets in the floor, causing a fire. (Claim #1, property damage.)

On its way to the floor, the carafe full of water, ricochets off the right foot of Herb, a gentleman having dinner with his wife, fracturing three metatarsals. (Claim #2, bodily injury). Herb’s wife, Grenadine, believing Gladys dumped the tray on purpose, convinces Herb to sue Ernie’s. (Claim #3, general liability.)

The risk manager now has three claims to contend with, all stemming from Gladys’s stumble, but that may be unrelated in terms of coverage. For that matter, it’s possible for the claims to be managed by different people who may have no way and no reason to connect the dots. If, on the other hand, the claims had been tracked by incident (poor Gladys), then all the dots would have been connected.

If the claims system the risk manager used tracked incidents — used tag-based organization for documents to eliminate network folders and files; attached image files, videos, PDFs, and other documentation to each incident and anchored every claim to an incident — dots would connect themselves. As a result, claims would be managed more efficiently, patterns would be more readily identified, risks would be assessed more effectively, and conditions and circumstances could be adjusted to mitigate those risks.

We can’t promise to protect Gladys. But we can definitely help the risk manager who’s trying to.

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a close up of a compensation form on a computer screen

TPA: Total Processing Adaptability

Especially for workers comp claims — and especially for companies that use TPAs (third-party administrators) — it’s crucial to have Total Processing Adaptability.

What we mean is that your claims system should let you manage everything you want to manage and to have an optimally flexible relationship with your TPA(s). And it entails the ability of that system to give you the reports you need to enable you to spot trends in your claims experience. Are claims being reported properly? What kinds of claims are prevalent? What types of injuries are most common? What body parts are most likely to be injured? What are the most common complications? What are typical recuperation or rehabilitation times for particular types of injuries?

Beyond that, Total Processing Adaptability means your claims system lets you control the flow of information. We’ve seen setups in which accident reporting goes straight to the TPA because the organization in question doesn’t have the technology to capture accidents. If you’ve got Total Processing Adaptability, you have first-report capability and can route accident reports to TPAs automatically, based on your business rules. The right choice of unbundled software — with no reliance on software provided by a TPA — means your data is yours. If you have multiple TPAs or want to switch TPAs, having your own claims software gives you a layer of protection; that is, an element of risk management that helps normalize your reporting and operations. That ensures one view of your data, regardless of TPA, insulating you from the negative effects of changing TPAs.

When we created Cloud Claims, we knew we wanted to give our customers Total Processing Adaptability. We wanted to ensure a first-class claims experience for claims managed in-house and those managed by a TPA. We wanted to automate workflows to eliminate manual processes. We wanted sending files to TPAs to be as easy as clicking a button. By freeing adjusters from administrative tasks, we wanted to let them concentrate on critical decision-making — and we wanted to supercharge every risk management department’s productivity.

You can’t completely manage the safety of your workers. But you can manage your workers comp claims. With the right TPA and Total Processing Adaptability, you can effectively manage those claims and reduce the costs of the claims that occur.

With the right claims system, you’ll be on your way to more efficiency, better outcomes, and fewer headaches.

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Claims Flexibility

Claims Flexibility

Safety First

We were doing some reading about claims in the transportation industry the other day because … well … because that’s what we do. During our reading, we happened to find a post on the website of HUB International. It was called, “Disruption Steers Fleet Operators Into 2021”. The post was full of sound insight and advice. But this, in particular, caught our eye:

Read more

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Claims to Fame

Claims to Fame

The challenges in claims management are fairly common. While this list might not be exhaustive, those challenges include:

Read more

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Claims Reimagined

Claims Reimagined

When we think about the phrase, Big Data, we sometimes think of another phrase: herding cats. With no disrespect intended toward our feline friends, they’re not the most manageable species in volume. The same can be said of data. While each datum doesn’t have a mind of its own like each cat does, managing data — to say nothing of taming it — can be particularly challenging. And when it comes to claims data, things can only get worse. Here’s why: Read more

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Paid Act

Clean Up Your PAID Act

If you’re required to comply with the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) of the Centers for Medicare and Medicaid Services (CMS) — and its Section 111 reporting requirements — things have the potential to get significantly more complicated. That’s because on December 11, 2020, The Provide Accurate Information Directly (PAID) Act was signed into law. Read more

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How Do You Spell Commodity

How Do You Spell Commodity?

There are two ways to look at the term, commodity: Read more

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