Put Workers At the Center of Claims Process for Best Outcomes, Experts Advise

Nancy Grover

Sarasota, FL (WorkersCompensation.com) – Starbucks has a unique way of reporting injuries; they let injured workers do it themselves. Contrary to what some feared, the practice has not resulted in increased claims frequency. But it has led to decreased litigation, quicker return-to-work rates and better outcomes. It’s an idea industry thought leaders believe could be a great way to encourage better employee engagement after an injury.

“Considering the common delays we see in reporting injuries, the opportunity to connect with the worker at the outset — the advantage is very clear,” said Denise Zoe Algire, director of Risk Initiatives and National Medical Director for Albertsons Companies. “I see it as another component of claims advocacy and claims engagement. When supervisors report claims, there are often things missing that can cause delays. By allowing the employee to report the injury, the employer is invested from the beginning.”

To overcome potential challenges of employees reporting their own injuries, companies can require injured workers to also inform their supervisors. “I think that’s a good practice,” Algire said. “It’s important to let their manager know about the injury.”

Algire’s comments came during a panel discussion on the 2018 Workers’ Compensation Benchmarking Study, which examines forces that are impacting claims management in workers’ compensation. This 6th version of the study, published by Rising Medical Solutions, focused on ways various companies are addressing increasing claim severity and the challenges of medical management during the last decade.

Total Worker Health

The study included more than 40 industry executives divided into two groups; claims leaders and clinicians/managed care leaders. One idea on which both groups agreed was Triple Aim, a basis on which to optimize healthcare performance and outcomes. Developed by the Institute for Healthcare Improvement, Triple Aim identifies three dimensions the Institute believes should be the focus of new healthcare designs:

  • Improving the patient experience of care (including quality and satisfaction)
  • Improving the health of populations
  • Reducing the per capita cost of health care

Workers’ compensation stakeholders can implement Triple Aim by defining and looking at healthcare measures such as productivity, injury rates, the rate of employee engagement, RTW and functional recovery. By focusing on the needs of the injured worker, rather than on reducing costs, organizations can see improvements in these metrics.

“The important thing to remember with costs is to achieve the outcomes we want, such as RTW,” said Marcos Iglesias, M.D., chief medical officer and SVP for Broadspire. “Triple Aim is exciting in workers’ compensation. It gives us that strategic framework that we can shoot for.”

A focus on health and wellness among employees can pay dividends in a variety of ways, the speakers said. For example, it leads to less time off work and may even prevent injuries.

“This can solidify the employer/employee bond, with faster RTW [rates] and good medical outcomes,” said Anne Kirby, chief Compliance officer and VP of Care Management for Rising. “This is a switch, to focus on employee total health and turn it on to the ‘person’ rather than the ‘injured worker.’ It is a transition smart companies are making, to really look at that person, with much more of a whole [person] view.”

Focusing on total quality of health, or total worker health, can help organizations keep their employees healthy and recover faster if they do become injured, the panelists said. The challenge is to make the idea of TWH top-of-mind for all stakeholders involved in a claim.

“Total worker health is not necessarily in the vernacular for claims managers,” Algire said. “They are trained to work on the injury.”

Claims managers can be educated on the importance of patient experience and engagement and the impact it has on outcomes. They can increase employee engagement by addressing functional improvement in a way that has meaning to the injured worker.

“For example, if a worker has a dog and it’s important for him to walk the dog, this would be a functional improvement that is important to them and engages them,” Algire said. “We really need to change our focus.”

Companies can start to implement TWH by identifying the desired outcome; whether it is RTW, return to baseline health or even better than baseline health. Wegmans Food Markets’ TWH started as an exercise rehabilitation program to help restore function to injured employees more than a decade ago.

“Claims have a different look today,” said Brian Trick, Wegmans’ Senior Claims Manager. “We have tools to use, such as dieticians, EAPs, etc., and we try to channel as many workers as possible into these programs.”

The company has seen a reduction in lost workdays and a “significant” reduction in repeat claims. Also, in some cases surgeries that had been recommended became unnecessary because the injured worker was able to recover and return to work.

Frictional Delays

Detailed accident investigations and utilization review may be important in some claims but they can also cause unnecessary delays, the speakers said. Participants in the focus groups shared some of the different ways they try to reduce frictional delays.

“They identified all those things that created delays,” Kirby said. “The ways they responded were [to determine] the number of calls an injured worker would need, and limit them to one call from a claims manager or nurse focusing on what the injured worker’s needs are.”

Claims managers in these organizations need to understand that they have to collect the information they need in different ways.

“There are clearly cases that do need detailed investigations, so the group was not calling for none, but really putting an employee-centered approach in place,” Kirby explained. “Another thing that came up was getting the person access to care right away.”

The idea is to look at the process from the perspective of the injured worker. Some organizations make sure workers receive temporary total disability benefits within 7 days, or authorize medical treatment the same day it is requested. “It makes the employee feel good,” Trick said. “A big factor is communicating throughout the claim. Engaging employees works.”


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