From pre-placement physicals, to safety and wellness plans, to employee and management education, strategies for realistic claims management can allow for favorable resolution and even immunity from litigation. In this session at the 2020 CLM Workers’ Compensation and Retail, Restaurant & Hospitality Conference, panelists discussed how employers can survive and thrive in the workers’ compensation claims management arena.
- Michele Punturi, Attorney at Marshall Dennehey Warner Coleman & Goggin
- Robin Jones, SVP Risk Management at Sedgwick
- David Shoaff, Claims Manager at Red Lobster
- Michelle Leighton, Vice President-Senior Claim Consultant at Connor Strong
One of the primary goals of the workers’ compensation claim and litigation process is controlling exposures. This goal permeates all aspects of the process, even before the accident takes place. Safety policies and procedures, along with employee education and training, are imperative for a proactive approach to claims handling.
Establishing a Positive Culture and Safe Environment
Integrating safety into the workplace culture is an important step toward managing exposure. Building executive support is crucial, but must be followed by strong communication between Human Resources, employees, supervisors and managers. Providing written safety policies is not enough. The employer should offer continuing education so that all employees and managers understand what is expected of them.
Maintaining and Documenting Personnel Files
An employee’s background and employment history can be valuable resources during litigation. It is important that personnel files are complete and accurate, including identifying information, addresses, prior workers’ compensation claims, disciplinary records and pre-employment physical or drug screening results. These files should also include job descriptions and information about benefits provided by the employer, including salary, bonuses and vacation time.
Directing and Controlling Medical and Strategic Medical Claims Management
Managing and controlling medical costs begins before the claim even occurs, starting with the Human Resources Department. It is important to look at the whole person and recognize that many factors can affect an employee’s ability to recover from injury and return to work. Employers can utilize wellness programs, fitness exams and biometric screenings to focus on key areas like obesity and mental health. A collaborative approach that interweaves wellness programs and safety initiatives can be extremely effective.
After a claim occurs, an understanding of applicable state laws and regulations concerning medical treatment is imperative. Some states allow directed medical treatment and some do not. In either case, it is important to maximize the resources of your medical network, including third-party adminstrators, insurance companies and medical providers. Developing relationships with providers who will be treating injured workers can help to focus that care on returning to work. When developing a network, a triage program where injured workers speak with a nurse case manager can help cut down on ER visits, provide direction and suggestion to providers and ensure that the entire team understands the course of treatment and observes proper protocols.
Techniques & Procedures to Minimize Claim Costs
In a post-injury investigation, utilizing best practices for prompt investigation is crucial. Post-accident reports and documentation, with statements from employees, are an important element of any investigation and should, ideally, be completed within 24 hours.
Claim review meetings are key to managing ongoing claims. If they are to be productive, they must be well organized and establish guidelines early on. The team should include the attorney, client, TPA, provider, nurse case manager and safety professional. This multi-disciplinary organization allows you to see how the claim is progressing, manage the individual claim and evaluate the overall claims management program.
Posturing the Claim for Settlement
Settlement should not be viewed as “backing down” or a failure. It can actually be a win-win for both parties. When moving toward settlement, it is important to determine proper timing and outline the strengths and weaknesses of the claim. A strategy should be developed to place the claim in the best position possible. There are 10 factors that could affect settlement value and should be taken into consideration:
- Income and compensation rate
- Type of injury
- Severity of injury and impact on work
- Current and future medical treatment
- Claim status
- Claimant’s attorney
- Injury leading to other medical problems
- Presiding workers’ compensation judge
- Fact witness and expert witness credibility
- Company philosophy