5/19/2017

Advocacy in Action

Achieving better outcomes by putting the needs of injured workers first

By Darrell Brown

A claims career is much more than filing papers, checking boxes, and meeting deadlines. The core of claims handling should be grounded in caring for individuals whose lives have been unexpectedly altered by an injury or illness.

The pathway to recovery and productivity can take many twists and turns and is best traveled with a strong partner and advocate. Being able to positively impact a person’s life during this time of need is an empowering feeling, and it is one claims professionals can experience every day. 

Our 106-year-old workers compensation system has not always kept up with the evolving needs of workers and changing health care delivery models. In response, claims handling has traditionally focused on navigating this framework through compliance measures and medical discounts. 

Compliance is important, but meeting the needs of the injured worker is critical. Placing the injured worker’s needs at the forefront creates a positive experience, and this enhanced experience leads to better claims outcomes through lower litigation rates, reduced claims durations, and improved productivity. 

While claims advocacy can take many forms, effective programs are built around urgency, empathy, effective communication, access to information, and compassion. Each response should be tailored to the injured worker’s specific needs, and identifying and meeting these needs are key components to demonstrating advocacy and securing great outcomes.

Great Outcomes with Quality Medical Care

Workers compensation has been stigmatized by some as a system that provides care at the lowest cost. We have a tremendous opportunity as an industry to change this perception, and, in that pursuit, access to quality medical care cannot be overemphasized. 

Rather than focusing on network discounts, an advocacy approach centers on securing treatment from proven medical providers that can provide timely, appropriate medical care. The outcome from treatment by a quality specialist will far outweigh the financial discounts offered by a general surgeon. 

The industry has come to recognize that both physical and mental wellbeing go hand-in-hand, and there is value in treating the whole person. Psychosocial issues, adverse childhood experiences, and the propensity for substance abuse can be clear impediments to securing an optimal outcome for the injured individual. In addition, injured workers’ fears about job security, recovery, and pain tolerance should not be ignored. In these circumstances, traditional care paths may not be effective, and additional resources, including behavioral health specialists, should be considered.

Pain management also can be an important component of an advocacy program. While prescription drugs may be needed early on to help alleviate pain, it is important to work with medical providers that adhere to responsible prescribing patterns to help avoid potential addiction problems. Far too many lives have been diminished or lost due to rampant misuse or abuse of powerful drugs and opioids.

The Role of the Advocate

Compassionate and knowledgeable advocates are essential to a successful program. Injured workers benefit greatly when they have someone who they know is on their side. 

An unexpected workplace accident or injury can create a high level of uncertainty and apprehension. Many injured workers have not had previous exposures to the workers compensation system, which can be a complicated and convoluted landscape. First reports must be filed, recorded statements must be taken, and accident investigations will follow. As a result, people may start the claims process with a negative perception. 

Anxiety can build from uncertainty around future income, job security, medical care, and recovery. When this uncertainty is not effectively addressed, some may turn to attorneys for assistance. Friction, contention, and resentment can add to an already difficult situation.

A strong advocate can alleviate much of this uncertainty and fear. At the outset, the claims process should be outlined, benefits explained, remedies provided, and expectations established. Statutory timeframes help provide a framework, but should not replace a demonstration of urgency and empathy. The examiner should deliver benefits as soon as the facts allow. The need for outside legal assistance diminishes dramatically when these steps are taken. 

Information and Communication

Effective communication and providing access to timely information also are key characteristics of a strong advocacy program. Today, people have come to expect information on demand.

User-friendly, easy-to-access portals can provide injured workers with a wealth of information 24/7. Here, injured workers can find answers and explanations related to their specific interests and questions. For example, portals may contain an overview of claims statuses, payments of benefit, and listings of local medical providers. This is an easy way to eliminate the mystery and guesswork that previously surrounded the claims filing process.

Long gone are the days of telephone tag between claimants and resolution professionals. Advocates provide a wide variety of meaningful communication paths. Individuals can receive real-time claims updates via texts on their mobile devices or smartphones. Chat solutions with qualified professionals also can be valuable. 

It is easy to see why advocacy is flourishing in the workers compensation claims arena. An advocacy program puts the injured worker’s needs first, provides information and guidance throughout the process, and strives to improve the overall experience of the individual. 

The claims profession offers countless opportunities to make a positive difference in the lives of others. Today, make that one extra phone call to offer assistance, take a bit more time to explain benefits eligibility, or issue a check a few days early. Advocacy is not only the right thing to do, but also it is good business.



Darrell Brown is executive vice president and chief claims officer at Sedgwick. He can be reached at darrell.brown@sedgwickcms.com

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