The ecosystem of factors influencing a claim’s outcome has changed significantly. Take, for instance, litigation costs. In the last decade, costs have risen as a result of nuclear verdicts and social inflation.

“Risk managers and claims managers are not only tasked with proactively protecting against risks; they’re looking at how to reduce expenses,” said Jeff Sickles, chief claims officer at Broadspire, a Crawford Company. “That is why the adjuster is such an important part of the process. They have a financial responsibility that they are held more so accountable for today than 10 years ago.”

The adjuster plays a vital role during a claim’s lifecycle. From interacting with injured workers, claimants, carriers or other individuals on the claim, the adjuster is the person “in the know.” They may be viewed as a transactional resource in the past by some. Good for completing forms, checking boxes and sending out checks.

But there is much more to the role than that.

“In today’s world, adjusters are truly an extension of a risk management team,” Sickles explained. “Claims managers are tasked with mitigating exposure. Claims have a financial impact, and every dollar an adjuster spends is a dollar the client can’t invest.”

Adjusters have a unique opportunity to drive change and work toward positive outcomes that can benefit injured workers and client alike. As the role has evolved, so too have the responsibilities.

“The adjuster is a strategic resource that creates opportunities throughout the life of the claim to reduce cost and drive a better outcome. How this information is communicated is as important as the actions themselves. They are in a strategic position where they can communicate information to all parties on a claim and act as a lifeline to insureds and injured workers, suggesting next steps or other avenues to mitigate exposure,” Sickles said.

When everyone involved embraces this approach, the opportunities for better claims outcomes are exponential.

Here’s how employers, carriers and everyone in between can lean into this opportunity and drive positive outcomes.

Communicating at Scale: From 90-Day File Reviews to Instant Action

Jeffrey Sickles
Chief Claims Officer, Crawford TPA: Broadspire

As a critical element for success in any claims program, communication has improved with technology, both in frequency and quality.

“In the past, updates were sent to risk managers, carriers and other members of the claim via a data file or status report that they might be receiving every 90 days,” Sickles said.

“Today, information is needed in ‘real time’ as multiple parties are responsible for the outcome of a claim. When injured workers are actively treating, losing time from work, or when a claimant on a third  party liability claim undergoes surgery, information in today’s claim world must be communicated immediately. The goal is to not only communicate the historical issues and details. The adjuster shares their overall resolution strategy for the claim to address those issues with a solid plan, timeline and outline of the financial impact to the file. This is the art and science of strategic claims management in 2021. Since files are now paperless, there isn’t a hard copy claim file being sent around anymore. We can share these updates immediately.”

Simply knowing what is happening on a claim in a clear, understandable way puts risk managers and carriers in a better place to make confident decisions.

“In addition to the transactional history of what’s happened on a claim, what the adjuster plans to do is recorded and shared in a digital action plan,” said Sickles. “This has two functions: All stakeholders have real-time access to files and can see exactly what the adjuster is working on to keep the claim moving. Also, risk management can see the financial impact and report it to their senior management. Everyone knows what is happening, and the adjuster is able to act as a catalyst to achieving positive outcomes.”

Technology has certainly created an instantaneous avenue of communication between adjuster and an insured’s claims team. But it doesn’t stop there. Using actionable knowledge to efficiently drive decisions is where insurers see the most benefit.

Making Smarter, Faster Day-to-Day Decisions

When it comes to workers’ compensation claims, adjusters can intervene in a claim long before issues arise.

In the past, decisions on when to intervene were made on a case-by-case basis. Today, gaps between raw information and taking relevant action are being closed by technology built into the best claims programs. Adjusters no longer have to rely on a physical file to find opportunities to better mitigate a claim and bring it to conclusion; instead, the adjuster is able to leverage predictive modeling and AI to flag those opportunities and find solutions.

“Since all the information is digital, we can rely on technology more,” said Sickles “Adjusters see what needs to be addressed and take care of it immediately. If an injured worker needs medical management intervention, the adjuster can see the opportunity and take action much faster than they would have been able to in the past.”

As information is collected in a claim file throughout the life of the claim, predictive modeling reviews and flags anything that could act as a potential delay or issue on the claim. From there, the adjuster can step in and look at the tools available to them to mitigate a claim’s exposures and keep the file moving through the process.

Matching Tactical Claim Actions with Strategic Goals

The end goal for any claim is a swift, cost-effective resolution that also results in a positive outcome for the injured worker. As noted above, adjusters need a strategic plan to arrive there. So how do they get there?

While the exact details may differ on each claim, keeping the end in mind and having a broad view of what’s happening helps adjusters stay focused on success.

“In addition to helping adjusters make better day-to-day decisions, the technology enables adjusters to take their evaluations a step further. They can look at the claim from a more holistic view. They have this data, this information from the predictive modeling. Now they can ask themselves, ‘How can I use this to get us to the best ideal claim outcome?’ ” Sickles said.

The answer, he continued, is collaborating with stakeholders on each claim, putting a broad strategy into place and sharing the plan. This is also where constant communication comes back into play. “After they have created the strategic resolution plan, everyone involved needs to know what the plan is and how it’s progressing.”

Knowing when a claim may need intervention, deciding the next steps to either prevent it from heading to litigation or guaranteeing that medical management intervention happens on schedule are critical. These all place the adjuster in a strategic place to be as efficient as possible on the claim itself while also helping the injured worker recover.

A New Approach to Lower Litigation and Reduced Costs and a Better Claims Experience

It’s one thing to understand how and why the adjuster role has changed; it’s another to see the actual benefits clients and the marketplace at large gain from such a change.

Litigation and the likelihood a claim is litigated has dropped thanks to the strategic adjuster. Costs associated with managing claims, especially workers’ comp claims, have also seen an impact from adjuster intervention and aid.

All this enables employers and carriers to trust that their claims are going to be handled with care by their adjusters.

Connie Davidson, claims manager with Service American, a Broadspire carrier partner, can attest to the rewards of having a strategic adjuster on a claim: “Seeing detailed action plan notes in cases is great. It is easy to see the adjuster’s plan of action, why the file is still open, what is being done to bring it to closure and if the reserves were adequate. It is really nice to see these improvements,” she said.

The improved experience goes beyond the insured and improves quality for everyone involved. Placing communication with the injured worker at the forefront further ties into the advocacy-based model in workers’ comp as well.

“With fewer tactical decisions on their shoulders, adjusters are better able to improve communication with an injured worker. Beyond being the right thing to do, this kind of empathetic attention is a big driver of reducing time away from work and potential litigation,” said Sickles.

“Indemnity spend and lost work days used to be the most expensive part of a file. But that’s changed,” said Sickles. “Now medical costs are taking the lead. And so, what an adjuster is really doing is stepping in and building rapport with the injured worker and gaining their trust by getting them the appropriate medical care to return them back to work.”

Further, as Sickles noted, this rapport that the adjuster builds goes beyond one injured worker: “You don’t want, within an organization, to have one injured worker’s poor experience to boil over to other workers in that same facility. You want everyone to understand they’re going to get treated and cared for in the event they have to file a workers’ comp claim.

“People with any stake in the claim can have high confidence knowing the way the adjuster is managing the file is in line with the way they want the file managed and aimed at an outcome benefiting everybody,” Sickles added.

To learn more, visit: https://www.choosebroadspire.com/.

This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Broadspire, A Crawford Company. The editorial staff of Risk & Insurance had no role in its preparation.