At the 2017 Comp Laude educational event a panel discussed how to evolve your claims model to be more focused on being an advocate for injured workers. The panel included:
- Rachel Fikes – Rising Medical Solutions (moderator)
- Denise Algire – Albertson’s Company
- Darrell Brown – Sedgwick
- John Riggs – Disneyland Resorts
Advocacy means taking a holistic approach to claims management. It means striving to achieve the best possible outcome for the injured worker. You need to have an understanding that for the injured worker, the workplace injury is a traumatic and possibly life changing event. The foundation to it is communication.
According the the 2016 Rising Medical Solutions Workers’ Compensation Benchmarking Study, approximately one-third of claims payer indicate they have already implemented an advocacy based claims model. In the same study they asked if people really understood exactly what an advocacy based model means.
For an employer, an advocacy based focus starts with loss prevention and safety. There needs to be a culture of safety that permeates the organization from the top down. Having a strong return to work program is also part of an advocacy culture. Employers are focused on customer service for their clients. If you expect your employees to deliver good customer service to your clients, you should also provide them with good customer service if they have a workers’ compensation claim. That culture of customer service needs to be part of the organization.
There is no question that litigation on a claim leads to increased costs and often times leads to a worse medical outcome for the injured worker. Because of that, it is important to do all you can to avoid litigation. Litigation usually starts because the injured worker has fear. Fear of the unknown. Fear for the job. Fear about their injury. It’s important for the payer to understand that fear is present and the impact this can have on a claim. Take the time to explain things to injured workers. Treat them with respect.
In order for this model to work, you need to get buy in from your claims handling team. They need to understand the goals of the approach and how it benefits both them and the injured workers. For a TPA/carrier, this approach can lead to better performance which can be a selling point for your company. Adopting this approach does not mean you are not investigating a claim. It does not mean you are not reviewing medical care to make sure it is appropriate. It means rather than constantly trying to find a reason to deny claims you look for reasons to pay them. Claims disputes are often not successful because payers are too focused on the reasons to dispute so they miss the reasons to pay. It is important to pick your battles.
The advocacy approach also can impact talent attraction and retention. Employees feel more engaged with the injured worker and they feel they are delivering a service to the injured worker.
What does advocacy look like?
- Revamped communication with injured worker.
- Emphasisizing workers’ compensation as a benefit delivery system.
- Focused on claims adjuster training for empathy skills.
- Some employers have a dedicated injured worker advocate in addition to the claims examiner role.
- Executive level buy in pushed down.
Key metrics to measure success of advocacy program:
- Claim duration
- Claims costs
- Injured worker satisfaction
- Litigation rates
- Claims talent employee retention
- Days to reach decisions vs. statutory requirements