Spotlight Defense Base Act services
14 September 2020
Jane Hegeler (business development director) and Simon Cook (head of special investigation services) at Charles Taylor Claims Services, discuss medical and investigative case management for DBA services
Can you offer a little background information about Charles Taylor’s DBA services?
Jane: Charles Taylor’s commitment is to provide end-to-end solutions that meet the (often niche) needs of carriers and their clients. With this in mind, we have recently expanded our medical and security assistance and claims and risk management provision to include Defense Base Act (DBA) case management services.
Our new global services include - but are not limited to - medical case management and evaluation, cost containment, settlement negotiations, labor market surveys and investigations. They draw on our 40+ years’ experience of managing and validating medical claims in diverse, often remote, locations.
What should carriers expect from an outsourced DBA claims and investigative case management provider?
Jane: Carriers are increasingly looking for end-to-end, proactive DBA services: recognising the value of single providers that can follow a claimant’s pathway from notification to maximum medical improvement and settlement. They want dynamic, well-managed care and specialist case management that gets an employee back to work as soon as possible.
A global reach, combined with local knowledge and a breadth of in-house collaborative expertise - not least specialist claims handling, cost containment and worldwide medical assistance - can enable the very best, timely, medical care for claimants at a reasonable cost to carriers. This needs to be coordinated with plenty of vendor-led initiative, so that obstacles can be anticipated, and cases managed with optimum efficiency.
Carriers and brokers also increasingly request “live” access to claims data: enabling claims to be viewed real time enabling the carrier to make informed decisions in a timely manner.
As important is a provider’s dedicated compliance and regulatory teams - which should work closely with carriers to ensure the highest standards of corporate governance.
How important is cost containment?
Jane: Ideally, a vendor’s supply chain management team should clearly know its clients’ location of risks and understand the medical capabilities and have contingency plans to provide bespoke global cost containment where possible.
Directional medical care, established discounts with vetted hospitals, direct billing agreements with medical providers and invoice assessments all help to access competitive and reasonable prices. Medical treatment cost benchmarking, on-site and remote hospital audits and due diligence checks are also integral parts of the cost containment process.
All this is an essential part of protecting a carrier’s bottom line.
How does claims validation contribute to cost containment?
Simon: Claims validation services reduce carrier losses by enabling dishonest claims to be declined. They also ensure that genuine claims can be validated, processed and paid without delay and that carriers’ costs can be recovered from other sources, such as third parties, where relevant.
It’s essential to establish solid, reliable facts and to amass multiple pieces of evidence to ensure that there is no doubt about a claim’s validity.
How important is a global network of investigators?
Simon: A global network on the ground overseas is an important part of the claims validation process. Local investigators can visit hospitals and medical centres, examine patient files and interview individuals to assess the validity of medical bills and injuries. This can often reveal a discrepancy quickly, for instance when comprehensive medical records can’t be produced.
Local investigators also have a thorough knowledge of the areas in which they work, which means that they understand regional customs, comply with regulations, cooperate with locals and communicate effectively. In addition, they can help to contain costs by reducing the need to transport investigators to far-flung destinations.
What else is involved in the claims validation process?
Simon: On-the-ground investigations are often complemented by phone or video interviewing and desktop inquiries. It’s important to leave no stone unturned in unearthing that critical piece of evidence that may validate a claim.
But what if an individual is receiving disability benefits and has died without the family reporting the death? What if there is collusion between a doctor and patient to keep medication going unnecessarily, so that an ongoing illness can be feigned?
Claims validation techniques in these sorts of cases can range from simple incident surveys to alive and well checks and full surveillance. And access to a multi-skilled medical team is often crucial to identifying issues such as patient overtreatment, or correct levels of medical improvement.
This collaboration can empower the claims validation team to investigate a patient’s care, ensure that a medical complaint is still valid (and not being unnecessarily prolonged) or that an injury is genuine. It’s not uncommon for independent medical specialists to be brought in to review the situation too.
Click here for more information about Charles Taylor’s DBA services