2015 NWCDC

How a Claim Unravels

Risk Scenarios Live! explored what caused a claim to go off the rails.
By: | November 12, 2015 • 2 min read

A few gaps in communication can turn a simple claim into a long-term disability costing nearly a million dollars. That was the takeaway from the November 11 Risk Scenarios Live! session.

RiskScenariosLIVE-V2oDr. Robert Goldberg, chief medical officer for Healthesystems, and Dr. Jeffery Sugar, associate medical director, occupational medicine, for Sharp Rees-Stealy Medical Group, weighed in on a hypothetical claim around “Reggie,” a warehouse worker who tweaks his knee on the job while stepping down from a ladder.

Reggie does not immediately report the injury, and several co-workers who notice his limp – including the employer’s onsite group health nurse – do nothing to intervene.

“Early intervention is very important,” Sugar said. This initial delay in reporting allows the injury to worsen and denies the claims team an opportunity to assess the nature of the injury.

“The patient needs to be invested in their treatment plan.” Dr. Robert Goldberg, chief medical officer, Healthesystems

When Reggie finally reports the incident, he is referred to an occupational medicine specialist, who prescribes anti-inflammatories, physical therapy and a knee brace … and also orders an MRI.

“Ordering an MRI right off the bat is problematic because you’re then stuck with those results and have to do something about it,” Goldberg said. It would have been better to attempt physical therapy first, he said.

Reggie’s MRI shows a four-millimeter tear in the medial meniscus; an occupational surgeon recommends surgery to repair it. Reggie seems to want to question the treatment, but says nothing.

“The patient needs to be invested in their treatment plan,” Goldberg said. In this case, the injury likely would have improved with physical therapy and medication. Unnecessary surgery can cause more pain and impede a patient on the road to recovery.

Post-surgery, the surgeon prescribes physical therapy twice a week, but there is a delay in the approval process. By the time Reggie begins therapy three weeks after surgery, he is already highly dependent on Vicodin.

Session moderator Tracey Davanport, director of national managed care for Argonaut Insurance Co., concluded that this claim, which should only cost around $15,000 to $20,000, could easily cost at least a half-million if Reggie gets placed on permanent disability.

What could have kept this claim on track? Goldberg and Sugar said communication between the employer, insurer, claims adjuster and patient are key.

The lack of early intervention and delays in treatment approval set back the claim significantly, and made Reggie angry and less motivated to return to work.

Getting back to work is the second vital component.

“Modified duty is key,” Sugar said. This gives the injured worker a sense of purpose, motivation to stick to a recovery plan, and a sense that his or her employer truly cares.

Katie Dwyer is an associate editor at Risk & Insurance®. She can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

4 Companies That Rocked It by Treating Injured Workers as Equals; Not Adversaries

The 2018 Teddy Award winners built their programs around people, not claims, and offer proof that a worker-centric approach is a smarter way to operate.
By: | October 30, 2018 • 3 min read

Across the workers’ compensation industry, the concept of a worker advocacy model has been around for a while, but has only seen notable adoption in recent years.

Even among those not adopting a formal advocacy approach, mindsets are shifting. Formerly claims-centric programs are becoming worker-centric and it’s a win all around: better outcomes; greater productivity; safer, healthier employees and a stronger bottom line.


That’s what you’ll see in this month’s issue of Risk & Insurance® when you read the profiles of the four recipients of the 2018 Theodore Roosevelt Workers’ Compensation and Disability Management Award, sponsored by PMA Companies. These four programs put workers front and center in everything they do.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top,” said Steve Legg, director of risk management for Starbucks.

Starbucks put claims reporting in the hands of its partners, an exemplary act of trust. The coffee company also put itself in workers’ shoes to identify and remove points of friction.

That led to a call center run by Starbucks’ TPA and a dedicated telephonic case management team so that partners can speak to a live person without the frustration of ‘phone tag’ and unanswered questions.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top.” — Steve Legg, director of risk management, Starbucks

Starbucks also implemented direct deposit for lost-time pay, eliminating stressful wait times for injured partners, and allowing them to focus on healing.

For Starbucks, as for all of the 2018 Teddy Award winners, the approach is netting measurable results. With higher partner satisfaction, it has seen a 50 percent decrease in litigation.

Teddy winner Main Line Health (MLH) adopted worker advocacy in a way that goes far beyond claims.

Employees who identify and report safety hazards can take credit for their actions by sending out a formal “Employee Safety Message” to nearly 11,000 mailboxes across the organization.

“The recognition is pretty cool,” said Steve Besack, system director, claims management and workers’ compensation for the health system.

MLH also takes a non-adversarial approach to workers with repeat injuries, seeing them as a resource for identifying areas of improvement.

“When you look at ‘repeat offenders’ in an unconventional way, they’re a great asset to the program, not a liability,” said Mike Miller, manager, workers’ compensation and employee safety for MLH.

Teddy winner Monmouth County, N.J. utilizes high-tech motion capture technology to reduce the chance of placing new hires in jobs that are likely to hurt them.

Monmouth County also adopted numerous wellness initiatives that help workers manage their weight and improve their wellbeing overall.

“You should see the looks on their faces when their cholesterol is down, they’ve lost weight and their blood sugar is better. We’ve had people lose 30 and 40 pounds,” said William McGuane, the county’s manager of benefits and workers’ compensation.


Do these sound like minor program elements? The math says otherwise: Claims severity has plunged from $5.5 million in 2009 to $1.3 million in 2017.

At the University of Pennsylvania, putting workers first means getting out from behind the desk and finding out what each one of them is tasked with, day in, day out — and looking for ways to make each of those tasks safer.

Regular observations across the sprawling campus have resulted in a phenomenal number of process and equipment changes that seem simple on their own, but in combination have created a substantially safer, healthier campus and improved employee morale.

UPenn’s workers’ comp costs, in the seven-digit figures in 2009, have been virtually cut in half.

Risk & Insurance® is proud to honor the work of these four organizations. We hope their stories inspire other organizations to be true partners with the employees they depend on. &

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]