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Column: Workers' Comp

Can We Walk the Advocacy Talk?

By: | May 2, 2017 • 2 min read
Roberto Ceniceros is senior editor at Risk & Insurance® and chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at [email protected] Read more of his columns and features.

It’s impossible to avoid recent talk calling for increasing injured-worker advocacy and engagement by treating injured workers with more compassion and empathy.

It remains to be seen, however, whether taking a softer, more supportive approach to injured workers is just talk. Or will the philosophy take hold across the workers’ compensation industry, significantly reshaping claims management practices, such as slashing the percentage of claims referred for investigation and litigation?

Accompanying the argument for greater injured-worker engagement is the idea that the vast number of workers’ claims are legitimate, with employer-premium fraud and provider fraud being much bigger problems.

So why not spare the valuable resources spent chasing the tiny percentage of cases involving workers attempting to bilk employers?

Why not shift the attention to improving claims outcomes overall by engaging injured workers who need a paycheck as much as employers need them back on the job?

This is not an argument for eliminating all worker-fraud investigations. There are cases needing prosecution.

But it is a call for reexamining claims-management philosophies, re-evaluating which practices to emphasize and reshaping how injured workers are thought of.

The discussions about injured-worker empathy and engagement in the workers’ compensation arena are hard to miss, meanwhile.

Why not shift the attention to improving claims outcomes overall by engaging injured workers who need a paycheck as much as employers need them back on the job?

A recent newsletter from a major broker, for instance, recommended training managers in listening and showing empathy as a strategy for reducing workers’ comp litigation.

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During the 2016 National Workers’ Compensation and Disability Conference® & Expo, keynote speaker Tim East, a director of corporate risk management at The Walt Disney Co., encouraged claims payers to focus on advocating for injured workers.

And a workers’ comp practice leader at a major third party administrator, as another example, recently spoke to me at length about his organization’s adoption of “a culture and philosophy around caring.” He did this when I called asking about difficulties establishing injury causation.

And yet, those in a position to know have not seen a decline in claims referred for investigation. Court cases also reveal plenty of examples of claims payers, perhaps needlessly, pursuing injured-worker fraud.

A Louisiana appeals court, for instance, recently found for a worker who sold a horse for $3,500 while receiving workers’ comp benefits. His employer and the employer’s insurer argued the 76-year old committed fraud by claiming he had not received any income.

The courts believed the worker’s argument that he bought the horse 19 years earlier for $20,000 and that raising horses was a hobby. The insurer’s claims adjuster admitted at trial that had the claimant earned money from a garage sale it would be immaterial to his workers’ comp claim.

The claimant won attorneys’ fees for both trial and appeals court expenses.

Such outcomes do raise questions about the resources spent pursuing fraud.

Some leading-edge employers have shifted to emphasizing injured worker advocacy, and their claims service providers are espousing the philosophy.

But it will take time before we really see whether a system bias favoring fraud investigations is widely replaced by an advocacy approach. &

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The R&I Editorial Team can be reached at [email protected]