Claims Management

Workers Compensation

  • Proprietary medical management solution
  • Intake services available 24 hours per day, 7 days per week
  • Comprehensive disability management/return to work philosophy
  • Clients get access to ESIS’ SIU, Recovery, and Litigation services
Design.Integrate.Achieve.

Workers compensation costs are increasing and can quickly make a significant impact on your bottom line. ESIS® can help you implement innovative best practices to keep those costs from escalating unnecessarily.

Design.Integrate.Achieve.

Solution Highlights

Benefits

Our workers compensation solutions allow clients to effectively manage their risk management programs with services designed to meet their unique needs. Our integrated program design, designated claims experts, and innovative solutions, enable us to create efficiencies and reduce loss costs.  

When it comes to program design, we understand that our clients programs are different, and so is our collaborative approach. We know a successful risk management program relies on consistent and consultative client collaboration to ensure programs are tailored to suit each customer’s needs. Our specialized claims experts seamlessly conduct program analysis quickly identifying loss cost drivers. From day one, customization and collaboration are components you can count on.

Innovation is a product of our integrated risk management design and use of technology. Our Data-driven decision support model incorporates what we learn into actions, continuously improving a client’s claims handling process and model design.

As a client, you will receive access to Medical Programs, Special Investigations Unit, Litigation and Event Management.

Medical Programs

ESIS Medical ImpactSM has a significant impact on the outcome of workers compensation claims. Our outcomes-based model is comprehensive and built on ESIS’ philosophy that collaborative and consistent management is a key to success. Our best practices are developed to support this philosophy and ensure we provide high quality, cost-effective medical and vocational services to our clients.

We are an outcomes driven, customized, medical cost containment program fully integrated in our claims model, providing oversight on quality medical care, reduction of costs through negotiated preferred provider rates, and coordination with all parties to return the injured/ill worker to suitable, gainful employment.

The key to successful medical management begins before the injury occurs.  We work in partnership with our clients, prior to injuries, to identify local preferred providers, ensure medical panel cards are posted, and transitional work assignments are created in the event employees need alternate temporary positions. 

When it comes to workers compensation medical care management, ESIS Medical Impact stands apart from competitors thanks to the integration of extensive case management resources with our broad range of client claims management services. Every component of medical care – pharmacy benefit management, bill review services, triage nursing services, preferred provider network and more is integrated into our program design behind the scenes to produce superior quality of care and cost outcomes.

Client benefits include:

    • High quality and appropriate medical care
    • Timely and appropriate sharing of claims and medical information
    • Reduced cost
    • Prompt payments
    • Timely and appropriate return to work

Overview of Medical Solutions:
NurseLine
The NurseLine provides access to Registered Nurses via a toll free telephone number whenever an injury occurs; this is available 24 hours a day, 7 days a week.  Via the NurseLine, nurses assess workers’ injuries and help them receive the appropriate treatment at the right time in the right settings to ensure faster return to work.

ESIS Triage
Upon meeting specific intake or mid-case triggers, the claim is electronically referred to an ESIS triage nurse to complete a brief review of the file activity, compare against clinical guidelines, and document a one time Medical Review Assessment to assist the adjuster in ensuring appropriate medical direction of the claim.

ESIS Nurse ImpactSM – Telephonic Case Management
Telephonic Case Management (TCM) is a criteria-based, telephonic early identification and assessment product involving a medical case management system.  Registered Nurses receive early notice of work injury and facilitate appropriate medical care and return to work through direct provider, employer, employee, and claim adjuster communications.  If appropriate, this includes channeling the injured worker to a Preferred Provider facility for treatment (ExPO, Panel or PPO). If hospitalization services are warranted, the TCM nurse will conduct the pre-admission/continued stay review services at no additional charge.

ESIS Nurse ImpactSM - Field Case Management
Medical Field Case Management Services are provided by Registered Nurses dedicated to ESIS. The nurse assigned to a particular file works closely with the employer, physician, claim representative, and injured worker.  The objective is to assist in reducing disability, to insure that appropriate medical services are offered and implemented, and to facilitate return to work.  This service ultimately reduces claim costs. 

Utilization Review:

Utilization Review evaluates the medical necessity, appropriateness of setting, efficacy, or quality of care for services, treatments, procedures and supplies.  Often, a prior approval is required before a patient can be hospitalized, receive expensive tests or procedures, or be referred to a specialist or specialists. Utilization Review is an important tool. It not only helps avoid costly or unnecessary treatments, but also helps prevent inappropriate treatments that put patients at risk.  Additionally, Utilization Review is used to ensure that injured workers get needed care based on guidelines developed using clinical evidence based medicine.

ESIS Pharmacy ImpactSM

ESIS’ Pharmacy Impact is a comprehensive solution designed to:

    • Drive prescriptions “in network,” including those dispensed from physicians
    • Virtually eliminate hassles associated with third-party billers
    • Apply data analytics and predictive modeling to predict high-cost claims
    • Use evidence-based medicine and recognized regional and national medical guidelines to perform utilization management on the pharmacy components of the claims 
    • Integrate clinical triage and a comprehensive suite of tools and resources to help control utilization at every stage of the claim

Bill Review:

As a first step, bill review performs automated comparisons of provider bills to verify that charges fall within state mandated fee schedule guidelines, or within usual and customary charges (applied in states mandating fair and reasonable charges without setting fee schedules). Numerous other components of bill review include data integrity checks, auto indexing to ensure bills are matched to the correct claim, clinical edits, application of negotiated network discounts, and numerous other bill review functions. These services are performed by coding specialists, auditors and nurses to maximize outcomes. 

Preferred Provider Organizations (PPO)
ESIS’ Workers Compensation Preferred Provider Organizations is a mosaic integrated network based upon our  selection of the most comprehensive provider groups at the state level. The broad based network allows for complete coverage with more than one million hospitals, industrial clinics, physicians, chiropractors, dentists, physical therapists, radiologists, home health care agencies, pharmacy and ancillary service providers.

ESIS ExPO® Exclusive Network
ESIS ExPO is an outcome-based provider selection tool. We have created a hierarchy of providers who have demonstrated outstanding results over a range of ESIS-identified criteria. ESIS developed its criteria after reviewing in excess of five million bills against ultimate claim costs to compare performance of treating physicians against the population. More than 11 distinctive performance metrics were identified and provider outcomes are measured on a total cost per claim basis.

Special Investigations Unit

A critical component of workers compensation and liability claims management and cost containment is the identification of fraudulent claim activities. ESIS’ Special Investigation Unit (SIU) understands that exaggerated or false claims are both difficult and time consuming to deal with. That’s why we have established a dedicated unit to work on behalf of our clients to help or reduce the incidence of fraud.

Our SIU team is comprised of highly experienced specialists that have law enforcement and/or claim investigation backgrounds.

ESIS is proud to partner with our SIU vendor partners, ICS Merrill, Global Options, G4S Compliance and Investigations, and HUB Enterprises who provide ESIS clients with unique advantages by offering greater flexibility and selection of investigation firms at competitive rates.

Recovery

Our goal is to improve profitability for our clients by reducing their loss costs. We achieve maximum results by providing a cost effective dedicated experts to help clients manage subrogation claims.

Services:

    • Worker Compensation Subrogation
    • Property Subrogation
    • Automobile, Inland Marine and Recreational Marine Subrogation
    • Second Injury Fund Recovery
    • Bond Recovery

Benefits:

    • Experienced staff dedicated to specific lines of business (W/C, Auto, Property, etc.)
    • Management of the subrogation process through one trusted business partner
    • Fee charged only when a recovery is made
    • Flexible fee arrangements
    • Innovative recovery solutions to meet the specific needs of each customer
    • Seamless approach with ESIS claims
    • Member of National Association of Subrogation Professionals (NASP)

Organized in 1953, ESIS, Inc. (ESIS) provides customized risk management services. ESIS is a Chubb company. Chubb is the marketing name used to refer to subsidiaries of Chubb Limited providing insurance and related services. For a list of these subsidiaries, please visit our website at www.chubb.com. Chubb is the world's largest publicly traded property and casualty insurance group. With operations in 54 countries, Chubb provides commercial and personal property and casualty insurance, personal accident and supplemental health insurance, reinsurance, life insurance and related services to a diverse group of clients. Chubb Limited, the parent company of Chubb, is listed on the New York Stock Exchange (NYSE: CB) and is a component of the S&P 500 index. Additional information about Chubb can be found at www.chubb.com. Additional information about ESIS, Inc. and its products and services can be found at www.esis.com.

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Learn more about ESIS' claims management solutions.