Lessons from the Philippines

Having all the right information at the right time makes all the difference in the world. To make that vision a reality for maritime medical claims, we need to understand what’s actually happening in our world.

That was my mission on a recent trip to the Philippines. While in Manila, I met many talented and dedicated manning agents, doctors, claims managers, and correspondents. Each person I encountered plays a valuable role in managing illness and injury claims for crew members repatriated to the Philippines. I gained a great deal of valuable insight through our conversations. For instance, I now have a better understanding of issues related to post-repatriation claims concerning injuries and accidents that happen abroad, and a more thorough understanding of the pre-employment medication examination (PEME) process and clinics in the Philippines.

As far as the claims issues, one key takeaway I found is that claims professionals are looking for clear, sufficient, accurate information by which to fairly adjudicate claims. Currently, the information they receive ranges from non-existent to vague or unclear.

• Vacuum of Information: Almost all claims handlers expressed concern over the poor information they receive from doctors in the United States and around the world. In some cases, no documentation is received whatsoever, especially for crew members treated in the United States. To compound matters, claims handlers said subsequent requests for documentation are often ignored, and privacy laws in many countries present a barrier to accessing medical records.
• Inadequate Documentation: Another common concern is that when medical records are available, the documentation is often inadequate. Some records are illegible or incomplete, and others contain little information that can be used to accurately adjudicate a claim. In addition, vessels’ medical forms are often missing, and when included, they are also incomplete or illegible. Furthermore, language barriers can add an extra level of complication in understanding records, reports, and forms.
• Poor History: Missing medical history information presents yet another challenge for claims handlers. Even in the presence of legible medical notes, insufficient information is often provided concerning the history of the illness, patient’s medical history, the prescriptions the patient was on pre-examination, and so forth. Most claims handlers I spoke with cited this as a primary concern. Without an accurate medical history, they cannot determine preexisting conditions.
• Unclear Documentation: Universally, claims handlers said medical providers rarely sufficiently indicated if an illness or injury is a work-related illness or injury. Most claims professionals agree that this is a critical piece of information. Without this documentation, claims determination and adjudication are far more difficult than necessary. This issue may be rooted in perspective. From a medical provider’s perspective, at least in the United States, claims issues are not the concern. Instead, the medical issue is the main concern, and the documentation addresses patient wellness and serves to avoid medical legal liability. Claims handlers view the situation from an entirely different perspective.

While the claims complications can occasionally be individually identified, in many cases all factors are present to some degree. Understandably, this makes adjudicating claims excessively difficult. It doesn’t have to be this way. We can take steps to help claims handlers obtain the information they need from the outset.

The first step to creating a better process is awareness. Certainly, most medical providers have never been asked to provide documentation in a different way up front. Instead, medical providers respond to queries for clarification, questions about workplace illnesses and injuries, medical history, and more- information they often provide after the fact. Theoretically, medical providers could document these data points up front if they are aware of the need for the information. For people who provide and coordinate maritime care, we need to ensure that this awareness exists and create a process that meets the unique needs of claims handlers.

The challenge is making hundreds of individual providers aware of this need across the United States (and possibly thousands of providers around the world). This daunting thought is one reason many ship owners have Fit for Duty forms that attempt to answer medical questions of history, occupational cause or relation of injuries and illnesses, and so forth. But as noted earlier, these forms are rarely completed accurately, if at all.

While tackling awareness and response on a global basis will be a work-in-progress for many years, SphereMD has the awareness and capabilities to begin to collect this type of information with all our medical cases. In doing so, we will be able to provide complete, accurate, and clear information for a few thousand medical cases per year. While this is a relatively small number of cases compared to the tens of thousands of maritime illness and injury claims that occur every year, we feel this will make a difference.

After considering these issues, I have a final thought and a question. In managing maritime claims from a medical perspective, I firmly believe that claims and medical care can be managed with a greater deal of control and precision. I believe this because in the United States, insurance companies have been achieving this for decades. Better control is possible, and I wonder, would you, as a claims professional, doctor, correspondent, or P&I Club stakeholder, be interested in collaborating on a project with SphereMD to collect an idealized set of data to help claims managers effectively, fairly, and efficiently adjudicate medical claims? If so, we would love to collaborate with you. In a future article, I will share some of the perspectives I gathered concerning PEMEs performed in the Philippines.

If you are interested in collaboration, please contact David Shubin at shubin@spheremd.com.