When claims occur, our specialists and business partnerships deliver tools, resources and services that will help you successfully manage them through closure.
Paradigm assists when a catastrophic claim occurs by providing access to claims professionals whose sole purpose and expertise is to manage the claim. This is achieved by bringing medical benefits to the injured worker, and assigning experienced clinicians to their case. Paradigm Outcomes has managed over 15,000 catastrophic claims over the last 25 years, and provides a unique opportunity to “sell” the medical components of the claim, thereby creating a contractual negotiated limit on the medical exposure to the claim. Contact Karin Wedworth at 916-850-7300.
A dedicated Telephonic Nurse Case Manager (TCM) is assigned to perform a triage call with the injured worker upon authorization of a surgical procedure. The TCM will act as an extension of the employer, and the claims examiner with the focus being on educating the injured worker about the post-operative limitations and what adjustments the injured worker will have to make temporarily to their daily living activities. This is an optional program that is available to PWC members.
Contact Jen Hamelin for more information about this service.
If you participate in our workers’ compensation or liability coverages, you’re required to have a claims audit completed every two years per PRISM’s Policy Statement on EWC and GL1 Member Audits and Underwriting and Claims Administration Standards and Guidelines.
In Workers’ Compensation, PRISM has contracted with 3 auditors to perform audits (ALC, AON, and NBA). For more information or assistance, feel free to contact Jen Hamelin or Suzanne Nutter at 916-850-7300.
In Liability, there are 2 contracted auditors (Ken Maiolini – RMS and Praxis Consulting). For more information or assistance, feel free to contact Heather Fregeau at 916-850-7300.
PRISM has converted to a new claims system called ClaimsXPress by Insurity. Utilizing the PRISM contract, members can use ClaimsXPress as their primary claims handling system, and in many cases, at a cost much less than what would be available otherwise. The annual fees and conversion/ implementation cost structures have been negotiated as part of PRISM’s agreement and provide significant discounts over purchasing direct. While discounts exist for any member, smaller entities with fewer than five users will be supported by PRISM staff, reducing their annual maintenance.
For more information about using ClaimsXPress, please contact Jason Watson at 916-850-7300.
Because the PRISM claims staff monitors claims of all nature and variety throughout California and frequently interact with our reinsurers’ claims professionals, we serve as an excellent resource for members and their claims administrators. PRISM claims staff are available to identify specialists (attorneys and otherwise) and complete research on laws, statutes and precedents that might affect the value and resolution of your claim. We invite you to contact our Claims Specialists for assistance with any claims-related matters.
For more information on this program, please contact Jen Hamelin at 916-850-7300.
Company Nurse is a first call, first reporting system that provides both a medical needs triage at the time of injury and a means of completing the first report documents for the member. As a result, more injuries are designated as first-aid while others are immediately directed to the appropriate level of care. PRISM has negotiated a discounted rate that is available to all the members of the PWC Program. EWC members will also receive a discounted rate if, when they negotiate their contract with Company Nurse, they notify Company Nurse that they are a member of PRISM. For more information on Company Nurse, please contact Jen Hamelin at 916-850-7300.
PRISM has partnered with PROBE Information Services to provide employer defense investigations, regulatory compliance, and fraud abatement throughout California.
Specializing in all aspects of insurance defense investigations, PROBE leverages experience in multi-line coverages and provides investigative evidence to assist claims.
Indexing is beneficial in identifying prior or subsequent injuries that may be exacerbating the problems demonstrated in the subject accident. This removes the need for members and their claims administrators to pay for each submission. If your organization is not currently using this service, please contact Ashley Bray at 916-850-7300 to enroll your entity or claims administrator.
RPM Lien Resolution is a lien negotiation service that will close out old liens that are keeping your claims open. RPM will also walk your settlement papers through the WCAB at rates significantly less than those charged by attorneys. For more information on this program, please contact Jen Hamelin at 916-850-7300.
Donn & Company (DonnCo) is a restructuring firm that optimizes the financial, and operational, performance of Worker's Compensation managed care programs (medical bill review, PPO, PBM, utilization review and case management) to ensure maximum savings at minimum cost. DonnCo doesn’t provide managed care services; rather works with clients’ existing vendors—identifying areas for improvement in their process and resources, fixing those weaknesses, and auditing ongoing performance to make sure the vendors stick to the high performance commitments they negotiate. The goal is to optimize programs in two ways: through restructuring existing programs; and, if needed or required, through a competitive bid or RFP process. For small and medium sized payers, the financial impact can be hundreds of thousands of dollars a year in reduced medical and managed care fees.
Contact: David Donn at 415-409-3666.
PRISM has developed its own Medical Provider Network (MPN) with the assistance of a contracted administrator (WellComp). The MPN was established in accordance with the SB 899 reforms that occurred in April 2004, and can provide employer control over the injured worker’s medical care through the life of the claim. The MPN is required for members of the PWC Program and available to all EWC Program members should they desire to use it. The network includes Kaiser Occupational Health, Sutter at Work, and various individual physicians nominated by the PRISM membership. PRISM’s network contains more than 4,400 physicians statewide. The Medical Provider Network can be accessed through the MPN website. If you have any suggestions for additions or changes to the network, please contact Paul Stanley or call (916) 850-7305.
ProCare is a leading privately held medical transportation & language services company, offering: fully credentialed drivers and interpreters, proprietary referral management software, with a triple confirmation guarantee. For more information on this program, please contact Jen Hamelin at 916-850-7300.
Due to the significant reporting requirements that exist and penalties that can be assessed for failing to comply with the Medicare Secondary Payer Act (MSP), PRISM has coordinated with ExamWorks to provide CMS (Center for Medicare/Medicaid Services) query and reporting services. To coordinate these services with ExamWorks at PRISM preferred pricing, please contact Sean P. Roberts. If you have any question regarding MSP compliance or ExamWorks as a vendor, please contact Karin Wedworth at 916-850-7300.
PRIUM Medical Cost Management Services is a drug review program that reduces the potential for injured workers to become addicted to narcotics and decreases the use of unnecessary or inappropriate drugs. Contact Mark Pew at 888-588-4961 ext. 201.
Returning employees to work early in the life of a claim can be one of the most effective cost-control techniques available. Results have shown that early return to work programs can reduce indemnity and medical costs for employers. They also assist the employee to emotionally heal from their injury by returning them to the environment they know. To assist with this process, PRISM has contracted with Norm Peterson and Assoc. (NPA) to provide the OUR System to our members at a discounted rate.
The OUR System effects early return to work by identifying “bridge assignments,” which focus on the employee’s abilities, not on the physical restrictions caused by an injury. If members decide to enter into their own contract with NPA for these services, they should notify NPA that they are a member of PRISM. This will allow the members to receive a discounted rate. For more information on the Return to Work Program, please contact Jen Hamelin at 916-850-7300.
Subrogation is the legal process of recovering costs for losses caused by other parties or entities. Recoverable costs can come from a variety of sources. To help PRISM members with their subrogation needs, George Hills Company and Carl Warren & Company are assisting PRISM. They know the legal process to aid in securing recovery of costs from responsible parties and can also help identify costs incurred that are prime for recovery. This service is available at preferred rates for PRISM members.
A list of common examples of potential recovery cases include (but are not limited to):
For more information on Subrogation Recovery Services, please contact Heather Fregeau at 916-850-7300.
Brokers specializing in resolving complicated workers’ compensation claims via annuities. Contact Noah Schwartz at 916-649-7585 or John Pinto at 916-955-9120.
PRISM contracts with multiple Third Party Administrators (TPAs) for claims administration for primary programs. Members can select the company which is the best fit based on service level and cost.
For Primary Workers' Compensation (PWC) members, take a look at the Comparison of Claims Administration Services!