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Deodat Kritzinger MMPA congress Valley lodge May 2012
Compensation for Occupational Injuries and Diseases in the mining industry – Analysis and management of claims through RMA system enhancements. Deodat Kritzinger MMPA congress Valley lodge May 2012
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Content of presentation
RMA systems Medicare Clientcare Claims experience RMA medical offering Return to work
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RMA systems Integrated in-house system with 4 main components:
Claims, Medical, Underwriting, Pensions system Integrated with external managed healthcare systems Pharmaceutical benefit management system Hospital utilisation management
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RMA systems Medicare system Automated processes Case management
PMP and mobile clinics Communication stakeholders Medical invoice processing Member and MSP portal
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Medical Dept Objectives 2012
“Caring, compassionate, compensation” Improved communication with stakeholders Injured Employer MSP Improved response and turn around time on referrals to medical department Cost containment of medical expenses Acute Subsequent care Strategically “ODMWA administration preparedness”
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Clientcare Member groups and claims experience Premium payers Premises
Risk rating industry categories Underground (gold) Underground others Shallow underground Opencast Surface Admin and offices Policy schedule Assessment
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Clientcare data Sum of Employees Year Industry 2009 2010 2011
Deep Underground (Gold) 129354 125851 120448 Deep Underground (Other) 157222 157481 172222 Offices & Admin. 14159 15135 16307 OpenCast 19117 20810 20653 Shallow Underground 49871 37018 38385 Surface Employees 36077 34454 36097 Grand Total 405801 390750 404112
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Number of all claims per industry
Sum of Employees Year Industry 2009 2010 2011 Deep Underground (Gold) 10539 9464 9790 Deep Underground (Other) 7912 7359 8295 Offices & Admin. 289 294 307 OpenCast 502 605 524 Shallow Underground 1299 1074 1294 Surface Employees 1618 1501 1229
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Incident rates Incident rate all claims Year Industry 2009 2010 2011
An incidence rate of injuries and illnesses is computed by using the following formula: (Number of injuries and illnesses X 200,000) / Employee hours worked = Incidence rate) (The 200,000 hours in the formula represents the equivalent of 100 employees working 40 hours per week, 50 weeks per year, and provides the standard ) Number of reported incidents per 100 employees Incident rate all claims Year Industry 2009 2010 2011 Deep Underground (Gold) 8 Deep Underground (Other) 5 Offices & Admin. 2 Open Cast 3 Shallow Underground Surface Employees 4
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Claims captured 2009 DRG00 Fatal Pensions 125 0.6% DRG01
Sum of Number Of Claims DRG00 Fatal Pensions 125 0.6% DRG01 Spinal Cord Injuries 19 0.1% DRG02 Lower Limb Amputees 21 DRG03 Upper Limb Amputees 5 0.0% DRG04 Partial or Total Blindness 226 1.0% DRG05 Noise Induced Hearing Loss (NIHL) and Acoustic Trauma 1725 7.8% DRG06 Injuries to the Head 2211 10.0% DRG07 Injuries to the Neck 219 DRG08 Injuries to the Thorax 582 2.6% DRG09 Back Injuries 1034 4.7% DRG10 Injuries to the Abdomen and Pelvis 40 0.2% DRG11 Injuries to the Shoulder and Upper Arm 1178 5.3% DRG12 Injuries to the Elbow and Forearm 1161 5.2% DRG13 Injuries to the Wrist and Hand 4480 20.2% DRG14 Injuries to the Hip and Thigh 500 2.3% DRG15 Injuries to the Knee and Lower Leg 2240 10.1% DRG16 Injuries to the Ankle and Foot 2513 11.3% DRG17 Injuries involving Multiple Body Regions 253 1.1% DRG18 Foreign Body in Eye, Ear and Lung 1448 6.5% DRG19 Burns and Corrosion 326 1.5% DRG20 Toxic effects - solvents, metals, chemicals, gases 238 DRG21 Effects of radiation, heat, pressure, electricity, vibration 126 DRG22 Mental and Behavioural Disorders 95 0.4% DRG23 Diseases of the Respiratory System 788 3.5% DRG24 Skin Disease (Dermatitis / Eczema) 14 DRG25 Other Conditions - miscellaneous 118 0.5% NULL 531 2.4% Grand Total 22216 100.0%
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Claims captured per industry 2009
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Claims captured 2010 DRG00 Fatal Pensions 122 0.6% DRG01
Sum of Number Of Claims DRG00 Fatal Pensions 122 0.6% DRG01 Spinal Cord Injuries 18 0.1% DRG02 Lower Limb Amputees DRG03 Upper Limb Amputees 6 0.0% DRG04 Partial or Total Blindness 210 1.0% DRG05 Noise Induced Hearing Loss (NIHL) and Acoustic Trauma 1589 7.8% DRG06 Injuries to the Head 2077 10.2% DRG07 Injuries to the Neck 221 1.1% DRG08 Injuries to the Thorax 507 2.5% DRG09 Back Injuries 996 4.9% DRG10 Injuries to the Abdomen and Pelvis 31 0.2% DRG11 Injuries to the Shoulder and Upper Arm 1063 5.2% DRG12 Injuries to the Elbow and Forearm 1011 5.0% DRG13 Injuries to the Wrist and Hand 4141 20.4% DRG14 Injuries to the Hip and Thigh 506 DRG15 Injuries to the Knee and Lower Leg 1983 9.7% DRG16 Injuries to the Ankle and Foot 2211 10.9% DRG17 Injuries involving Multiple Body Regions 263 1.3% DRG18 Foreign Body in Eye, Ear and Lung 1183 5.8% DRG19 Burns and Corrosion 276 1.4% DRG20 Toxic effects - solvents, metals, chemicals, gases 313 1.5% DRG21 Effects of radiation, heat, pressure, electricity, vibration 150 0.7% DRG22 Mental and Behavioural Disorders 160 0.8% DRG23 Diseases of the Respiratory System 749 3.7% DRG24 Skin Disease (Dermatitis / Eczema) 17 DRG25 Other Conditions - miscellaneous 124 NULL 395 1.9% Grand Total 20340 100.0%
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Claims captured per industry 2010
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Claims captured 2011 DRG00 Fatal Pensions 147 0.68% DRG01
Sum of Number Of Claims DRG00 Fatal Pensions 147 0.68% DRG01 Spinal Cord Injuries 9 0.04% DRG02 Lower Limb Amputees 14 0.07% DRG03 Upper Limb Amputees 3 0.01% DRG04 Partial or Total Blindness 184 0.86% DRG05 Noise Induced Hearing Loss (NIHL) and Acoustic Trauma 1523 7.09% DRG06 Injuries to the Head 1912 8.90% DRG07 Injuries to the Neck 202 0.94% DRG08 Injuries to the Thorax 476 2.22% DRG09 Back Injuries 1013 4.72% DRG10 Injuries to the Abdomen and Pelvis 27 0.13% DRG11 Injuries to the Shoulder and Upper Arm 914 4.26% DRG12 Injuries to the Elbow and Forearm 1009 4.70% DRG13 Injuries to the Wrist and Hand 3724 17.34% DRG14 Injuries to the Hip and Thigh 469 2.18% DRG15 Injuries to the Knee and Lower Leg 1935 9.01% DRG16 Injuries to the Ankle and Foot 2200 10.24% DRG17 Injuries involving Multiple Body Regions 249 1.16% DRG18 Foreign Body in Eye, Ear and Lung 1027 4.78% DRG19 Burns and Corrosion 259 1.21% DRG20 Toxic effects - solvents, metals, chemicals, gases 174 0.81% DRG21 Effects of radiation, heat, pressure, electricity, vibration DRG22 Mental and Behavioural Disorders 71 0.33% DRG23 Diseases of the Respiratory System 2017 9.39% DRG24 Skin Disease (Dermatitis / Eczema) 25 0.12% DRG25 Other Conditions - miscellaneous 115 0.54% NULL 1592 7.41% Grand Total 21474 100.00%
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Claims captured per industry 2011
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Total cost over 3 year period
DRG00 Fatal Pensions DRG01 Spinal Cord Injuries DRG02 Lower Limb Amputees DRG03 Upper Limb Amputees DRG04 Partial or Total Blindness DRG05 Noise Induced Hearing Loss (NIHL) and Acoustic Trauma DRG06 Injuries to the Head DRG07 Injuries to the Neck DRG08 Injuries to the Thorax DRG09 Back Injuries DRG10 Injuries to the Abdomen and Pelvis DRG11 Injuries to the Shoulder and Upper Arm DRG12 Injuries to the Elbow and Forearm DRG13 Injuries to the Wrist and Hand DRG14 Injuries to the Hip and Thigh DRG15 Injuries to the Knee and Lower Leg DRG16 Injuries to the Ankle and Foot DRG17 Injuries involving Multiple Body Regions DRG18 Foreign Body in Eye, Ear and Lung DRG19 Burns and Corrosion DRG20 Toxic effects - solvents, metals, chemicals, gases DRG21 Effects of radiation, heat, pressure, electricity, vibration DRG22 Mental and Behavioural Disorders DRG23 Diseases of the Respiratory System DRG24 Skin Disease (Dermatitis / Eczema) DRG25 Other Conditions - miscellaneous Grand Total
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Total cost over 3 year period
All Payments BenefitGroup All DUG Gold DUG Oth O & A OC S UG Surf Days Off Fatal Medical Not Classified PD Recoveries - Sundry Grand Total
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RMA service offering and challenges
Medicare system Case management of authorised cases Quality of information, completion documents Quality of medical reports Electronic submission of invoice Chronic medication Re-opening of claims Audiology repository Early return to work policy
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Case management Pharmaceutical Benefit Management
Generic substitution Compliance Hospital Utilisation Management Length of stay Level of care ICD 10 and tariff code integration
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Medical reports Outstanding reports – first, progress and final
Quality Unnecessary lost shifts Role of Occ Health Centre COF Separation Impairment Assessment Clinic ? Dedicated doctor / disability manager to perform assessment - assisted RMA doctor Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec FMR 553 455 525 541 437 324 279 378 249 375 333 338 IAC 9 23 19 25 45 40 31 36 30 32 48
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Submission of medical invoices
Preferred choice electronic submission > 80% of invoices Minimum criteria for processing invoices Claim number, Name and surname Rx date ICD 10 Tariff codes Remittances to MSP Reconciliation of payments Duplicate invoices
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Re-opening of claims and chronic medication
Pre-authorisation required Prescribed format Motivation and how treatment will improved or reduce disability Authorisation of specific treatment or medication
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Audiology repository Database of screening audios performed in industry SIMRAC Project - RMA and members Employers to submit screening audios (download) Access for members to view individual audiograms and compensation RMA in position to feedback on trends in industry, commodities, occupations
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Early return to work Chances of successful return to work best when RTW process start as soon as possible Early assessment can help to identify problems Priority should be given to early and safe return to work duties Injury management directed to enable injured workers to return to work – “maximising treatment while minimising lost time” Benefits Employee – remain in work, financial and job security Employer – retains skilled workforce, motivation through employee well being, lowered cost and premiums CF or mutual – reduce cost of claims, less dependency on fund for financial support Amendment to COIDA
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Amendment COIDA Obligation to rehabilitate Compensate during rehab
Implement the rehabilitation, re-integration and RTW policy “HIRA” Suitably place or design to accommodate Not dismiss within 12 months Compensate during rehab Disability manager Consultation employer and employees RTW interventions Case manager Assist Monitor progress Rebate or assessment at lower rate for those employers with policy in place
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Member and MSP Feedback?
Service delivery Acute Subsequent Communication and interaction Validation and payment of medical invoices Training needs RMA processes RMA benefits Impairment assessment RTW
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Thank you!
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