How to Win at Work Comp Claims

So many people want to blame the injured worker for the high cost of workers’ compensation; they say the worker doesn't want to get better. But consider these two patients, limping into two different medical clinics with the same complaint. Both have trouble walking and appear to require hip surgery. The first patient is examined within the hour, is X-rayed the same day and has a time booked for surgery the following week. The second sees the physician after waiting three weeks for an appointment, then waits eight weeks to see a specialist, then gets an X-ray, which isn't reviewed for another week, and finally has surgery scheduled for six months later, pending the review of a utilization board, which will determine the employee's remaining value to his employer. Why the different treatment for the two patients? The first is a Golden Retriever taken to a veterinarian. The second is an injured employee entering the workers’ compensation system. Maybe we need to send our injured employees to a good vet! The No. 1 cost driver of a workers’ compensation claim is that the injured worker is not getting better. But the sad reality is that the injured worker isn’t even given an honest opportunity. Everyone just wants to kick the can down the work comp road, believing the best way to save money is by limiting treatment opportunities. Look at back pain, which is the most expensive industrial injury and the most common cause of disability in patients under 45 years of age. More than five million Americans are disabled by back pain, and more than half of those will develop a permanent condition. Studies show that direct healthcare expenditures exceed $20 billion annually, and indirect expenditures associated with back-related injuries are greater than $30 billion. Disorders of the musculoskeletal system are the most common causes of absence from work in both men and women between the ages of 30 and 65. Back pain is the dominating subgroup and is the second leading cause of workplace absenteeism. See Also: How Should Workers' Compensation Evolve? There are plenty of statistics showing the direct costs associated with occupational back injuries average $37,000. Indirect costs range from $147,000 to $300,000. It therefore follows that if an employer could redirect its resources and attention to the aggressive treatment of the acute back pain patient, with a view to preventing chronicity, the company would be able to reduce costs. In fact, we have a proven system that has direct and indirect cost savings; however, it requires the employer to take control of its workers’ comp group and change the way business is being done. Unfortunately, only a small minority of employers play at the tip of the spear and way too many employers who sit on the sideline and expect everyone else to take care of the issues. So, we are challenging you, the employer, to get in the game, change your team line-up and win the game of managing your workers’ compensation division. Here’s how: Once the injured employee enters the world of workers’ compensation as either a medical, indemnity or future medical claim, the healthcare professional becomes one of the key decision makers in the employee’s recovery and return-to-work. Usually, the professional helps the injured worker recover through minimum symptomatic treatment protocols authorized by utilization review boards and return to her job in a modified duty capacity with appropriate restrictions. The employee comes back to work, with restrictions, and in most cases the safety supervisor or human resources person assists in monitoring the employee to verify that the healthcare professional’s recommendations are being reasonably accommodated. In a perfect world, this scenario may work. The employee recovers, the medical bills are paid and the work tasks are re-evaluated. However, in most cases, once the employee is injured, delayed treatment ensues, the injured worker develops co-morbidities associated with his injury, an applicant’s attorney gets involved and the reserves then begin escalating. At this point, any optimal solution becomes a distant thought. The only player who has the incentive to change the game is the one paying the bills… the employer!! How can an employer change the workers’ compensation cycle to bring about solutions for all the players involved? It takes moral courage to change your team line-up and manage your claims better. Can it be done? Absolutely, and we’ve done it. Employers have historically taken an adversarial approach to workers’ compensation claims even though the law is on the employee’s side. It makes sense to immediately engage the injured employee and set the expectations for recovery. This is part of the overall strategy to create a claims handling “team” that will align with the core competencies of the business environment. Setting the team line-up to implement an active approach to claims management will be a game changer. As an employer, here’s an outline of what this would look like:

1. Identify your team members; business unit manager, risk manager, safety professional, claims examiner manager, claims examiner, medical director, healthcare providers, nurse case manager, legal counsel and medical fitness consultant.
2. Have a prominent seat at the workers’ compensation round table, whether you are fully insured or a self-insured employer.
3. Know the workers’ compensation claim life cycle and your role in influencing outcomes.
4. Be sure the claim examiners on your files know and understand the employer’s risk management goals and objectives.
5. Have essential job functions (EJFs) for all positions readily accessible for the healthcare professionals and claims examiner.
6. Perform quarterly claim review meetings on all open and recently closed claims. The meetings should include your entire workers’ comp team, so discussions can progress around treating the whole person and not just the affected body part. Remember, at some point a body part adds to the potentially new claim of cumulative trauma.
7. As the employer, limit the claim examiner case load to 100 claims or less per examiner. This allows for more in-depth understanding of claim resolution solutions in addition to claims handling by regulatory deadlines.
8. Make sure your insurance broker supports your desire to incorporate a medical aftercare program managed by a medical fitness organization that understands the workers’ compensation process and your strategic claims management system.

Savvy Health Solutions has worked strategically with employers as part of their claims management team and addresses the whole person by focusing on improving overall strength and flexibility, postural responsiveness to activities of daily living and a motivational element that embeds the components of the program into sustainable lifestyle changes. Savvy has found that, the sooner an employee begins the program, the quicker the employee is returned to full duties, and the claim is closed:

1. The safety person, now having a more comprehensive understanding of musculoskeletal issues, can revisit the company’s job hazard analysis for accuracy and completeness. This technique breaks each job down into individual tasks to identify hazards and focuses on the worker, the task, the tools and the work environment. The analysis is also a key component for compliance with OSHA’s injury and illness prevention program requirements.
2. The claims examiner is educated on the work environment. With fewer claims to handle, the examiner can spend extra time on the job to better understand the work environment from an employee’s perspective. Essential job functions and job hazard analysis have more meaning once seen in action. Claims examiners will begin to understand how people do the work, in addition to meeting the expectations of the Department of Workers’ Compensation in managing a claim.
3. A team approach helps the claims examiner to think more like a business person. Outside consultants, like Savvy Health Solutions, help the employer see a new way of claims resolution and prevention of further injuries.
4. The effectiveness of the workers’ compensation team can be measured with metrics created as part of your annual insurance renewal process/contract or as part of your third party administrator contract renewal.

Too many internal silos and “leaving it to the claims experts” can run against a culture of treating employees with respect and dignity when injured. The employer needs to be the key stakeholder in the process, having the same key performance indicators (KPIs) for workers’ compensation as it is done for safety metrics and profitability. This methodology is counterintuitive to the typical workers’ compensation claims handling structure. Success starts with the employer and involves every single team member, business unit manager, risk manager, safety professional, claims examiner manager, claims examiner, medical director, healthcare providers, nurse case manager, legal counsel, insurance agents and brokers and medical fitness consultants. Developing a winning line-up with your team will improve your ability to control costs and reach a desired outcome for the employee first, and then the organization. Because when the injured employee recovers from his injury, restores normal function and improves quality of life, then everyone wins.