Balancing Stakeholder Communications to Optimize Claims Resolutions

When it comes to workers’ compensation claims, your insurance partners hold a unique set of skills that, when leveraged appropriately, can promote the well-being of an injured worker and the momentum of the claim. The best hope for a successful outcome includes a strong partnership between the insured, TPA, broker, and carrier that addresses pain points in the claim and strategies for mitigating future exposures.

“When our brokers, TPAs, and insureds partner with us early in the process, we are able to increase our effectiveness, bringing decades of complex claims handling skills and experience to the table, often resulting in the best possible outcomes for all stakeholders,” said Tara Klemm, Client Engagement Manager at Safety National. “This type of collaboration and communication strengthens our relationships by building trust, fostering teamwork, and increasing productivity.”

Common Challenges

Managing communications between all stakeholders becomes increasingly complicated with catastrophic or otherwise complex claims, whether it is initial reporting, consistent updates, or finding a timely and effective resolution. Some of these barriers include:

• Timely claims reporting – When an incident occurs, an employer is typically occupied with triaging and prioritizing care for the injured worker. However, reporting a catastrophic claim promptly offers several benefits because it allows the carrier to utilize its extensive resources to assist the insured or TPA. This helps to ensure that the injured worker is receiving the best care to achieve the best possible outcome. Employers should focus on reporting what they can, such as what is known about the incident, the extent of the injury, where the worker is hospitalized or staying, the worker’s age, adjuster, and field case manager (FCM) information.

• Appropriately qualified resources – Having the right expertise on a claim can make all the difference in a potentially positive outcome. Once the claim is reported, it is imperative that the TPA assigns a well-qualified adjuster. While rare, in the event of litigation, it is advisable that knowledgeable resources also be assigned to defense counsel and claims administrators. Both groups should be familiar with jurisdictional differences.

• Effectively collaborating on resolutions – Often, a broker is positioned to act as an intermediary between the carrier and the insured. However, the most effective resolution strategies happen when all parties collaborate, and the broker is able to act as a true advocate for the insured. Each party can assist in optimizing both the clinical and financial outcomes of the claim. In each case, the goal should be to restore the injured worker to pre-injury function in a timely matter.

Balancing Communication Needs

Standards for communication should be set from the start of the partnership, which requires established trust. Part of that begins with recognizing and utilizing the expertise of all stakeholders. A carrier will have extensive claims knowledge, and their experience can help further mitigate substantial losses, whether through claims handling or settlement guidance. A TPA can manage essential functions, such as setting loss reserves, facilitating claims investigations, issuing claims payments and settlements, coordinating medical management, and organizing transitional work for an injured worker. A broker can provide guidance on compliance and best practices, and, when necessary, will advocate for a fair claims settlement. An insured will have in-depth knowledge of the claim and the injured worker. They will be able to provide regular updates on the injured worker and provide insight into venue considerations if the claim moves to litigation.

Partnership trust must also include a certain level of shared responsibility. Instead of pointing fingers and placing blame, everyone should manage expectations to work toward a common goal that suits the needs of all stakeholders. If it is likely that the injured worker will need modified work duty based on the severity of the injury, the TPA and the insured should collaborate to find a position that meets their needs. If the injured worker is struggling to navigate their home post-injury, the TPA and carrier can work with contractors specializing in home modifications to provide the safest and most appropriate living conditions related to the patient’s injuries. In cases of impending litigation, if the carrier wants to pursue a settlement, the insured’s knowledge of the injured worker can help facilitate their communications to find a resolution more easily.

Empathy is also a key consideration in communication. The employer should communicate with their injured worker, ensuring that they are making progress in their recovery, attending doctor’s appointments, and attaining the proper support. The TPA will also be actively involved in this process, while also communicating with the injured worker’s family consistently. In catastrophic injury cases that may involve multiple injured workers, a carrier may be able to offer resources for crisis management services for employees and public relations expertise to handle media involvement when necessary. Regardless of the severity of the claim, empathy should be prioritized in all interactions with business partners and injured workers, exhibiting a commitment to care for the length of the claim.