4 Steps in an Effective Workers’ Compensation Claims Management Process

When should we start the claims reporting process? Who should be involved in the handling? Should we settle, and what happens if that is not possible? Every claim is different and will include a multitude of questions that an employer should not expect to answer alone. Leaning on valuable resources with unique expertise can often provide optimal claims management outcomes for any scenario.

“There should be timely communication with the primary insured, injured worker, and medical providers, with details that include prior accidents and co-morbidities, which can be key in an injured worker’s recovery process, but can also help identify any potential red flags,” said David Schuermann, Regional Claims Manager at Safety National. “Starting with the investigation process, your third-party administrator (TPA) should be able to identify opportunities for recovery, apportionment, Second Injury Fund relief, and subrogation.”

An effective claims management program will include these four steps.

1. Start with an Early and Ongoing Investigation

An adjuster cannot start investigating the compensability of the claim until the claim is reported; therefore, employers should use urgency when reporting the claim to the TPA. Once reported, the investigation process should occur within the first 30 days of the filed claim. With catastrophic cases, the employer does not have the luxury of waiting for medical reports before reporting the claim, so reporting should happen within 24 hours.

Reporting all of the key information can be difficult, but provide the information that you can, like what is known about the incident, the extent of the injury, where the worker is hospitalized or staying, the age of the worker, adjuster, and field case manager (FCM) information.

2. Stay Actively Involved Throughout the Life of the Claim

TPAs should continue to send periodic updates, and when a carrier is involved, they can provide necessary feedback to steer a claim in the right direction. For example, a carrier can help review medical records associated with the claim, which can assist in identifying exposures and enable further collaboration to ensure the best care possible for an injured worker. The review process can involve expert medical opinions to consider if the current treatment is the right course of action or if the injured worker should be moved to a Center of Excellence.

3. Establish Appropriate Staffing and Resources

A claim can quickly go awry without adequate handling, reserving, and frequent communication with all stakeholders. Administratively, the TPA should have appropriate staffing and workloads, effective technology and support, and proper adjuster training, including specialization in empathy and compassion. Established procedures and practices should be in place that provide guidance and oversight of the entire program.

Experienced adjusters and internal resources, like field case managers, can quickly recognize an adverse development of a claim. Additionally, assigning an FCM as soon as possible allows the greatest impact on continuity. This individual helps verify the severity of the claim, obtain medical records, identify any problems, and meets with the family. The FCM builds a rapport with the family, ensuring they have a point person to communicate with, making them more comfortable.

4. Consider Settlements

When a claim is disputed or an injured worker reaches their maximum medical improvement, it may be time to settle. Employers should work with their carriers when necessary and appropriate under the applicable policy to develop a proper resolution strategy, as insurance providers can hold unique expertise in this area. Additionally, jurisdictional limitations on medical settlements can keep claims open for life. Your carrier can provide expertise in this area, including advising on indemnity benefits when these limitations prevent total closure.