60 Tips for Superior Claims Handling

This rapid-fire panel on the final day of the National Workers’ Compensation & Disability Conference offered 60 usable tips to help improve workers’ compensation claims handling.

Panelists included:

Stuart D. Colburn, Esq. Downs Standford P.C.
Todd DeStefano, President, Risk Managment Practices,York Risk Services Group
Jodie Massingill, Senior Manager, Casualty Claims, Sysco Corp.
Robert G. Rassp, Esq., Law Office of Robert G. Rassp
Ann Schnure, VP, Risk Management, Macy’s Inc.
Patrick J. Walsh, VP and Chief Claims Officer, Accident Fund Holdings Inc.
Moderator: Matthew B. Schiff, Partner, Sugar Felsenthal Grais & Hammer LLP

60 Tips for Superior Claims Handling:

1. High job satisfaction is important for adjusters. The outcome will be better claims handling.

2. Managed care is part of claims management.

3. Call the claims bluff and authorize treatment. Sometimes this is the only way to keep the claim moving forward.

4. Hire for attitude and train for skill. When it comes to claims, no one’s going to college for it. Find good people and train them about the insurance industry.

5. Review your contracts with all of your vendors. This is a rapidly-changing industry with new vendors and new offerings that you should know about. Also, this is the only way to know why you are staying with your existing vendors.

6. Claims examiners should pre-authorize treatment and not use utilization review.

7. Continued education matters for adjusters. Make the investment to train them and you’ll have better adjusters.

8. Use integrated/aggregated services. Do not unbundle.

9. Consider reverse annuities to fund claims and death benefits.

10. Put yourself in the shoes of the front line employee. Learn and listen from them. You will make better decisions by knowing what they go through.

11. Predictive analytics do not have to be expensive or complicated. Take data and use it to determine possible outcomes, then marry the use of the data with experienced adjusters.

12. Claims examiners should interact with the employer to promote return-to-work strategies.

13. Mix seasoned adjusters with newbies. They have an institutionalized knowlege and know how to get things done. Recognize that your seasoned adjusters are assets and use them to train new adjusters.

14. Predictive analytics – the key is execution. Use them in your pre-loss strategy.

15. Have MSA evaluations done well before the settlement. Start working to package them together well before you have to submit them.

16. Work with the A’s – Accountants, Actuaries, Attorneys, Auditors. They are the key to your success.

17. Evidence-based medicine provides better outcomes.

18. Claims examiners that have limited case loads will produce better results.

19. Medical-only claims are sometimes your worst. The medical only ajuster is handling very sophisticated files and we should change the way we train them.

20. Injuries must be reported immediately and it is important to establish a process to do so.

21. Do a social media deep dive for surveillance. Surveillance is so expensive, but now there are so many sites that people think you aren’t looking at. It can help increase your chance of success exponentially.

22. Sometimes tell yourself to shut up. Everyone involved in a claim is bringing different perspectives and it is important to pay attention.

23. Pharmacy is the benchmark to make sure your program is actually working. Implement a strategy to determine what’s being spent and how to control it. It’s worth that time and effort.

24. Claims should be round-tabled by the claims professional and the employer. Do this separately than the round table meeting you have with attorneys.

25. Understand the big picture in every case, which is that we want to get the injured worker back to work. If you make it personal, you start making mistakes.

26. Report claims promptly to the TPA or carrier. This can be very impactful to the cost of your claims.

27. Use outside modified duty vendors. Keeping workers engaged. Check with your adjuster to see if it is allowed in your jurisdiction.

28. Learn to communicate. People will create their own reality if they do not have the information and, when they do, it’s often negative.

29. Internet searches are tremendously helpful. One way to utilize is to determine psychosocial elements that could impact the claim, like financial stress.

30. Don’t fire an injured worker while he is receiving temporary total disabililty benefits. If you use workers’ comp as the reason to fire a marginal employee, there are legal consequences.

31. A workers’ compensation adjuster is not a paper pusher. Work comp claims are more difficult than general liability claims. If you think of them as a paper pusher, that’s the output you’ll receive.

32. Reach out to injured employees. Communication is key. People are scared and need to see the employer cares.

33. Are your occupational clinics working for you? They help set the tone of the claims. Have regular meetings, set up account instructions and communicate.

34. Create optimism. It is a force multiplier. Workers’ comp is emotionally draining and you need your people to want to be there.

35. Measure provider performance on outcomes. Not just bottom-dollar outcomes, but find out if your injured workers are happy with the performance as well.

36. Don’t be rude to your injured workers. That’s when lawyers get involved. Speak with respect and dignity.

37. Win the war mentality. Get what you want accomplished at the end of the day. Don’t worry about battling every battle. Concentrate on what you want to accomplish and take the steps to do that.

38. Have an established return-to-work program. There are stats that show an injured worker out for six months has 50% chance of returning to work, however, at 12 month, the likelihood of them returning to work is less than 5%.

39. Is the occupational physician getting a complete medical history? You want the best treatment possible.

40. Use facts, no matter how emotional others can get around you. Be calm and rational and you will get better outcomes.

41. Nurse case management – take it beyond observion and documentation. Adjusters can do that. You hire the nurse for the clinical experience. Use the nurse for the areas that they can impact.

42. Send temporary total disability checks on time. Injured workers have bills to pay.

43. Admit your initial decision was incorrect. The decision can create the mindset. If you can change the wrong decision early in the process, you could have better outcomes.

44. Invite your designated physician to view your operation. This helps create smart light duty job development.

45. Send a get well card letting the worker know that they are missed. Communicate and treat the whole person, not just the claimant.

46. Make decisions and make them with conviction. A closed claim is a happy claim.

47. Identify claims that will turn into long-term pain management. There are things in the claims that will point this out and help prevent them.

48. Give the injured worker you e-mail address. Answering their questions quickly helps.

49. You get more with honey than vinegar. This is a great technique for getting information (and a great way to avoid paying legal fees).

50. Return-to-work jobs at non-profits are a great way to boost morale amd gives the injured employee an alternative if they can’t get to work at your location.

51. It is the job that is modified, not the employment policies. Making exceptions to policies and procedures can cause chaos.

52. Learn to write a decent letter. Communication is key.

53. Partner with your defense attorney. Lots of them have a ton of experience and can help with great claims outcomes.

54. Cookbook medicine can be a superior treatment alternative to evidence-based medicine.

55. Pennyside: pound foolish. Change the culture in what you do and you’ll get better results.

56. Create an attorney-approved drug testing program for post-accident drug testing.

57. Update your account service instructions. They are where the employer can tell the adjuster what is important to your company and your business.

58. Embrace the worst experiences you have. Take the negative, analyze what happened and figure out how to make the situation better in the future.

59. Make a solid return-to-work program that syncs with FMLA.

60. Return the injured worker’s phone calls. The worst things happen when you aren’t communicating information to them.