An effective workers comp claims review meeting should engage key participants in strategizing about how to best resolve the claims and return workers to their jobs. The session should have a clear objective that will ensure follow-up actions, observers said.

“A claims review can be incredibly beneficial” in resolving workers comp claims, providing it is strategic, says Charles Martin, managing director and casualty operations consulting leader at Marsh USA Inc. in Norwalk, Conn. The strategy should address “what you're going to do to keep those claims on track to get the right outcome both clinically and financially.”

Observers agree. In fact, at ARAMARK Corp., “we don't do claims reviews—we do strategy sessions,” said Carla Wynn, the professional services company's associate vp of strategic claims management in Philadelphia. “It's really important to set the stage and the expectations early on with the (third-party administrator) so they understand that, unlike a claims review, a strategy session is not a diagnostic of what happened at the beginning but how are we going to move forward based on the current state of the claim and how are we going to bring closure?”

At ARAMARK, the TPA, a nurse, outside counsel, the risk management department and sometimes the broker “come together as a collaborative team” that strategizes to develop an action plan to close the file, to make sure the reserves are appropriate, and to evaluate the effectiveness of the TPA in bringing about closure, which includes whether it has pursued possible subrogation, she said.

In one strategy at Safeway Inc., “every single case” that is set for a legal event in the next month—whether a deposition, a trial, a conference or a hearing—is reviewed, said William Zachry, vp of risk management in Pleasanton, Calif. Present at the meetings are the claims manager, the supervisor, the attorney assigned to the case, a nurse case manager, perhaps a medical director and someone from the special investigation unit “if we think there's a potential for fraud,” he said. The goal is “to make sure we have a consistent plan of action to bring the claim to conclusion” and not go to trial, he said.

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This mechanism “avoids what we call DITMR—or deer-in-the-middle-of-the-road,” which occurs especially with newer claims adjusters when cases become too large and complex, Mr. Zachry said. In another type of review, the broker is involved in ensuring that reserves are correct. With these strategies, Safeway has reduced the pending inventory of claims by 50% in the past 10 years, Mr. Zachry said.

Safety professionals often are included in claims reviews at Newport News Shipbuilding in Newport News, Va., said James Thornton, director of environmental health and safety. “I will sometimes mediate when there isn't 100% agreement on how to deal with the claim,” he said.

“There's only two ways to cut your (claims) costs—prevent accidents and get (injured workers) good medical care,” he said. Safety staff look at where accidents are occurring, what the impact is on claims, and “whether there is some intervention we should take to mitigate those claims,” he said. “Claims management is the small benefit. The big benefit is seeing the injury trend and subsequent actions to take,” Mr. Thornton said.

John Spath, senior consultant at Aon Risk Solutions' global risk consulting and casualty risk consulting business in Boston, is seeing “a wider range of people” at claims reviews. One review session he attended recently included “the facility manager—the senior person at the site,” which is helpful because when it comes to making safety modifications to reduce injuries and workers comp claims, facility mangers “are able to get things done and also pay for it,” he said.

Besides, the facility manager is the best source of information during a claims review, said Bill Barbagallo, managing director for PricewaterhouseCoopers L.L.P.'s property/casualty actuarial and insurance management team In Los Angeles. That individual “can describe in greater detail the job function, physical requirements, and strengths and weaknesses of the employee injured,” he said.

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In addition, he said, many claims are affected by a worker's home environment. “Employers are aware if the injured worker is divorced, paying support or undergoing treatment for a nonindustrial illness that may affect the worker's ability to return to work.”

The foundation for an effective claim review session is laid “even before a claim occurs,” said Andy Jimenez, vp of claims at the California State Compensation Insurance Fund in Fresno, Calif.

The insurer wants to make sure “the policyholder has safety as a norm, cares about their employees, has established a good working relationship with medical providers who will care for them, and has made a connection with whoever is handling the claim to make sure they share this philosophy and are interested in returning the individual to work as soon as possible.”

He added, “If that is the foundation, then the conversations that occur at the claims meeting cements that. Everybody knows their role and everybody is playing their role.”

“The (review) sessions do provide value, but if you're limiting your interactions to just the meeting, that may not be enough. In that case, you're probably being more reactive vs. establishing a sound foundation of relationship and roles” that can manage claims effectively, Mr. Jimenez said.