The Claims Advocacy Approach to Workers’ Compensation

 

 

The claims advocacy model for handling workers’ compensation claims has been a growing trend the past few years.

 

 

  

What is Claims Advocacy?

Claims advocacy sets itself apart from more traditional compliance-oriented claims handling systems. It aims to create a claims culture where the focus is on nurturing trust between employees and management, where access to benefits is simple, and the structure is supported with executive-buy in, organizational values and efficient systems. 

Specifically, claims are easy to file, there is ease of access to medical specialists and medications, and there is always help navigating the healthcare maze.  Trust is key.

Inherent Conflict

A fundamental characteristic of the claims advocacy approach is the shift away from focusing on medical costs and time off the job. There is an obvious inherent conflict here that can stand in the way of transitioning from adversary to advocate. According to its supporters, though, forward-looking employers need to make a paradigm shift in how they think about workers’ compensation. By taking this approach to claims handling, they say, workers’ comp costs are actually reduced in the long run simply by not worrying about cost-benefit analysis but rather focusing on the dignity of the individual claimant. 

Here are three reasons why this approach is gaining in popularity:

1. Putting the injured worker’s needs first builds trust and confidence in the process

   Every outreach should reassure injured workers that their claims and clinical teams are working in their best interests. “After all, along with recovering from the injury, an employee must also work through the complex workers’ compensation (WC) claims process — often for the very first time,” says Wesley Hyatt, senior vice president, workers’ compensation claims for Liberty Mutual Insurance Company.

   One aspect of this approach involves changing the claims processing language to eliminate jargon and replace negative wording with positive terms. For example, “covered” is now substituted for “compensable,” and “claims examiner” is replaced by “claims representative.”

   Another way of easing an injured worker’s mind about the claims process is to provide information, preferably in video format, at the outset of the claim that outlines the claims process and explains the tools available to them. 

   “The idea is to expand on the human connection between adjuster and worker, alleviating an employee’s stress and fears of the unknown,” Hyatt says. “It’s not just about what you say, but how you say it and deliver it.”

   The very first contact an injured worker has with the process should be imbued a sense of trust and set the stage for their expectations of how the entire claim will be handled. 

2. Responsive follow-up leads to faster return-to-work

   “Think about the whole person, not just the specific injury,” says Debbie Michel, Executive Vice President, Liberty Mutual. As many as 18% of injured workers never reach the ability to return to work in the same capacity. “Anticipating a worker’s needs in a holistic way demonstrates that their well-being is a priority.”

   For example, nurse case managers can use motivational interviewing and therapeutic listening to help identify factors that can impact an employee’s ability to return to work — then coordinate additional services if needed.

   Another approach is to empower employees with a range of choices, says Michel. Options can include a gradual part-time to full-time transition, providing temporary limited duty or alternate work tasks, and temporarily working remotely.

   Returning to work full time after an injury doesn’t always have to be an all or nothing proposition. Keeping an injured worker engaged and empowered thorough the recovery process can strengthen the employer-employee relationship and better prepare for a successful return to work plan.

3. Compassionate strategies improve overall claims outcomes

   When taking an advocacy focus, soft skills are crucial. “Empathy and concern, as well as positive and effective communication with injured workers, are as important, or more important, than the technical aspects of processing the claim,” says Michel.

   According to research by the Workers’ Compensation Research Institute (WCRI) workers’ feelings about the employee-employer relationship after an injury can drive outcomes related to the claim. Workers who are strongly concerned about being fired after an injury, for instance, experience poorer return-to-work outcomes than workers without such concerns.

   Fear and anxiety have a direct impact on the overall cost of a WC claim. Among workers who had the worst claim outcomes, according to the WCRI, nearly 50% stated they had a strong fear of being fired due to the workplace injury.

   Job concerns and lack of employer support influence workers’ views of the claims process. Linking empathy and employee satisfaction with the WC process can help avoid the tensions that often lead to litigious actions, according to Michel. 

For more information or help, contact the Insurance professionals of the PCOC Insurance Program. Call us at: 877.860.7378.

Paul Lindsay
Senior Vice President, Principal, Programs
EPIC Program Solutions
10877 White Rock Rd. Suite 300 Rancho Cordova, Ca 95670
paul.lindsay@epicbrokers.com
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