Expert Commentary

Advocacy: Claimants as Consumers

Having started in the claim business early in my career, I can validate that the business model for service delivery has changed dramatically. For me and my then colleagues, newly minted claim adjusters all, our mandate for adjusting casualty claims was to take our company-provided cars and hit the road 4 days a week, interacting with claimants, witnesses, lawyers, and other service providers and stakeholders.


Claims Management
October 2016

We were required to be in the office no more than 1 day a week when the administrative aspect of the job would get completed. In truth, as in most new entry-level jobs, more time was needed for both assigned activities to deliver on the caseload assignment levels of the day. No worries, we were all greatly enthused with this interestingly diverse line of work, feeling more like the "investigators." After all, our core responsibility was to investigate, gather, and synthesize the facts into a usable form for decision-making.

The heart of those decisions led to a determination of how a claim would be resolved and closed; importantly, how the "claimant" would fare compared to their expectations of the claim and all its component parts. Safe to say that, typically, those expectations were assumed to be most related to the financial aspects of losses. In fact, it is now more widely understood that, for many if not most, the real priority was and is fair and equitable treatment among stakeholders and the quality of the ultimate outcome.

It wasn't even 5 years after I started in the claims profession that the tide began to turn, resulting in changes in that business model. These changes were driven in large part by a need for greater efficiencies in order to meet business performance expectations of the various stakeholders. For most, that meant ditching the company cars and bringing the adjusters inside to desks where the vast majority of these investigative efforts would typically be performed via telephone (PCs were just beginning to become commonplace then). Nevertheless, the newly designed protocols for task accomplishment were centered in remote interactions with the various players involved. There was tolerance for a limited amount of "fieldwork," but, over time, the pressure to minimize these more expensive efforts increased as the role became largely defined as "desk adjusting."

This change in approach was not inherently bad or wrong. Insurers and others delivering claim services were increasingly under pressure to find efficiencies in an increasingly competitive industry and world. For most claims then, and I suspect now, this approach works just fine, but it does carry with it an inherent distance from people that sometimes leads to less than great interactions and understanding among parties. The effect is not unlike today's obsession with texting in lieu of calling (let alone in-person interactions). Texts are not only impersonal but often result in confusion and even confrontation—clearly never a desirable outcome. Poor communication can be an outcome destroyer, especially when lawyers are retained to "resolve" claims, leading to protracted and more frequent disagreements among parties. As you would expect, the implications of cost increases are significant in many types of claims, especially workers compensation claims.

Recently, a straightforward yet powerful concept has emerged that addresses many of the challenges created by the distance that has evolved between claimants and claim professionals. That concept is "advocacy"—where "claimants" have evolved into "consumers."

What Is Advocacy?

Generally, advocacy is supporting or championing an idea, cause, or policy, helping educate, edify, and even eliminate obstacles to these pursuits. But, in the context of great management of, for example, workers compensation claims, it takes on a more specific meaning, beginning with engaging the injured worker (IW) to obtain a fair and equitable claim result. This begins with an intentional effort at:

  • Explaining the claim process
  • Helping the IW through the vagaries of the process after an accident
  • Using well-developed, interpersonal skills and even emotional intelligence that can calm their fears and anxieties
  • Making sure the IW's questions are answered quickly and accurately
  • Interacting in such a way that a trust relationship is established and furthered

Why Adopt an Advocacy Approach?

The claims process is not always transparent. It can be a daunting, confusing, frustrating, and even scary experience, especially for first time IWs. Helping IWs navigate through the process and the various players in that process can create trust and reduce IW anxiety. We can simplify a complex process. That makes it the right thing to do.

This simple advocacy approach naturally leads to fewer IWs who feel the need for a lawyer to represent their interests and concomitantly reduces litigation. It also can lead to IWs returning to work sooner, which reduces the hit to productivity among coworkers on the team. Not all litigation can be avoided, however, especially in workers compensation (WC). The following are more likely to retain an attorney in the WC realm:

  • Those over the age of 45 are 3 times more likely to retain a lawyer
  • Those with less education
  • Those who do not speak English well
  • Those with comorbidities and psycho-social issues
  • Those who have performance issues at work

The key is to build enough trust, quickly, so that there is no perceived need for retaining a representative.

Every party desires better outcomes for the IW. However, the claim environment is becoming more complex. Despite reductions in frequency, severity is up due to an increase in continuous trauma, growing opioid misuse, increasing complexities of comorbidities, and more psycho-social issues. Examples of the impact can be profound, such as:

  • The doubling of medical costs in the last 5 years
  • Indemnity costs increase exponentially
  • Rapid escalation in opioid utilization
  • Migration of claims and/or claim costs into other programs
  • Increasing difficulty and delay in resolving claims

The cumulative impact of all these elements can and often is significant in both expenses as well as frustration for IWs. When IWs are frustrated, all players feel the pain.

Early and consistent application of advocacy principles is central to its successful execution. That means the first line of defense is the claims professional, the same person conducting the investigation and tasked with determining if the claim is payable. It begins there, where the opportunity to employ these components for the IW starts and must be sustained. Yet, there are other contributors to the processes underpinning successful IW advocacy. They include:

  • The employer (e.g., risk management, human resources, operations, or the supervisor)
  • A nurse case manager where appropriate
  • All medical professionals engaged in the care provided

As all stakeholders work together to produce the desired outcomes, it is important to know when to engage in advocacy and what the limits of its use may be.

What Should the IW Expect from Advocacy?

Every IW deserves to be treated with dignity and respect. Likewise, the IW needs to assist in the claim investigation. Examples of this two-way give and take of key information that enables the best claim result include:

  • IW receiving preferred medical provider information
  • Accident facts and other details needed for investigative purposes, to both determine compensability as well as to prevent future similar occurrences
  • Information necessary to ensure fair delivery of benefits so that IWs clearly understand their rights and obligations
  • Information needed for nurses to work with IWs and their doctors to ensure they receive quality care and understand their treatment plan
  • Information about return-to-work planning and possibly alternative jobs if the IW is not ready to return to their regular job
  • Information to IWs about all benefits due and when they can expect payment

What Is the Employer's Role in Advocacy?

The employer's most important role is to show consistent and sincere care and concern for the IW. This includes demonstrating empathy. It means getting them prompt medical care, as needed, as well as helping them select medical providers and providing physician's forms, pamphlets, and prescription information.

The employer is also critical to providing investigation information about the accident, completing first reports, providing employee information and accident facts, identifying witnesses, sharing safety rules and policy, offering transitional work, if possible, and in general keeping the parties connected in the interests of the IW. Superior employer engagement can be practiced by engaging in "care calls" to the IW, sending "miss you" cards to them and/or their family, visiting the IW in hospital or even at home, and generally reinforcing that the IW is empowered to get the best claim result by staying fully engaged in their treatment and recovery.

Claimants to "Consumers"

Using the traditional term "claimant" sets up an adversarial relationship from the first interaction. While exerting a "claim" is a legal right, under the right set of conditions, an entitlement to benefits that are dictated by the relevant WC statute makes IWs "consumers" of WC services. Yet, the other aspect of advocacy that is emerging is viewing the IW as a "consumer" or customer, not a claimant. While "the customer is always right" is the ultimate version of this view, advocacy does not assume this by default. The IW deserves the benefit of the doubt, and it is critical to convince IWs that you sincerely care for and will protect their interests as your priority. This is definitely a departure from tradition.

What Is the "Consumer's" Role in Advocacy

For these advocacy principles to work, the IW/consumer must not only be engaged in their claim but be accountable for that engagement. That accountability includes, among other things, these elements:

  • Reporting accidents immediately
  • Obtaining prompt medical attention, as needed, and in accord with the rules for doing so
  • Cooperating with treating physicians and the medical treatment plans and direction they give
  • Keeping the employer (manager/supervisor) aware of the claim status, the progress of the claim, and bringing any concerns the employer can address
  • Cooperating in transitional duty opportunities
  • Cooperating with the handling claims professional
  • Asking questions and reaching out for help when confused, frustrated, or concerned

What Is the Claim Professional's Role in Advocacy?

As with the consumer, the claim professional must be accountable in the claim process. This includes these elements:

  • Explaining the claim process to the consumer
  • Investigating the injury fairly and promptly
  • Determining compensability as soon as possible and communicating the findings
  • Demonstrating empathy and urgency throughout the pendency of the claim
  • Explaining the WC benefits and IW/consumer's obligations
  • Ensuring all benefits are timely paid
  • Keeping in touch with the consumer regularly

What Is the Nurse's Role in Advocacy?

  • Reviewing medical treatment sufficiency and progress
  • Working with doctor for timely diagnosis and evidence of an effective treatment plan
  • Working with the IW/consumer to ensure understanding of their injury, treatment plan, healing process, and what to expect along the way
  • Prompt utilization review
  • Watching prescriptions and working with the doctor to avoid dependency

What Is the Role of Medical Providers in Advocacy?

  • Building relationship with the consumer/patient
  • Providing the right care, at the right time, with the right specialist providers, as needed
  • Targeting the best outcome possible
  • Championing the consumer/patient's recovery

What Are the Benefits of Advocacy?

When the elements are employed well, IW/consumers should expect:

  • An overall better claims experience for the injured worker
  • Avoiding litigation and its delays and costs
  • A shorter claim duration
  • A better outcome
  • Earlier return to work
  • Understanding between IW and other stakeholders

Conclusion

Now that the roles in advocacy are clear, it's all about the execution. Even without all players hitting on all cylinders consistently, the elements that are deployed can still have a favorable impact on the claim. Successful execution comes from effective education, training, and reinforcement of the overarching principles and acceptance by stakeholders. When the potential benefits are understood, that acceptance should be readily obtainable.

The days of company cars and in-person adjusting may be long gone, but advocacy—properly employed—can make up for most if not all that was lost in the modernization of claims management.


Opinions expressed in Expert Commentary articles are those of the author and are not necessarily held by the author's employer or IRMI. Expert Commentary articles and other IRMI Online content do not purport to provide legal, accounting, or other professional advice or opinion. If such advice is needed, consult with your attorney, accountant, or other qualified adviser.

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