Expert Perspective | Set the Tone for Successful Claims From the Very Start

Plotting out steps to recovery at the onset of a claim helps engage injured workers in their treatment and can minimize treatment delays.
By: | February 3, 2020

For every workers’ compensation injury, there are probably dozens of ways that injury could unexpectedly spiral out of control, compromising a worker’s recovery and dramatically hiking up costs.

Payers and employers strive to spot red flags and address them swiftly. But, too often, issues aren’t flagged until treatment has already been compromised.

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That’s why strategic engagement at the beginning of a claim matters, said Melissa Burke, vice president and head of managed care and clinical at AmTrust.

Risk & Insurance® spoke with Burke about achieving best practices by engaging at the onset of a claim, managing expectations and maintaining transparency.

In your experience, what are some of the biggest obstacles that you see getting in the way of successful injury outcomes?

It starts in the beginning of the claim.

When you get injured at work, there are a lot of fears that run through your mind. Where will you get treatment? Who will pay for the treatments? Where’s your next paycheck coming from if you’re out of work?

How else does fear impact recovery?

So many of us really identify who we are by work. It’s a big part of who each person is. It’s important for an injured employee to maintain their identify as part of the workforce and being connected to their coworkers.

The unknown factors in a workplace injury can create fear. The best ways to prevent that is with information right at the beginning of a claim. If information isn’t provided early on, fear can start to take over and impact the recovery.

Many times if you end up putting a nurse on a file later in the claim, now you’re trying to unravel what it is that got them there, and we’re finding many times that there is some fear, or some unknown co-morbidity that’s been driving their chronic pain.

Had we addressed it earlier, we may have had a different outcome for that claim.

What other factors can negatively impact a claim early on?

There are a lot of traps out there for injured employees — empty promises or bad roads that a claim can go down if we don’t set them up right from the beginning. The goal is to make sure injured employees are informed and understand not only their rights but also that this is about them returning to work as soon as medically appropriate.

It’s also about setting an expectation about pain. There’s going to be certainly some pain involved, right? If you’re having an injury, you’re going to have acute pain and we’re going to manage that and work through it, but this is not who they’re going to become. They’re not an injured employee. They’re still going to get back to their life that they had prior to their injury as best they can.

We need to set expectations with the injured employee. I think the word expectations is one of the biggest lessons in managing a workers’ comp claim. Expectations will change the outcome. It’s important right from the beginning, whether it’s a catastrophic claim or a simple sprain or strain.

The more that the care team drives information to the injured employee, the better it will be as well. Information really is power. It allows the injured employee to feel that they own their claim process, they own their health care, they own their recovery.

We know based on other health care studies that the more activated and the more ownership an individual has for their wellness, the better off they’ll be. That’s why we want to drive those same concepts in workers’ compensation.

How does engaging a nurse early help set the tone for success?

Right from the beginning a nurse can be that resource for an injured employee. They can be a source of medical information, their partner in their journey to recovery, setting the expectation about what doctor will do, about how the doctor will help them, about how we’re going to return them to their prior functional ability. The nurse can set those expectations right away and work with them.

Nurses can also engage with injured employees to let us know what else could be impacting their health. Do they have other chronic conditions that we need to be aware of that may be impacting their injury or their ability to recover? We want to engage the injured employee and let them tell their story so that we can find out what else is important and how we can best support them.

A nurse can really drive the patient engagement in their own claim and help them to be active in their own health care, in their own wellness so that they can get back to work as soon as appropriate.

Can the same approach help payers keep prescriptions in check?

All of our prescriptions that require a clinical review are routed directly to nurses, When nurses look at these medications, they can assess, is this the right drug at the right dose for the right injury, at the right time, and then review that against evidence-based guidelines. We want to use the most conservative and safe treatment for an injured employee. That’s what our nurses are able to verify.

What helps injured workers to connect with nurses and to feel like they can trust the process?

In order to drive trust with any professional and an injured employee, you really need to start with transparency. Give them information, let them know what the process is so they know what to expect.

Engagement, expectations, documentation, transparency — those are all very big components to building that trust with an injured employee. Letting them know who they’ll hear from, who they’ll interact with and when they are expected to return to work based on their injury. Get their input on what happened and finding out what their needs are, so that we can address them to help them return to work.

All parties being in communication, the adjuster, the nurse, the provider, the employer — they all need to work together. The whole care team needs to work together to drive an optimal outcome.

We’ve been talking about engaging early in a claim life cycle, but what can be done before claims occur to help facilitate better outcomes, and ensure that there are no organizational barriers to getting injured employees back to work?

It’s about having the right programs available. If an injury occurs, what are the transitional or modified duty programs that you have available? We work with the employer so that we understand the job description and what’s truly involved in the job. Is it lifting 30 pounds up? Is it lifting 30 pounds up and over your head?

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Having job descriptions ready that are clear and concise for the provider, so that they know when an injured employee is ready to return to work based on what they can do.

Being able to understand the details behind each job description can help the rest of the team, the adjuster, the nurse, the provider, all work together to identify the best way to get an injured employee back to work as soon as appropriate.

It’s also about letting employees know what to do ahead of time if they have an injury, who to report to, who to go to for that initial information. Having the network available so they know where to look for care.

We know that drives a difference in the outcomes — making sure that those lines of communication are open, that an injured employee isn’t fearful of reporting an injury, so that they do come to them right away. It’s about having those resources available. &

Michelle Kerr is workers' comp editor for Risk & Insurance. She can be reached at [email protected]

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