The Advocacy-Based Claims Model: How to Reduce Costs and Improve Outcomes

The traditional workers’ compensation claims process is fundamentally broken. It is an adversarial system that treats an injured employee not as a person, but as a potential liability. This approach creates confusion and fear, which are the primary drivers of claim costs.

There is a better way. An advocacy-based model transforms the claims process from a source of conflict into an opportunity for support. By focusing on the employee’s well-being and guiding them through the system, you build trust, speed up recovery, and directly lower your workers’ compensation costs.

Why the Old Model Fails

For most employees, a workplace injury is their first and only experience with the workers’ compensation system. This unfamiliar process breeds anxiety, which quickly turns into fear.

Fear is the single most expensive emotion in a workers’ compensation claim. According to one industry study, the word “fear” or a related term appeared in the adjuster’s notes for 84% of claims that cost more than $100,000.

The traditional system fuels this fear. Almost immediately, the injured employee is rebranded as a “claimant.” They are subjected to an “investigation” by an “adjuster” and a “claims examiner.” This language is inherently adversarial. It signals mistrust from day one and pushes the employee to seek legal counsel, dramatically increasing costs.

The Advocacy Model: A Strategic Shift

The advocacy-based model replaces suspicion with support. It recognizes that the employer and the employee share the same primary goal: a full and safe recovery.

This model focuses on clear communication, empathy, and guidance. It helps the employee navigate the system, understand their benefits, and make informed decisions. The result is a faster recovery, higher employee morale, and a significant reduction in litigation and overall claim duration.

Implementing the Advocacy Model: Seven Core Principles

Shifting to an advocacy model does not require a complete overhaul of your operations. It begins with implementing a few simple, powerful principles.

1. Change the First Conversation.
   Your initial contact with an injured employee sets the tone for the entire claim. Do not begin by discussing investigations or insurance procedures. Start with empathy. Express your concern and make it clear that your top priority is helping them get the care they need to recover. Explain the process, what they can expect, and who they can contact with questions.
2. Designate a Consistent Point of Contact.
   Do not let the insurance company be the sole point of contact. Assign a specific person within your organization—a supervisor, HR representative, or risk manager—to check in with the employee regularly. This prevents them from feeling abandoned to a faceless system. A simple check-in call, a get-well card, or asking “How can we help?” goes a long way in building trust.
3. Simplify Access to Medical Care.
   Navigating the healthcare system is difficult for anyone, especially after an injury. Your role is to make it easier. Partner with occupational health providers who understand the goal of a safe return to work. Using a triage nurse for initial injuries can ensure employees get the right level of care immediately, preventing minor issues from becoming major claims.
4. Modernize Your Communication.
   Outdated communication methods create delays and frustration. While a phone call is important, use modern tools that your employees prefer. Starbucks, for example, allows employees to report injuries immediately online or via a dedicated app. This has reduced reporting lag time without increasing fraudulent claims. Make the process easy for everyone.
5. Tailor Your Approach.
   Every employee is different. Communication that feels supportive to one person may feel intrusive to another. Work with the employee to find a communication rhythm that is both helpful and respectful. The goal is to show you care, not that you are monitoring them.
6. Plan for Return-to-Work Immediately.
   The return-to-work conversation should begin on day one. Ensure the employee and their doctor know what light-duty or modified-work options are available. Involve the employee in identifying tasks they can perform within their medical restrictions. When they participate in planning their own recovery, they are far more likely to engage in the process.
7. Handle Claim Denials with Care.
   When a claim must be denied, the communication is critical. A denial is the most common trigger for litigation. Instead of a formal, cold letter, have a respectful conversation. Explain clearly and with empathy why the injury does not meet the criteria for a workers’ compensation claim. Advise them of other benefit options that may be available to them, such as short-term disability.

These actions may seem like small gestures, but their impact is significant. When employees feel that you are genuinely invested in their recovery, they become partners in the process. An advocacy model is not just about goodwill; it is a strategic approach to managing risk, controlling costs, and protecting your most valuable asset: your people.