From adversary to advocacy: the claims process

Advocacy-based claims models emerged as "buzz" in the industry in 2016. At its core is a focus on people. Employees respond better and take ownership when they become part of the claims process. It's about caring for themselves and their co-workers.

While many employers recognize the value of employee involvement in claims processes, they often don't connect the dots that it will have a long lasting impact on reducing costs. Lower litigation costs, speedier recovery at work, improved medical outcomes, shorter claim duration, and more productive employees lead to a healthier bottom line.

When an injury occurs, there's a good chance that it is the employee's first one. Even a minor injury can seem like a big deal because they have never dealt with the system before. Stress, confusion, anxiety, and frustration can lead to fear. And fear drives costs. The word "fear" or related words were in 84% of notes taken by workers' comp claims adjusters for claims costing more than $100,000 according to a white paper by Lockton Cos. L.L.C.

With the traditional claims approach, it's easy to understand how the employee feels they have fallen into an abyss, with no one there to help. The process can be intimidating and the language adversarial. Suddenly, they become "the claimant." They don't trust insurance companies based on what they've heard and this mistrust is quickly reinforced when they have to deal with the "claims examiner" and the "adjuster" who are "investigating" and "assessing" the claim. Missing is an expression of concern, a voice of empathy, and an open line of communications.

The advocacy-based claims model turns the process around. It focuses on the employee, helps them understand and navigate the process, provides information to help make decisions, makes access to benefits as simple and easy as possible, and builds trust. In effect, it treats the injured employee as a consumer.

While the structure of an advocacy-based claims model will vary with company size, type, and culture, there are common elements that are simple and easy to implement:

1. Change the script. Don't focus on how the claim will be investigated or all the insurance jargon. Begin with empathy, concern, and compassion. Let the employee know you will be there throughout the process and that the top priority is to get them back to work as soon as safely possible. Take the time to inform the employee of what to expect and when and who to contact with questions.
2. Designate someone to contact the worker on a regular basis. Don't rely on the insurance company to be the prime contact, designate a supervisor, risk manager, or HR representative to maintain contact throughout the claims process. Simple gestures such as get well cards, hand written notes, texts, and a visit to the hospital go a long way in reassuring the employee and building trust. Find out how you can advocate for them. There are many potential stumbling blocks along the continuum of care causing a claim to be snagged, slowed down, or stopped dead in its tracks. Some helpful questions: How are you feeling? How is the carrier doing? Are you getting your checks in a timely manner? Do you have transportation to your medical appointments? Have there been delays in getting your doctor appointments? How can we help you? And always remind them, "We're looking forward to having you back."
3. Make medical care easy. Navigating the medical system is tough. And the system is still driven by a pay for service model, which encourages excessive procedures and inflates prices. Having the support of occupational doctors and therapists and a triage nurse, who share the same objective of improving the injured employee's health for a recovery at work, eases the process.
4. Recognize generational differences and make the process easy for everyone. Phone calls and snail mail just don't cut it with Millennials. A cumbersome process doesn't work for anyone. Starbucks, which employs many young employees, now allows its workers to report an injury themselves immediately online or via a special phone line. The result has been less lag time in reporting injuries and no uptick in fraudulent claims.
5. Don't have a blanket approach. While one employee may respond well to several texts or phone calls in a week, another may find it disturbing and feel the employer does not trust them. Find a balance that works and set the right tone for maintaining communication.
6. Engage in the recovery at work conversation early. Be sure the employee and the treating physician knows the options available and that the supervisor is on board. Be mindful of the employee's situations and needs and show respect for the employee as a person. Throughout the process, discuss work capacities and restrictions and involve the employee in the process of establishing accommodations or alternative job functions, so that they engage in, rather than thwart, the recovery at work effort. Find out what they feel comfortable doing and what they are worried about.
7. Handle denials differently. A denial is often the trigger for litigation. Let the employee know that the claim does not meet the definition of a compensable workplace injury and avoid the word denial. Do so with empathy and advise them of any other benefit options that could help.

While some of these are small gestures, they have a positive and long lasting impact. When employees receive emotional support and believe you care about them and doing all you can to help them recover, the claim is unlikely to spiral out of control.