How Advocacy Impacts Claims Management
At the 2017 PRIMA Annual Conference a panel discussed how an advocacy approach can impact your claim managment program. The panel was:
- Dawn Watkins – Director Integrated Disability Management, Los Angeles Unified School District
- Kevin Confetti – Deputy Chief Risk Officer, University of California
- Teresa Bartlett – SVP Medical Quality, Sedgwick
An advocacy based claims program can be especially important to public entity employers due to the fact that they work in a highly political environment and they are managing taxpayer funds. Claim disputes can easily end up with negative press coverage because things that happens with public entity employers are often scrutinized.
The keys to advocacy are:
- Open communication – Explain things thoroughly and try to avoid overly technical terms.
- Transparency – Be honest on time frames, requirements, benefits, etc.
- Setting clear expectations – This is a two-way street. It is important that you follow through on what you say.
- Being objective – Try to avoid bias and remember that most injured workers are not familiar with the system.
- Awareness of needs – Make sure you are providing information to the worker, physician, employer, etc as needed.
Adopting an advocacy philosophy:
- Remember the human element.
- Be a guide, not a gatekeeper.
- Care first, then respond.
- Work is an important part of the recovery process.
- Get to win sooner.
- Lead with care.
Litigation is a big cost driver on claims and an advocacy approach can help to decrease this. The big reasons claims litigate are:
- Denied claim.
- Contact from employer or claims examiner that was rude.
- Late payments or medical bills denied.
- Utilization review process confusing and cumbersome.
- Plaintiff attorney outreach.
- Friends, co-workers, etc encourage litigation.
- Dissatisfaction with employer.
- Injury was preventable but safety measures not in place despite requests.
- Hostility from coworkers or lack of modified duty.
How LAUSD uses an advocacy approach:
LAUSD is the second largest school district in the nation with over 60,000 employees in a wide variety of occupations and labor unions. They have 4,300 new claims per year and are self insured for their claims using a TPA for claims administration.
The LA basin where they are located has the highest workers’ compensation litigation rates in the nation and for them litigation is the norm. Unions will actively tell injured workers’ to contact attorneys. To try and counter this they developed a customer service component to their program. Their customer service representatives work with injured employees to try and facilitate the claims process and decrease litigation. Their customer service program focuses on the following:
- Show understanding.
- Use proper tone.
- Set expectations.
- Make timely decisions.
- Facilitate faster payments.
- Communicate effectively
- Employ discretionary effort.
- Do the right thing.
- Coordinate resources.
- Leverage technology.
They conduct satisfaction surveys with their injured employees and consistently have scores over 90% in this area.
Communication with workers is the key. They focus on the following when it comes to communication:
- The first conversation with the worker sets the tone. They talk about return to work, and the fact that they will make sure they see the best physicians to have the best possible recovery.
- Listen more than you talk.
- Explain forms and letters.
- Provide contact information and encourage them to call with questions.
- Avoid using industry jargon (TTD, PPD, etc). Talk in terms of payment for lost wages, etc.
- Make sure they know someone is there to help them heal.
- Follow through on your promises.
- They send out get well cards to all injured workers. This card includes contact information if they have any questions.
- If the employee is off more than 5 weeks a second get well card goes out that talks about the availability of reasonable accommodations.
How the University of California uses an Advocacy Approach
The University system has 10 campuses, five medical centers, and one national lab. They have over 200,000 faculty and staff in a wide variety of occupations and multiple unions. They have over 5,000 new claims per year. They are self-insured and use a TPA to administer their claims. They have employees in every zip code in California, in all 50 states, and in many different countries.
The focus of their advocacy approach is to try and reduce claims litigation. The goal is to provide benefits to injured workers as quickly and effectively as possible. They want to avoid disputes whenever possible. They have three main focus areas:
- Catastrophic case management – When they have a serious injury claim they use Paradigm to manage the claim and have had great results with this. They have only had litigation on one claim where Paradigm was involved.
- WorkStrong – They have lots of long-term employees and because of that they have lots of people with repeat claims. Their most is an employee with 44 claims over 20 years. As part of their chargeback program to departments for claims they include a “tax” to collect funds that are used for loss control/loss prevention efforts. With these efforts they dropped claims from 7,000 to 5,000/year. In addition, the “WorkStrong” program was developed and designed to improve the overall wellness of university employees which will hopefully decrease future injuries. This program is only offered to people who have had a workers’ compensation injury. The program provides these employees with access to university fitness centers, fitness coaches, dietitians, and other experts. The program costs $3,000 per employee and is paid off the claim file. They use this for anyone who has had two injuries in 24 months or someone that has significant co-morbid conditions that could lead to future injuries. They have had 11,000 employees utilize the WorkStrong program. Their results show not only a decrease in repeat claims, but lower claims costs on existing claims.
- UC “Care” cards – They send out get well cards to all employees that provides them with contact information. It is something less formal than the state-mandated forms and it stresses “we are here to help”. They not only send out care cards for occupation injuries but for any disability and they have customized cards for different circumstances.