The Unique Demands of Workers' Compensation Claims

By Laurie Parsons, WCLA, FCLA, Director of Claim, A.I.M. Mutual Insurance Companies

Laurie Parsons, WCLA, FCLA, Director of Claim, A.I.M. Mutual Insurance Companies

In workers’ comp, the clock starts ticking right away. Claim reporting, medical care for injured workers, and processing benefits are critically time sensitive. Add state compliance issues, litigated cases and provider payments to the list, and it’s clear this complex arena demands heightened tech support.

Unlike other commercial lines, workers’ compensation presents a unique set of challenges, among them, confidentiality, a fragmented network of external resources, and stringent requirements that vary by state. Carriers not only need responsive systems, but they need to stay on top of an ever-changing landscape.

Technology strides are readily apparent in four key areas:

First Report of Injury

Online reporting is invaluable when it comes to expediting and triaging claims. At A.I.M. Mutual, our automated process captures more than the minimum reporting requirements, flagging injuries that are potentially more serious at the outset. More information means adjusters can assign nurse case managers faster, if needed, make more accurate determinations for claim expenses, and fully establish the case file for team access.

Predictive Modeling

Predictive modeling is a differentiator among carriers, with recent research showing it’s a rapidly-growing best practice with proven results. Not only can it help to better manage claims and project outcomes, it can make a major impact on the initial and ongoing course of treatment for an employee injured on-the-job.

As early as 2005, A.I.M. Mutual supplemented state-mandated reporting with additional data collection, authorized by the injured worker, which includes background information such as smoking history. With this enhanced criteria, claim managers get an early ranking of an employee’s general health, which can be a basis for whether surgical intervention is a viable option, for instance. We’ve learned an employee’s physical condition at the time of injury is a key determining factor for recovery and return to work, coupled with the nature of the injury and its severity. A “one-size-fits-all” treatment plan won’t work for everyone, and our medical outcomes reflect our more considered, comprehensive approach.

Injury and Pharmacy Management

With online access to approved providers and pharmacies, we are making medical care easier for injured workers to navigate. We continuously work with our pharmacy network to code and manage prescription access, minimizing delays through the course of treatment and controlling costs in a far more efficient manner. Our percentage of injured workers on an approved course of opiates is lower than the industry average, in fact, due in part to those medications requiring prior medical review in our formulary.

Trauma Services

As technology accelerates the information flow, we are broadening the scope of some claims, particularly those involving a traumatic accident at work. Co-workers who witness the event are often in need of medical care, which frequently goes undiagnosed.

In these cases, we can now alert our trauma counseling partner, who in turn, can be onsite next-day to evaluate what services are needed. It’s not enough to send a referral; we ensure employees get immediate access to a qualified counselor by checking availability through an integrated, online network.

Automation as a Claim Management Tool

Anytime you introduce technology to claims management, the goal is to improve speed and, hopefully, quality. But there will always be a need for the human touch in workers’ compensation: we’re dealing with people, not car parts or machinery. That can’t be overstated.

I tell our adjusters to go with their gut after talking with the injured worker and conducting a complete case review. An injured worker may rank poorly for anticipated outcome, based on analytics, but you might discover through investigation that he’s dedicated and highly motivated to meet his treatment plan. Technology at its best will augment—not camouflage—the human element.

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