Members of the claim management team face the challenge of closing complex and high exposure workers’ compensation cases. This results in delays in settling other claims and limits the energy they can spend on other matters. This also limits the ability of the team to reduce workers’ compensation program costs. Interested stakeholders can address these issues by developing a plan to promote savings within a program by becoming a professional closer – and settling complex and high exposure cases.
Common Complex and High Exposure Cases
Several types of cases fall into this category of issues that cause problems within workers’ compensation programs. These cases include the following:
- Catastrophic cases: These usually include instances where the employee has been rendered quadriplegic, “incomplete quads,” or loss of limbs;
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- Occupational exposure cases: This category of claims include repetitive trauma cases, or exposure to substances such as asbestos, or the development of occupational allergies; and
- Multiple dates of injuries: Employees who work for an employer over a long period incur many different dates of injuries. In some instances, this results in an ultimate breakdown or inability to work. Permanent Total Disability exposure is high.
Problems like these need to be addressed within a workers’ compensation program.
Seeking Opportunities to Close Claims
There are numerous benefits to closing workers’ compensation cases when identified as a complex or high exposure case. It is often the mindset that these claims will never close that drives inaction on the part of management within the claim’s teams. By changing this mindset, claim management teams can better before the following characteristics:
- Managing claim file loads on the claim team as a whole;
- Better reserve cases;
- Enhance team morale that changes the mindset and mentality of induvial claim handlers; and
- Provides better claim management in other areas.
It will also enhance the bottom line of any program.
Working as a Real Team
The team involved in closing cumbersome workers’ compensation cases should include people beyond the internal claim management team. It should also include defense counsel, structured settlement brokers, Medicare Secondary Payer compliance, and professional administration. When working with these outside partners, more ideas can be brought to the table and hopefully include better, more creative solutions.
The next step involves establishing various factors that commonly drive high exposure and complex cases. These can include the following elements:
- Opioid drug use that has the approach of being used for palliative care;
- Employees that have comorbid conditions such as obesity, substance abuse, underlying psychological/psychiatric problems, and a significant number of other claims.
- The possibility of multiple future surgeries or dependence on the care could be classified as “maintenance care. One example is excessive use of chiropractic care and treatment.
This list is not exhaustive. Careful consideration should also be given to claim characteristics of specific industries.
Searching for Leaders on the Team
There are countless opportunities for persons on the claims team to lead on the proper handling and resolution of complex and high exposure claims. Often the person best positioned to lead the charge is the claim handler themselves. This is based on the following factors:
- Direct knowledge of the claim’s more refined details with an intimate understanding of factors that could be driving the claim and litigation surrounding it;
- Immediate and direct access to all the main supporting actors that include the defense attorney, service providers, and employer representatives; and
- Ability to identify claim trends.
Leaders and upper-level managers within claim teams should seek out experienced claim handlers to identify these issues and drive cumbersome cases to closure. This can be accomplished by claiming handlers the resources they need and ultimately holding them accountable. Additional support and flexibility should allow these identified claim handlers to make decisions regarding other settlement authorities without going through the extra layers of bureaucracy that are often required.
In sum, claim handlers can be given the authority to lead the way without a specific title.
Closing complex and high exposure workers’ compensation cases is a challenge many claim teams face. To resolve these matters effectively and timely, it is vital to recognize the types of claims that cause problems, work as a team, and empower individual claim handlers to make decisions that can settle cases promptly. When this is accomplished, the workers’ compensation program can become more effective and reduce program costs.
Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is the founder & lead trainer of Amaxx Workers’ Comp Training Center, which offers the Certified Master of Workers’ Compensation national designation.
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