TPA Best Practice: Accountable Facilitator Of Claims Outcomes

Regardless of the employer’s size and operational locations, the complexity of navigating all aspects of workers compensation can be overwhelming. Your TPA may offer a number of solutions, but are you aware of these services? Are you leveraging them to your advantage? In a large organization a risk manager can feel lost and not know who to contact for a resolution.

 

A best practice in a TPA service offering is to provide coherent and consistent services that allow the client to understand their options and create a return-to-work and claim resolution program that fits their individual business needs. This is done through a single, accountable, point of contact that is the chief facilitator in understanding and delivering on client expectations.

 

 
What Does an Effective Model Look Like?

 

Traditional workers compensation programs have failed to provide the employer clients this single, accountable, point of contact in managing all aspects of workers compensation. The roles this person plays are as follows:

 

 
• Facilitator

 

Understanding and delivering on client expectations is key for any successful TPA. Having a facilitator that is a subject matter expert on both the service offerings of the TPA, as well as the client account instructions will deliver the most beneficial outcome. He will act as a matchmaker to give recommendations for the correct mix of services to deliver on client expectations. This creates an informed consumer that is in a position to make effective decisions, as well as create a communication point to continuously monitor client objectives.

 

The Facilitator also acts as a liaison to the claims and clinical staff at the TPA. Having intimate knowledge and communication with the client, the Facilitator is able to give guidance to their staff of client expectations and outcomes. Their accountability to the client leads to holding their own staff accountable, as well as lends support and guidance to ensure their team is on track for the client deliverable.

 

 
• Educator

 

Another element of an effective TPA is one that can provide the necessary education clients need in the adversarial and complex workers’ compensation system. For example, the program must be able to guide and mentor clients on how to deliver resources to claim and clinical teams. This translates into innovative solutions for clients, and meets the challenges in return-to-work programs. It also provides a conduit for building effective programs in the areas of disability and absence issues in the complex matrix of state and federal laws governing these issues.

 

 

• Clinical Vocational Expert

 

The struggling economy and graying of the American workforce has created unique challenges in managing injured workers. While the number of work injuries per capita is declining, current trends demonstrate an increased severity in injuries that occur in our workplace. This is resulting in employees missing more time from work, especially in the older populations. Employers need to investigate and select a TPA that is able to provide guidance to nurse case managers and reviewers so they can meet these challenges.

 

The clinical vocational expertise adds the consistency across the board in working with medical diagnosis and treatment plans. The field of medicine is complex and ever-changing. It is unrealistic and inappropriate for a claims person to be an expert on medicine. It is appropriate and highly effective when the claims handling expert receives clinical support from the Clinical Vocational Expert.

 
Benefits of a Single Point of Contact

 

The main challenge risk managers face in today’s complex business environment is the need for simplicity that delivers an effective disability and absence management program. An effective TPA must have a single, accountable and knowledgeable point of contact to drive the return-to-work and claim resolution process. This single point of contact must also draw on experience and expertise to drive innovation in a collaborative manner that includes the employers and brokers, and provide medical and vocational solutions that drive quantifiable results.

 
Conclusions

 

Due to a changing workforce, employers need to seek innovative ideas that provide practical solutions in a cost-effective manner. Based on these factors, employers need to seek and utilize a TPA that offers tools that can be easily implemented for a more productive workforce.

 

 

 

Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact: mstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

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WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

 

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