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Claims Management 03

Managing Claims for the Benefit of Consumers

Christopher Mandel | March 18, 2016

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Injured businessman at his desk

Most claim professionals have, from the inception of their careers, been typically focused on either property or casualty claims. While over time they may get exposed to both, when they switch focus, it is usually either due to a promotion or reassignment for developmental purposes. Even today, claim professionals rarely get exposed to the benefit claim world due to the significantly different focus of these claims and, to a lesser degree, the ways in which they are handled.

"Handling" for one (property/casualty claims) is rooted in civil legal procedure, whereas handling for the other (benefit claims) is rooted in the more administrative considerations that are a function of contractual commitments dictating process routines, which enable compliance. P/C claims are adjudicated in civil courts of law, and benefit claims are typically under employer-defined administrative claim resolution forums. Both may be expedited by arbitration or other third-party resolution processes.

The result has been that claim skill sets are often very narrowly focused on the specific types of claims assigned. Not inappropriate and, in fact, essential to handling claims with the best practices and excellence, this inures to the benefit of both claimants and employers/insureds, when applied consistently. Other stakeholders—including courts, service providers, lawyers, and communities—also benefit from greater efficiencies, of which the outgrowth can be lower, system-wide costs.

This might imply that this specialization is preferred for the reasons stated, but a well-rounded claims professional who is capable of handling any type of claim based on the needs of the business may be a more satisfied professional with a career track more motivating and energizing in the long haul. For insurers, self-insureds, third-party administrators, and claim adjustment firms of all types, this is a critical element of building and maintaining a high-performance workforce.

Collaborative Strategies

The long-minimized and largely untapped synergy between casualty and benefit claim programs offer opportunities for both risk and benefit managers that would not only facilitate career opportunities for claim professionals but leverage synergies between the related exposures that could benefit all stakeholders. Some argue that the worlds of these two claim specialties are just too different and distinct to bring together, whether through simple alignment or partial-to-full integration. Managers are often more comfortable in their own functional areas, and sometimes crossing over can stretch expertise and focus. Fundamentally, however, claims are claims, though subject to the unique rules of processing and resolution. But with all this in mind, the ultimate benefit may lie at the intersection of workers compensation claims and "nonoccupational" (benefit) claims, where disability, medical care, and other components of the handling process overlap.

There's been a shift in thinking and a growing interest in a more collaborative, aligned, and even fully-integrated services approach. While it takes many forms, at its core, it incorporates a more collaborative and combined strategy from the date of the accident or the inception of symptoms through claim closure. The targeted goals for these types of strategies are as follows.

  • Ensuring a good, if not great, employee experience throughout the life of the claim. This is the new "job one" and key driver for this approach. Except for the savings from process efficiencies that flow naturally from this focus, ensuring that injured or sick employees are able to navigate through the "system" with minimum difficulty is the minimum due the people dealing with significant stressors.
  • Targeting and delivering outcome optimization. This is the holy grail of disability management, and it expands on the previous goal. At the end of the day, whether an on-the-job injury or a sickness- or disease-induced disability, what everyone wants most is a rapid recovery with the resumption of as much normality as possible and the least possible amount of dissonance and friction in the recovery process.
  • Minimizing the cost of risk associated with the reasons employees require medical care and/or are unable to contribute productively to their employer's mission. While expense control is not an insignificant driver for risk and benefit manager activity, it should not be the first priority. There will always be some pressure to make it so, but the most progressive practitioners are those who understand and act with the interest of injured or ill employees at the fore. When this approach becomes consistent, the money follows. Risk and benefit managers need to recognize this fact and act accordingly.

Other Shared Goals

On its face, the value of collaboration seems obvious. From both an employee benefits and risk management perspective, providing care for the individual should be of the utmost importance. The main objective is ensuring the right outcomes, which includes leveraging the basic skill sets of investigation, verification, documentation, and equitable resolution that are common between these two realms. The nuances and distinctions that exist between these disciplines are not insignificant. Other key goals include the following.

  • Showing sincere care for people under medically related distress (regardless of source).
  • Minimizing disruptions to workforce productivity.
  • Closing claims efficiently and effectively with fairness to all parties and their respective goals and objectives.

Although these objectives have varying levels of importance in each realm, they are fundamental to process effectiveness in both. This is not to say that there aren't peculiar and unique aspects of each that require certain expertise and specialized skills to achieve more specific end goals. However, while blending skill requirements among a common group of claims professionals can be challenging, it has been successfully accomplished.

Defining and filling positions to enable successful claims handling in both worlds is challenging yet doable. The biggest hurdle may in fact be the necessary extent of collaboration among and between these typically distinct functional areas and their leaders to secure the best outcomes for injured employees. That can run the gamut from minimal to fully integrated, and will largely be a function of the company's culture when it is deployed.

Emerging Trends

Many employers are already effectively managing employee injury, illness, and disease exposures. However, there are discernable trends emerging in favor of linking siloes and driving more performance-oriented measurements that are focused on both short- and long-term strategies. Those companies are taking a more collaborative approach benefit from this in the following ways.

  • Happier, more engaged, and more cooperative employees. If employees believe that their employers really do have their best interests in mind, their motivation for returning to work earlier, cooperating fully with doctors and other medical providers, minimizing related expenses, committing to rehabilitation goals, etc., will be more likely and will drive greater alignment with employer interests.
  • Integrated reporting and measurement across departments. While there may remain more than one functional leader at the highest levels who is ultimately interested in results, a more holistic and refined approach is critical to how success is measured and reported. If, as I posit, the ultimate reporting goal is to get the right information to the right people at the right time, then a consistent yet comprehensive set of metrics and an aggregated rollup of those metrics into a single, integrated report to all stakeholders should be the goal. In support of this would be the collaborative pursuit of a data collection and a management platform serving all stakeholder interests, managed with a common enterprise-focused set of interpretable information in mind.
  • Robust analytics that result in prescriptive actions with impact. As an extension of the last point, these more powerful approaches foster more robust analytical capabilities that are focused on not just predicting what may be, but are also focused on having access to actionable information that allows for specific decisions to be made to solve incremental issues along the recovery path for each employee. For the collective group of employees that underlies the aggregated exposure (i.e., the workforce), the same, even more powerful benefit is possible. There are no shortages of technology tools that can bring these goals to life.
  • Innovative tools targeted to specific process opportunity areas. Beyond the technology referred to in the last point, tools and techniques that support the subcomponent process areas, which support the strategy for alignment or integration across siloes, are continually evolving. Engaging the appropriate elements of process engineering capabilities can also lead to process improvements that are focused on efficiencies and effectiveness, which serves the interests of injured or ill workers first, and which then naturally inures to the benefit of other stakeholders, particularly the employer. In both cases, while investment is required, we know that nothing of value is free.
  • A more holistically focused use of often-disaggregated resources. Medical providers have often acted in isolation in treating the injured and ill, but more and more frequently, the more progressive providers, including not only doctors but other nonmedical providers, are collaborating to ensure the best outcomes are achieved and the interests of the ill or injured are properly prioritized.
  • Achieving a healthier, more productive workforce. While treating each ill or injured employee is a singular event with a singular focus, the aggregate of these individually focused activities feeds into the enterprise interest in a workforce minimally disrupted by injury or illness and toward happy, productive employees whose priority is their individual and collective contributions to enterprise success. Everything about this approach aligns with this long-term focus and, when instituted consistently and with excellence, can lead to a true competitive advantage.


So, whether you have direct responsibility for occupational/nonoccupational injury and illness areas (or both), I urge you to consider the tactics and strategies that would leverage this powerful opportunity to put employees first, make sure they know that they are your priority, and secure the benefits that will come to your organization and culture as a result.

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