Culture change: weaving together strands of workers' comp claims management for New York City.

Anyone who has toiled in workers' comp knows what it's like to walk into a situation expecting a well-oiled machine and finding a rusty, antiquated boiler instead. "It was stagnant," said Ruben Robles, loss control manager at the New York City Mayor's Office of Operations Central Insurance Program. "They were receiving claims, processing them and seeing what was going to happen. There was some loss control, but it was after the fact."

His first mission was to suggest changes that would enhance the operation. He had to convince senior management of his findings and provide valid reasons why these changes were necessary.

So instead of tearing his hair out, Robles set his sights on turning around the workers' comp program and educating the agencies and employees on the differences between workers' comp and simple health insurance. Robles' office insures more than 1,000 nonprofit agencies that have contracts with the city. "The plan was to change the overall program, to try to change the culture, and it slowly has changed," said Phil Kagan, account executive, client services, with ACE ESIS, the operation's TPA and insurer that Robles brought in to help make the necessary changes. Shifting the culture was, and still is, no simple task. "He's a dynamic speaker, and each year he gets the agency heads together, like a Workers' Comp 101 class, and also discusses health insurance and makes the distinction between them," said Kagan. That was one of Robles' key problems.

Before Robles' intervention, when someone got hurt, nothing happened with the claim. "A year could go by, well beyond the required 30- to 40-day period."

But after Roble's intervention, 65 percent of all claims were handled within a three- to 15-day period.

Robles faces an unusual problem.

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"The workforce needs their jobs, and they're very dedicated. This might be the only source of income for their families," he said.

Consequently, they won't file a claim for an injury and they go to work when they're still injured. But eventually the injury catches up with them and they may end up being out of work for many weeks. "We want to be there for the employee, so the earlier we get them into the claims process, the better effect we have," Robles said. One of Robles' tools has been to automate the system. "He streamlined the process by automating the reporting of an injury," said Kagan, which has not only made the reporting of claims faster and timelier, but has also cut down the use of paper by 50 percent.

His latest project is his return-to-work pilot program he's been operating with what he calls "the fantastic five"--five agencies involved with managed care. "In the past, if you were injured, you just didn't come back. It was part of the culture. With a bad back, you didn't have a RTW program," said Kagan. With the pilot program, if someone's out of work with restrictions, they try to find an agency where he can work.

With the pilot program, the injured employee, with or without limitations or assistance devices, talks one-on-one with a doctor or employer or a claims employee to try to develop a RTW assignment. "Sixty percent of cases get back to work within three months," said Robles. Now, RTW lost time claims average seven days, he said.