Focus on Claims Management: A Patient-Centered Approach

Executive Summary

Redesigning the workers’ compensation claims process to be more patient-focused and supportive of injured employees can have a positive effect on employee health outcomes and employer spending. A well-trained, multidisciplinary team offering immediate assistance and patient advocacy allows injured employees to get quality care and compassion when they need it. In addition to reducing costs for employers by improving outcomes and minimizing indemnity claims, it improves morale by letting employees know they are more than a number on a ledger. Modern technologies like the web and mobile devices are key to facilitating the communication and coordination this patient-centered model requires.

Introduction

For all too long, the workers’ compensation claims process has been considered a necessary evil. Companies dread the hassle of filing an incident, while employees assume making a claim will be an adversarial process in which they have to fight to have their needs met. In reality, improving the reporting process and facilitating effective early intervention is a valuable opportunity for enhancing health outcomes, enabling faster return to work, and reducing workers’ compensation costs.

A Patient-Centered Approach

Getting injured at work can be an overwhelming experience marked by fear, embarrassment, pain, and uncertainty. A seemingly uncaring employer, distracted healthcare providers, confusing workers’ compensation reporting procedures, and busy claims adjusters can all add to this stress. The perceived emphasis is on who will take responsibility for the care versus ensuring the injured employees receive the best care for their situation. This can lead to delays in reporting, failure to receive timely care, and the emotional burden of resentment and anger.

Ultimately, the adjuster, employer, and employee have the same objective in any workers’ compensation incident: full medical recovery and return to the prior work position with no unnecessary pain and suffering. The traditional filing process makes this shared goal less obvious. Instead, the frustration of the process and approach can make the injured employee disgruntled. Couple this with slow reporting, and you have a recipe for inflated claims or enhanced memories of the pain and suffering experienced. It’s the classic big fish story where someone’s recollection is exaggerated.

A shift in the workers’ compensation process to a more patient-focused approach can minimize these challenges. Studies have shown that what patients want most during interactions with the healthcare system is solid communication and empathy. Through a more collaborative approach involving employers, providers, and payers, the workers’ compensation claims process can offer better communication and advocacy to injured employees.

A patient-focused approach relies on training, multi-disciplinary experience, and coordination for positive collaboration. In this model, a case manager with clinical experience and communication training responds first to the claim. The priority is directing injured employees to resources that can deliver the care they need. A 24/7 nurse triage hotline offers immediate clinical support for minor injuries, and employers have access to resources to improve workplace safety. When the workers’ compensation filing process focuses on patient advocacy, connecting injured employees with immediate, appropriate care, and consistent information sharing, the experience is dramatically different.

Improving the Experience with Technology

Fully implementing this patient-centered model requires different process flows enabled by technology. This starts with the simple act of reporting. Today’s mobile and web technologies can make reporting a claim almost instantaneous. Allowing real-time filing via phone, mobile device, online, or email can speed up the process and facilitate faster access to critical care.

One way to accomplish this is by having that initial interaction done by a medical professional who can quickly assess the injury, create a personalized treatment program, and direct the employee to the right caregivers for optimal care. Another critical component of advocacy is open information sharing among parties. By implementing a singular database that includes claims and care information that key stakeholders can directly access, companies set a distinctively different tone in their approach to workers’ compensation claims and can dramatically enhance care efficiencies. This shared information improves the accuracy of the initial claims reports.

A Better Experience Minimizes Escalations

Employers overwhelmingly want to create workplace cultures where employees feel safe and comfortable reporting injuries before they snowball into lost time and more severe conditions. A patient-focused workers’ compensation claims process enabled by modern communication technologies furthers this goal. It also improves injured workers’ chances for a swift recovery to total health and continued productivity.

The importance of early intervention when a workplace injury has occurred cannot be understated. Delayed reporting can cause claims costs to skyrocket. Early intervention reduces claims costs by improving health outcomes and morale. This can show up by reducing indemnity claims, reducing medical-only claims to first aid incidents, and reducing the percentage of claims that become litigated. Across the industry, companies saw an increase in indemnity claim severity of six percent year over year, according to a May 2023 report from the National Council on Compensation Insurance. In this same environment, CorVel has taken an early intervention approach, which has helped its clients reduce indemnity claims, shifting 12% of indemnity claims to medical only.

Another example of savings resulting from an early intervention strategy comes from one of CorVel’s clients, Carhartt, one of America’s largest producers of premium workwear and outdoor apparel. After switching to CorVel in 2015, the program experienced increased claim closure and decreased incurred costs.

In 2019, Carhartt’s litigation rate was 0%, total paid decreased by nearly 10%, and they experienced a 33% improvement in return to work (RTW) within guidelines.

Early Intervention in Practice

Consider the case of an employee who suffers severe head trauma in his workplace parking lot. Mobile and web-based tools allow almost real-time report submission anytime, anywhere. As a result, the database file can be immediately opened, and the nurse case manager can make early contact with the injured employee.

Because of the severity of this case, the case manager would be dispatched directly to the hospital where the employee was admitted to provide immediate support and assistance. By being onsite, the case manager can provide real-time updates to the employee’s family, the employer, the claims adjuster, and the medical director while facilitating communication between all parties involved. An investigator would also be dispatched to the injury scene, with a preliminary report filed within 24 hours.

As a diagnosis and prognosis became apparent, the case manager maintained contact with the injured employee’s family, the employer, and the claims adjuster while working with the medical care team. Based on the case details already in the system, the nurse could also reference a rules-based decision support engine that suggests evidence-based care options to help develop and implement a coordinated care plan.

While an indemnity claim is likely unavoidable in a case of this magnitude, technology integration and patient advocacy-focused processes enable companies to control costs through facilitating in-network care, preemptive negotiations with out-of-network providers, or enhanced bill review.

By being onsite, the case manager can provide real-time updates and facilitate communication between all parties involved.

An Integrated Approach to Early Intervention

CorVel breaks from the industry status quo with a forward-thinking attitude toward care advocacy and a willingness to invest in user-friendly, technology-enabled solutions that promote effective, streamlined claims management. CorVel’s collaborative, patient-centered approach is enabled by a staff of experienced clinicians that provides an immediate initial response to claims. Coupling this with a robust suite of reporting and monitoring tools, the company’s response to incidents focuses on improving health outcomes.

Claim information entered in real-time into a comprehensive database is always available for collaboration by all parties involved in a workers’ compensation claim, including patients, employers, providers, and CorVel nurse managers. A customizable dashboard makes it easy to review pertinent data, including the number of visits, duration of care, improvement in function, and other metrics. These tools allow CorVel to respond to claims within moments rather than days, coordinate care for injured employees quickly, proactively support families, and provide transparency for employers at all times.

The CorVel service model applies technology, intelligence, and genuine compassion to the claims process to reduce inherent delays, improve return-to-work rates, and maximize client savings. This early intervention approach is not only cost-effective, but also the right thing to do for injured employees.