Case Study: Claims Analysis Proves Crucial for Integration Between Disability and Medical Coverage

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Claims Analysis Proves Crucial for Integration Between Disability and Medical Coverage

By Allen Woolf, M.D., Chief Medical Officer for CIGNA Claims Insurance.


Early in the history of benefits integration, multi-line carriers approached the market with comprehensive offerings integrating the sequence of non-occupational disability, and/or workers’ compensation solutions, and in some cases medical programs. However, this approach fared poorly in the market for a variety of reasons and most employers continued working with multiple, single-line vendors. Employers may question that assumption after examining the cost data from this analysis of a major multi-line carrier’s claims base. In addition, we think you’ll find the FMLA data very interesting

Employers are always looking for ways to offer their employees competitive benefit packages, while at the same time controlling costs. However, the way employers are thinking about how they build their employee benefits programs is starting to change as they examine the impact of total costs and employee productivity on their bottom lines.

In order to meet their employees’ benefit needs, it’s common for employers to work with several different organizations with expertise in a distinct area of benefits. Another approach—designing a seamless offering of disability, medical and behavioral benefits through an integrated medical and disability provider—could prove effective in several ways. For example, this approach allows for the integration of employees’ clinical needs and management of their experience through holistic data analysis and identification for appropriate treatment and educational programs.

CIGNA recently conducted research examining the effect of integrated programs on disability and medical costs. The analysis compared outcomes for employees with active coordination of care management programs for disability, health care and behavioral health, vs. employees in non-integrated programs.

In the cases where the programs were integrated, coordination began prior to the filing of a disability claim and continued until the employee had returned to work. In other words, employees with preexisting medical conditions that are likely to lead to a disability are contacted before a disability claim occurs, to remind them about their disability coverage. This facilitates early disability claim reporting and enables eff ective coordinated case management from the very beginning of the process.

The analysis demonstrated that employees covered by an integrated clinical program have at least a 5 percent—and up to 37 percent—greater likelihood of returning to work by the end of the short-term disability (STD) benefit period as a result of integrated clinical activities when compared to their counterparts in non-integrated, disability-only plans. This is not the same thing as direct cost savings, however, this figure could represent substantial savings, since substantial costs occur when an employee crosses the threshold from STD to long-term disability.

The 37 percent rate improvement was found when comparing the integrated vs. non-integrated samples (40 accounts with 300,000 employees) most of which are larger accounts.

The 5 percent improvement was found when comparing the integrated vs. non-integrated data for the carrier’s entire book of disability business (approximately 5,700 policies with 4 million covered employees), a very large database with a greater variation in account size.

For employers, and large employers especially, this should translate into lower overall benefit costs and improved employee productivity. Most importantly, for individuals, it means a better health outcome and the opportunity to return to work.

Early Intervention

An important feature of integrated programs is the ability to identify early those employees whose condition and/or treatment is likely to result in an STD claim. For example, individuals who request pre-certification, are hospitalized, are pregnant or have certain diagnoses and require referrals for specialist are reminded by healthcare case managers of their potential eligibility for disability coverage and encouraged to notify us early. This allows the disability case managers to begin working sooner with the employees, their employers and physicians, to facilitate a timely and safe return to work.

Once an STD claim is filed, the employee is then offered the opportunity to speak with an employee assistance program (EAP) professional, either through a direct “warm transfer” by phone or by providing a toll-free number to call 24 hours a day. Throughout the life cycle of the claim, claim managers and nurses continue to assess the individual’s situation and refer to EAP as indicated.

A disability can be a very stressful event, which could potentially create issues related to child care, elder care or raise financial concerns. Trained EAP professionals are available to help employees through this difficult time. In addition, a work-life program available through EAP can assist with these issues and others. For example, counseling is available to help employees deal with problematic relationships at work, or the stress surrounding return to work.

The disability management process also includes automatic referrals to disease management and health advisor programs for employees with chronic and lifestyle-related conditions. The disability event can often represent a “teachable moment” for the individual and the disabled employee may be more open to making changes to improve his or her health. This presents a great opportunity to engage someone in a program for the first time or increase the level of intervention for those who may already be participating.

Utilization of disease management programs varies among employers. This carrier’s analysis showed that 70 percent of the referrals made to disease management programs by disability case managers were subsequently accepted into the program.

Clinical Expertise

A critical aspect of effective integration is utilizing the clinical expertise across all types of benefits (medical, behavioral, disability) to serve employees to the fullest.

Employees can authorize disability nurse case managers to access the employee’s medical, pharmacy, behavioral health and disease management clinical profiles related to his or her care. This expanded clinical picture enables the provider to more holistically assess employees’ needs and facilitate more effective integration and co-management with our medical and behavioral health experts. It can also prevent the need to relay the same information to multiple people. Clinical resources working together improve the experience and promote more eff ective treatment and outcomes.

Strong integrated programs should provide access to vocational rehabilitation counselors (VRCs) who are experts in facilitating return to work. Through close and early interaction with disabled employees, their employers and physicians, VRCs are able to provide the insight needed to determine the most appropriate resources to help them return to work. Sometimes this involves modification of job duties or to the work environment that enable employees to perform their job, despite limitations they may have. When on-site resources are needed to facilitate return to work, an extensive field-based nursing and vocational resources provider that specializes in disability case management is available, to meet that need.

Implementing successful return-to-work programs for employees reduces costs. Most importantly, these programs restore employees to a productive work and family life, enabling a faster recovery and an improved self image.

An Ongoing Challenge

Today’s employers are faced with increasing health care costs and continued pressure on their bottom lines. The aging workforce, increasing rates of health risks, especially obesity and the increasing prevalence of chronic diseases, will continue to drive these costs. Employers must act to address these trends in order to remain competitive by engaging consumers in managing their own health, wellness and productivity.

An integrated offering provides a comprehensive suite of tools such as health risk assessments, personal health coaches, disease management experts and EAP counselors, to help employees identify their internal motivation to change health behavior and guide them through that process. In addition, this carrier continues to enhance and expand its capabilities to provide employers with a single-source solution for absence management.


A multi-line carrier can offer employers the opportunity to provide employees with a comprehensive benefits package that includes disability, medical and behavioral benefits. As a result, employers can better leverage their employee benefit dollars and realize a stronger return on investment, including having a healthier and more productive workforce.

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