By DARRELL BROWN
Advocacy is rooted in the notion of putting the injured employee’s needs first and making information and resources readily available to improve the overall claims experience. Undoubtedly, the workers’ compensation system has become more complex throughout the years, and many injured employees are left feeling overwhelmed, confused, and frustrated by the process. Ensuring timely and appropriate medical care, providing immediate answers and accurate information, and fostering maximum recovery and a return to productivity are simply the right things to do. Intuitively, an advocacy-based claims model makes sense.
That said, some people are surprised to learn that there is a sizeable body of empirical research that supports an advocacy-based claims approach. When injured employees feel that they will lose their jobs, are dissatisfied with the medical treatment received, or believe that they will not be paid the workers’ compensation benefits to which they are entitled, they often seek legal counsel. In 2008, the Johns Hopkins School of Medicine conducted a study based on a sample of claims paid by the Louisiana Workers’ Compensation Corporation, Louisiana’s largest workers’ compensation carrier. Researchers concluded that, when attorneys are involved in the claims process, durations are longer and claims costs are higher.
The California Coalition on Workers’ Compensation published similar findings. Its 2014 study found that the cost of claims grew exponentially when there was attorney involvement. According to the study, the average cost of a litigated claim was estimated to be $62,652, compared to the average cost of a nonlitigated claim estimated at $8,251.
Most industry observers agree that litigation can be construed as a measure of dissatisfaction with the claims process. As these studies point out, litigated activity has been shown to result in longer claims durations, higher claims costs, and poorer outcomes. What the empirical studies demonstrate is that employers and claims administrators absolutely can influence claims outcomes. With this in mind, an advocacy approach can help achieve program goals and improve the overall claims experience.
Let’s look at some of the programs and practices employers are using to focus on injured employee needs and create a more positive claims experience.
Conduct an extensive data review. Before establishing an advocacy program, it is important for employers to find out what employees value in terms of program resources. By way of illustration, transportation alternatives, proximity of medical care, assistance with family obligations, immediate access to information, and reassurance of employment opportunities may be important considerations for those suffering an unexpected injury. Advocacy practices can be built around these preferences, whether it is a mechanism to provide transportation to medical appointments or the provision of a first-fill pharmacy card to allow prescriptions to be filled easily with no out-of-pocket expense. Online banking has led to direct deposit of benefits by some employers. This added convenience is another way to minimize payment delays and injury disruption.
Provide access to an advocate. Filing a workers’ compensation claim can be intimidating, and questions can arise quickly. A strong advocacy program will include access to an objective person who is familiar with the workers’ compensation process, but is not necessarily the same individual who will be adjudicating the claim. Some employers use a nurse to fulfill this role. A nurse advocate can help with injury assessment and the selection of a medical provider who can provide immediate and appropriate care for the injury at hand. A nurse advocate also can be available to answer questions and offer encouragement throughout the recovery process.
Ensure answers are readily available. Many injured employees have little or no experience with or exposure to the workers’ compensation system. A work-related injury can create fear, uncertainty, and frustration. Injured workers may seek legal counsel because of the information void that exists when employers do not have a reliable communication strategy. Few people outside the industry understand that workers’ compensation is a statutory system in which benefits are determined by the states. It is understandable that injured employees want to know the benefits to which they are entitled and when payments will be issued. They also need to be aware of return to work availability. If a workers’ compensation claim is denied, an employer can help the individual understand why the claim was ruled ineligible and assist with helping gain access to other benefits to which they may be entitled.
Communicate effectively. The advancement of technology has led to many avenues of communication. It is important to consider generational and cultural preferences when establishing communication practices. Baby boomers may prefer to exchange information by letter, phone, or email whereas millennials may prefer texts, online chats, or web-based portals. As the workforce becomes more diverse, language and cultural traditions should not pose barriers to the claims process. Those serving the needs of injured workers must have the ability to empathize and communicate in a way that respects these differences.
Adjust claims vernacular. Our industry is filled with technical jargon, which adds confusion to an already complex system. In establishing advocacy programs, some employers are eliminating such terminology as “claims examiner,” “accident investigation,” and “recorded statement.” Instead, they use terminology rooted in more positive phrasing such as “employee advocate,” “benefits coordinator,” or “care conference.” How employers say something often is as important as what they say.
Use actions to reinforce care. Wishing an injured employee well using a standard form letter is very different from reaching out to the injured employee by visiting the hospital or sending flowers. Delivering the first benefits check to the hospital is very different from having it sit at a post office waiting for pickup. A supervisor accompanying an injured employee to the doctor for treatment is very different from simply giving a list of network physicians to the injured employee from the front office. Genuine care and concern for an injured employee cannot be purchased or manufactured; it must emanate from within the corporate culture before actions will follow.
Measure program effectiveness. Like many management programs, an effective advocacy program must identify key performance measures to monitor success. Employers should use those measures most reflective of their organizations and objectives. Popular program measures include lost workdays, claims durations, average claims costs, litigation rates, number of injured employees filing multiple claims, and workers’ compensation costs as a percentage of total cost of risk. An effective advocacy program will be fluid and responsive. It likely will look very different in three years than it does today as refinements and improvements are made.
Using proven advocacy practices, employers and claims professionals have an opportunity to make a notable impact on the industry. We truly are at the beginning of a paradigm shift in the way claims are handled. Shifting focus from the claims transaction to improving the injured employee’s experience is only the beginning as we work to elevate the workers’ compensation system and claims profession as we know it.
ABOUT THE AUTHOR, SOURCE
Darrell Brown is chief claims officer with Sedgwick, where he serves as a senior adviser in setting Sedgwick’s claims management vision, strategy, and best practices, backed up by his 20 years of experience in claims management. This article originally appeared in the CLM publication WC magazine, and is reprinted here with permission.