Managing Complex and Catastrophic Claims

At the 2018 Comp Laude Awards and Gala, a panel discussed the challenges of managing complex claims. The panel was:

• Eddy Canavan – Sedgwick
• Tamara Ulufanua-Ciraulo – Stater Brothers
• Darin Hampton – International Paper
• Susanne Walden – Scripps Health
• Dawn Watkins – LAUSD

One of the challenges in managing complex claims can be employee unions. Too often an injured worker will seek advice on their claim from the union rep which can lead to litigation and add unnecessary challenges to the claim. They have worked with their unions to encourage them to refer people with questions about their claim to the risk management department first so they have the opportunity to try and address the problem. Often times it is a minor issue and just a lack of communication so working with the union closely helps resolve problems before they start.

In healthcare, there is a shortage of skilled workers which makes return to work a priority. One of the challenges they have is that their workers are clinicians so they have very strong opinions on what treatment they should be receiving. Once again, communication with the injured worker is extremely important so they can understand the requirements of the workers’ compensation system.

A manufacturing employer added an employee advocate position to assist the injured worker in navigating the workers’ compensation system and helping them take advantage of other benefits that may be available to them such as their Employee Assistance Program (EAP).

In the retail environment they try to focus on loss prevention training and work closely with their locations to train associates to prevent accidents from happening in the first place. There is no substitute for on-site interaction with your workforce. When claims happen, they have dedicated nurse case managers and field case nurses to assist the employees so that the best clinical outcome can be achieved and litigation can be avoided.

Return to work is one of the biggest challenges for any employer. It’s important know the essential duties of each job and how that job can be modified temporarily as needed. Employers also need to plan ahead for modified duty positions if the injured workers’ primary job cannot be modified. In a heavy manufacturing environment they have a lot of long-term employees which can make return to work a huge challenge.

Some times it’s important to look at what you can do to assist the injured worker in their recovery instead of just what you are required to do. An example was an employer that had a seriously burned employee. The worker lived in a rural location and did not have good access to fresh water which was needed for his home care. They paid for a new pump on his well because they knew this would help to facilitate his recovery. This step of going beyond what is required was noticed by their workforce and garnered a lot of good will.

One challenge is identifying complex claims timely. It’s easy to identify a catastrophic injury case, but much harder to find the claim that start out fairly routine then develop into something much more complex. Excessive prescription medications are a red flag for a claim taking a turn for the worst.

It’s important to have a good working relationship with your TPA. You want to be the account that examiners enjoy working with, not the one that they dread. Set expectations on how your claims will be handled and follow up to ensure things are being done as needed. One employer requires adjusters to have a five-day action plan on how to proceed with any lost time claims.

Silos between risk management and HR can create challenges on workers’ compensation claims. If you have someone with a workers’ compensation claim that also has an employment practice claim or a performance issue, the chances are that will be a very challenging situation. Breaking down those silos is also extremely important from a return to work standpoint to ensure compliance with ADA, FMLA and other leave of absence policies.