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Claims Management

6 Steps to Initiate the Best Possible Catastrophic Claims Experience

Catastrophic claims are not linear, but involving the right resources early in a case can ease the adjustment and re-engagement process. We detail the necessary steps to transform these claims.

April 22, 2024

The severity and complexity associated with catastrophic claims, combined with their high costs and long duration, make them significantly more challenging to navigate. These claims often involve workers who are seriously injured or have suffered a major loss, and the resulting emotional toll can be devastating.

“Catastrophic claims require particular sensitivity and effective management for there to be any potential of a best possible outcome,” said Jessica Unser, Managing Director of Claims at Safety National. “Everyone involved has to be prepared to adapt too. If an injured worker’s condition changes, it can involve reassessing all resources and gathering the team of stakeholders to collaborate and prepare for these changes.”

These steps can assist in maximizing outcomes while helping to minimize costs.

1. Reporting in a Timely Manner

This process starts with the third-party administrator (TPA) or self-administered account reporting all the key information. While medical information may not yet be available, the reporting individual will be responsible for providing as much information as possible, including what they know about the incident, the extent of the injury, and where the worker is hospitalized. Reporting a catastrophic claim promptly offers several benefits because it allows the carrier to utilize its extensive resources to assist the insured and TPA. This helps ensure the injured worker receives the best care to achieve the best possible outcome.

2. Assign the Catastrophic Team

The right catastrophic team is instrumental in handling the sensitive nature of these types of claims. These cases may involve navigating complicated family dynamics and a hypervigilant public eye due to social media factors. Empathy is vital to managing these claims. Since the catastrophic team will work closely with all vital stakeholders, they need to ensure they remain sympathetic to the situation everyone is going through.

3. Identify Stakeholders & Key Parties

Determining the responsible parties that will be actively involved in the case is necessary to move the claim in the right direction. From the insured to the TPA and carrier, and potentially, legal representation, all stakeholders must maintain frequent and consistent communications.

4. Retrieval and Review of Medical Records

While vital, obtaining medical records can be difficult. Due to the nature of loss and the quick response to requesting the medical information, often times the medical provider may restrict information or disclose only what is required to treat an injured worker. These records will determine the complexity and severity of injuries. Additionally, they provide a complete picture of the injured worker through details like comorbidities and pre-existing injuries, which allow medical experts to chart the best course of treatment.

5. Conduct an Introductory Call

This collaborative conversation aligns stakeholder efforts to establish an appropriate game plan. During this call, the field case manager will provide medical updates as they are the eyes and ears of the case. This call can also help determine each person’s role based on their expertise level. Discussions may also include subrogation recovery or compensability and legal issues.

6. Obtain Referrals

What specialized resources will be essential in optimizing the outcome for the injured worker? Utilizing vendors can help control the high-dollar costs associated with a catastrophic claim. Vendors can provide valuable insight that assists the adjuster in investigation and compensability. Actively involving the TPA on the team should always be a priority and can also help control costs.