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Using an advocacy-based model for workers compensation claims can reduce attorney involvement, improve medical outcomes and speed return to work.
Though few employers have implemented an advocacy-based claims model, the concept is “certainly something the industry is talking about broadly,” said Kimberly George, Chicago-based senior vice president and senior health care adviser at Sedgwick Claims Management Services Inc.
At its core, an advocacy-based claims model involves designated service providers assisting and empowering injured workers at any point during the claims process.
One way to advocate for injured workers is by not calling them “claimants,” sources said.
They're just patients, “people who need medical care,” said Phil Walls, chief clinical and compliance officer at Tampa, Florida-based pharmacy benefit manager Matrix Healthcare Services Inc., which does business as myMatrixx.
Similarly, titles such as claims examiner and adjuster reinforce the industry's adversarial reputation, sources said.
Such positions are called “claims representatives” at Walt Disney World Resort, which uses an “advocacy-based model for delivering workers compensation,” Michele Adams, vice president of risk management services at the self-insured and self-administered Orlando, Florida, company said during the Alliance of Women in Workers' Compensation's conference in Boston earlier this month.
Advocacy is about “protecting the best interest of the patient,” Mr. Walls said. “However, in workers comp … all parties may not agree on what is in the patient's best interest.”
Mr. Walls said he recently helped wean an older patient off the powerful opioid fentanyl, which he considers a “huge win.” Despite it being in the patient's best interest to stop taking the drug, Mr. Walls said the man calls his nurse case manager weekly asking for more.
Advocacy-based claims models also immediately connect injured workers with someone who has medical knowledge, such as a triage nurse, sources said.
When a worker is injured on the job, the first priority is their health, not filing a workers comp claim, said Paul Braun, managing director of casualty claims at Aon Global Risk Consulting in Los Angeles.
If an employee is bruised in a fall, for example, a triage nurse can suggest icing the area and potentially prevent a loss from occurring, Mr. Braun said. “It's not to try and prevent claims or pay the medical outside the claim, it's to talk about giving that worker information that will help them either decide to file a claim or not,” Mr. Braun said.
When medical treatment is necessary, a triage nurse can help locate physicians and schedule appointments, taking the burden off employees, Ms. George said.
Empathy is another component and includes training supervisors and other employees on interactions with injured workers,
Ms. George said. For service providers, empathy is more than just saying, “Here's what your diagnosis means” — it's ensuring the people you communicate
with understand what you've shared.
Mr. Walls said he suggests getting to know injured workers, since they might be dealing with other problems, such as a spouse battling cancer, that could affect their recovery.
Advocacy is about establishing expectations, said Joe Picone, Glen Allen, Virginia-based claim consulting practice leader at Willis Towers Watson P.L.C. Injured workers want to know what their recovery will entail and who to contact if a check comes late.
Failing to set expectations increases the likelihood of litigation and higher costs, sources said.
“It's so important to maintain ongoing interaction with that injured worker,” Mr. Picone said. “The supervisor or (human resources) department or risk management department should be in contact with that employee and advocating for them, whether it's every 30 days, (and ask), 'How is the carrier doing? How are you doing? We're looking forward to having you back. Is there any part of the claim process right now that you have questions on? We can get answers for you.'”
While sources agree it's easier for large employers to implement such a claims model, they're split on whether employers should outsource advocacy from companies such as King of Prussia, Pennsylvania-based MedRisk Inc. and Irvine, California-based CorVel Corp. “If everybody is doing their job, I just don't see a need for it,” Mr. Picone said.
The return on investment for an advocacy-based claims model can be measured through litigation rates, claim duration, the number of medical-only claims versus lost-time claims, return-to-work rates and injured workers' satisfaction, sources said.
Independent medical reviews have helped reduce unnecessary medical treatments for injured workers, but there is worry that costs could increase since the independent reviews are being requested more often than expected.