ASC's External Newsletter Current Issue
The Return-To-Work Claims Advocate in You
Returning to work for many injured workers is a must; therefore, the importance of a worker’s satisfaction throughout the treatment and return-to-work process is a necessary undertaking for developing overall trust post-injury while avoiding costly litigation. Most workers do not contemplate getting injured on the job, but they do expect to be taken care of throughout the process, which is where the claim adjuster comes in.
Employee satisfaction begins before an injury occurs which is why an employer and claim adjuster should be prepared in advance. Before a claim is reported, it’s essential to identify company jobs by their description so the employer and claim adjuster can take a proactive approach for evaluating physician and client pre-approved return-to-work opportunities. Depending on the extent of the injury, and assessing every claim on its own merits, it may be helpful to have an alternative, transitional light-duty position available and wage-earning capacity assessment completed. The importance of having transitional work/modified duty available before an injury occurs can significantly reduce an injured workers’ doubts and fears of returning to normalcy and being productive again. Getting ‘the ball in motion’ shows proactiveness and can help reduce the chance of having an attorney involved.
When a worker is first injured on the job, the claim adjuster and the employer will develop a medically approved return-to-work plan almost immediately. Return-to-work is effectively achieved when return-to-work evaluation begins by contacting the injured worker and treating physician within 24 hours of injury notification. The purpose for timeliness is to lower overall costa and reduce lost time/absenteeism by assigning the right medical resources early in the life of a claim, which becomes an integral part of the claim adjuster’s action plan that must be developed.
One component of an employee care plan may include meeting directly with the treating physician to discuss the plan together to determine if there is an agreeance on a job restriction based on the results of the treated injury. The claim adjuster and employer may choose to obtain and share photographs, work sample products, and videos of job tasks with the treating physician to delineate job tasks and allow the physician to make an informed decision regarding return-to-work issues. When the treating physician agrees with the transitional work position, then the claim adjuster and employer can encourage the injured worker with a promise of continued employment while receiving the necessary workers’ compensation benefits.
A unique alternative to employer available transitional work is modified duty work at a local non-profit. Sometimes employers simply do not have transitional work available at that moment. Modified duty off-site with a non-profit is employer determined. The transitional position may be paid, partial paid or no pay alternative work by the employer to assist a non-profit agency that benefits from a set of extra working hands. This temporary offsite transitional duty can help the injured worker resume a productive work lifestyle and foster goodwill while transitioning back into their regular employer job position or other onsite employer modified duty as it becomes available. This modified duty off-site work is managed by a managed care nurse, in conjunction with the claim adjuster, the non-profit, and the employer.
It is important for a claim adjuster to develop an ongoing working relationship among all parties to focus on returning injured workers to work as soon as feasible, either in the pre-injury position or in a transitional setting. For example, the claim adjuster serves as an empathetic injury counselor working alongside a nurse case manager, and a treating physician. In addition to reducing absenteeism, this collaborative effort can also help identify and eliminate presenteeism (on the job - but physically or mentally out of it) and identify and overcome other barriers such as cost-effective transportation and co-worker transportation for an employee released to temporary, restricted duty and prohibited from driving. The purpose of ongoing involvement is to eliminate as many obstacles to return-to-work as possible.
It is ultimately the health and well-being of the injured worker that makes the claim adjuster’s work so important. The empathetic claim adjuster in conjunction with the employer can be the biggest claim advocates available to that employee. When onsite transitional work or offsite work is available, or if the injury allows for the worker to return to their old position, the claim adjuster, employer, nurse case manager, and treating physician are improving the employee’s trust, loyalty, productivity, and assurance in their abilities.
Congratulations to Rachel Trollinger, Claim Adjuster in our Nashville, Tennessee office for her
Star Award. Ms. Trollinger received the Star Award for going above and beyond on a weekend for a claimant. Rachel also visited the claimant in the hospital and provided reassurance on how the Injury-on-duty (IOD) program works while encouraging the claimant and his family.
Gratitude shared for WC Claim Adjuster Mr. Phillip Mims by a City of Plano, TX injured Fire & Rescue worker. Mr. Mims was recognized last quarter for his advocacy supporting an injured worker after his knee surgery. Mr. Mims empathatic ear and quick action to relieve the workers continued pain resulted in quick response by the treating doctor. "If not for the actions of Phillip Mims, I might still be in pain - he really went above for me and I'm extremely appreciative for that."
Legislative & Regulatory News
Q3, 2018 Issue:
When it comes to hiring a third party administrator (TPA) or maintaining a successful business relationship with one, it requires choosing a TPA with the following characteristics: expertise in your industry, an adaptability to adhere to your risk management needs, a high claims staff retention rate, and a robust risk management information system (RMIS). Let’s take a closer look at some of the reasons why many have chosen their TPA and how they get the most from their TPA.
The Business Relationship
At this point, it is likely you have chosen a TPA based on a number of reasons. One of those reasons may be the TPA’s experience in your industry. We have found that clients often prefer their prospective TPA to have prior experience with similar types of accounts in their industry. This association provides a level of trust for the client knowing that the TPA is familiar with the type of injuries and liabilities that occur at this type of workplace.
When it comes to knowing the uniqueness of your industry, it is also important that your TPA understands your business culture and the nature of your business. Understanding your processes begins by having your TPA visit your facilities to learn about your daily work environment from the ground up. For example, TPAs must be willing to work within the client’s culture and organizational framework, which may include the TPA staff working on the client’s holiday schedule, and working onsite as a dedicated resource. More about dedicated claims staff later.
Another uniqueness that a TPA should understand about your business is the diverse cultures of the region where you have exposure. Claims may be handled differently in New York and Florida than in the Midwest. The differences can range from the technical handling to the psychosocial handling of the claim. Each state varies with claim handling requirements while each region can vary with claimant personalities and dialects. Knowing what staff options you have (e.g., bilingual, regional offices, etc.) will help you get the most out of your TPA.
The relationship is everything, which is why TPAs would be wise to first invest their time with everyone involved in the program. Your TPA needs to have an excellent alliance with all vendors (e.g., managed care), brokers, carriers, and the insured to coordinate a collaborative effort for the best possible outcomes. This is where dialogue comes in which forms the basic process for building a mutual understanding of your claims program.
As a way to measure effective dialogue, you should require regular claims reviews for in-depth discussion. Claim reviews are the time where you can cement the relationship with your claim adjuster(s) who provides face to face responsiveness for collective learning and inquiry. Claim adjuster discussion holds considerable assurance as a problem-solving strategy when reviewing open claims. Here is where you can review select claim files to measure proper contact made, reserves calculated, investigations completed, and more.
“Shopping” a TPA
Clients are likely not shopping for a service if they are happy with their current TPA. The long-term relationships that have been built can be more valuable than saving a few thousand dollars. When you consider the time and resources it takes to train a new TPA on the client’s company culture and needs, the “soft “costs from switching can outweigh the savings. For example, what if the new TPA is not as effective at closing claims early? Claims pricing is only one factor, so make certain you receive the best claims service to avoid costly claim outcomes.
Many clients have recognized the value in going beyond the biggest TPAs or the well-known TPAs who have a high search engine status on the Internet. Lesser-known TPAs may offer a specific culture or service package that may be as good as or a better fit for the client. We call this a “boutique” TPA service. Alternatively, clients find familiarity with TPAs based on name recognition and structured claims administration appealing. Either solution, it’s important that you receive the best claims service from the best claims resource available to you.
Now that you have finalized your selection, you may have noted the importance of selecting a TPA who places a high value on its claims staff. Employee satisfaction is one way to determine if your claims team will be engaged and happy serving your claims program. The critical factor with employee satisfaction is that a satisfied claims staff must do the job and make the contributions that the client needs. This begins with choosing a TPA that fosters employee motivation, goal achievement, and positive morale in the workplace.
Here are three aspects of the workplace that successful TPAs implement to keep claim adjusters and support staff happy and reduce turnover rates:
- A recognition program
- A lucrative benefits package
- A manageable caseload
A TPA’s recognition program is a very effective way to keep claim adjusters motivated and satisfied with their work. A monetary reward for meeting or exceeding their measured claims handling goals is one method of appreciation. Another is a support staff bonus based on the success of the TPA as a whole. Satisfied employees provide exceptional service. Exceptional service makes for satisfied clients.
Minimizing stress on claim adjusters through lucrative benefit packages and work/life balance opportunities can also reduce turnover. For example, a TPA that allows its workers to work remotely from home on occasion throughout the week. Another contribution is a generous PTO policy that re-energizes the mind and body.
Manageable claim caseloads are necessary to avoid claims staff burnout. A TPA that regularly monitors and measures claim types, and the time it takes to administer each new claim, can greatly distinguish between truly happy employees and those who are just getting by. Mismanaged claim caseloads by overworked claims staff will lead to poor claim outcomes.
Another operational component to consider is an alternative staffing model. As an option to traditional, designated claim adjusters, you may have chosen a dedicated/exclusive claims staffing model. Dedicated claim adjusters that work onsite or nearby the client make another excellent example of dialogue that generates positive outcomes.
With a dedicated service model, you are encouraged to participate in the hiring process to choose among candidates with the required expertise & professional personality/demeanor best suited to your company’s culture. A TPA that knows how to establish a dedicated claims model for its client can provide claim adjusters who attend regular or impromptu staff meetings, and interact with company/entity department heads regularly. It’s this business relationship that makes the claims team feel like a valued member of your risk management team which results in a very high staff retention rate. Knowing your claim adjuster by name makes for a loyal, long-term relationship.
With positive TPA operations come high employee satisfaction. High staff retention creates familiarity with the claim adjuster and employer that leads to better communication, higher responsiveness, and better overall outcomes.
RMIS Systems That Work
Clients require an intuitive RMIS that operates as a useful research tool for their staff. Proactive RMIS users want more value than just looking up individual claims. The ability of a RMIS system to handle predictive analytics has become very important to clients. In addition, the ability to run scheduled or on-demand claim data reports are a necessity. It is important to know what functions are available and what training will be provided as a resource in order to get the most value out of your TPA.
Getting the most from your TPA comes from first knowing your TPA. Whether you choose your TPA for their loyalty to their employees, their service with integrity, their flexibility of size and service models, or their expertise in your business, the decision should be a rewarding one.
Congratulations to Ms. Lillian Hall, Claim Supervisor in our Plano, Texas dedicated unit client office for a recent recognition from the Plano City Manager, Mr. Bruce Glasscock. An award was presented to Lillian Hall by Senior Claim Analyst, Ms. Elsa Gonzales for Lillian's handling of a sensitive claim.
Gratitude from WC and Leave Administrator, Ms. Janelle Nowicki with ABC Fine Wine & Spirits for Ms. Geri Wines' quick action on a CAT claim handled while on vacation. Geri's quick action averted a crisis for an injury that "could have gone down a different path."
Legislative & Regulatory News