Turning Around a Claim Before It Goes Off the Rails

Every claims manager knows the feeling. A routine injury — maybe a shoulder strain, a twisted knee, a bruised hip — starts to drag on.
Appointments are missed. Modified duty is refused. The injured worker grows frustrated, distant, and disengaged.

Then the costs start to rise — from a few thousand dollars to tens of thousands, and before long, you’re staring at a claim that’s completely off the rails.

The good news: these claims aren’t doomed. With the right systems, communication, and timing, you can turn them around — protecting both the worker’s wellbeing and the employer’s bottom line.

Recognizing a Claim That’s Going Off Track

The first step to saving a claim is realizing when it’s in danger.

Ordinary injuries that quietly evolve into high-cost, long-duration cases.
These are not the amputations or brain injuries — they’re the shoulder strains that somehow cost $150,000 and keep someone off work for a year.

Here are the most common early signs that a claim is heading for trouble:

• Delayed reporting. The injury isn’t reported until days or weeks later.

• Lack of engagement. The employee avoids calls or stops responding.

• Missed appointments. Therapy sessions are skipped or rescheduled repeatedly.

• Resistance to treatment. The worker criticizes the doctor or refuses recommended care.

• Refusal of modified duty. Offers for light or transitional work are rejected.

• Negative attitude. The worker appears angry, anxious, or hopeless about recovery.

Each of these may seem small, but together they form a flashing red light — a claim in danger of becoming catastrophic.

Step 1: Identify High-Risk Claims Early

You can’t fix what you can’t see. The most successful programs are those that identify 80–90% of high-risk claims within the first six weeks.

How?
Start with informal screening — human observation. Supervisors and frontline managers often know when someone’s attitude, reliability, or emotional state signals trouble.

Then, add formal screening tools like the REBRO Short Form or the PHQ-4 questionnaire. Both are short, validated assessments that predict long-term disability and delayed return-to-work risk with remarkable accuracy — often as high as 89%.

When you use these tools systematically, you stop guessing which claims will creep into catastrophe — and start catching them before they do.

Step 2: Understand the Real Barriers

Once you’ve identified a struggling claim, resist the urge to jump straight to compliance or discipline. The problem is rarely just medical — it’s human.

That’s where the biopsychosocial model comes into play. The worker’s mindset, emotions, and life circumstances often determine the pace of recovery far more than the injury itself.

Maybe the worker is afraid of reinjury.
Maybe they’re dealing with divorce, debt, or depression.
Maybe they don’t trust the system — or feel abandoned by their employer.

Your job isn’t to solve every personal issue — it’s to acknowledge reality and offer the right kind of support to get the claim — and the person — back on track.

Step 3: Intervene Intentionally

Once a claim is identified as high-risk, time is your greatest asset. The earlier you act, the greater your leverage.

Here’s what an intentional intervention looks like:

1. Re-engage through communication.

A personal call from a supervisor or HR leader can rebuild trust. Ask, “How are you doing?” before you ask, “When will you be back?” That tone shift matters.

2. Use cognitive behavioral therapy (CBT).

CBT is one of the most effective, research-backed tools for turning around claims that have stalled due to psychosocial factors.
It’s short-term (4–10 sessions), goal-oriented, and focused on helping workers manage fear, stress, and negative thought patterns that block recovery.
And no — it doesn’t create a separate psychological claim. It simply helps people cope better and return to work faster.

3. Coordinate a return-to-work plan.

Even if full duty isn’t possible, getting back into a routine has therapeutic value. Modified duty, volunteer projects, or part-time assignments keep the worker connected to the workplace and reduce isolation.

4. Bring in a nurse case manager.

A skilled nurse case manager bridges the gap between medical providers and the employer, ensuring treatment stays on track and communication remains steady.

5. Track and measure progress.

Use a scorecard or loss-run dashboard to track claim metrics — days off work, costs incurred, intervention results. Data keeps the focus on outcomes and helps secure management buy-in.

Step 4: Build a System That Prevents Derailment

Turning around one claim is great — but the real goal is to prevent the next one.

That requires structure, not luck. Here’s the system high-performing organizations use:

1. Fundamentals First: Before advanced screening or CBT, make sure you have the basics — injury triage, communication protocols, and a formal return-to-work program.

2. Screening at Two to Four Weeks: Identify lagging recoveries using formal tools.

3. Targeted Intervention: Match the right resource — nurse case manager, CBT, or job modification — to each risk level.

4. Continuous Feedback Loop: Review your results quarterly. What worked? Where did you lose control? Adjust and repeat.

This transforms your program from reactive to predictive — from chasing claims to managing outcomes.

The Power of One Saved Claim

The math is simple but staggering.
If 5% of your claims drive 80% of your costs, then preventing just one of those from spiraling can reduce your total program cost by 15–20%.

But beyond the numbers lies something more important: impact.
When you help an injured employee recover and return to meaningful work, you change a life. You restore confidence, identity, and stability — all while strengthening your organization’s culture.

That’s what it means to turn around a claim before it goes off the rails..

Michael Stack, CEO of Amaxx LLC, is an expert in workers’ compensation cost containment systems and provides education, training, and consulting to help employers reduce their workers’ compensation costs by 20% to 50%. He is co-author of the #1 selling comprehensive training guide “Your Ultimate Guide to Mastering Workers’ Comp Costs: Reduce Costs 20% to 50%.” Stack is the creator of Injury Management Results (IMR) software and founder of Amaxx Workers’ Comp Training Center. WC Mastery Training teaching injury management best practices such as return to work, communication, claims best practices, medical management, and working with vendors. IMR software simplifies the implementation of these best practices for employers and ties results to a Critical Metrics Dashboard.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Injury Management Results (IMR) Software: https://imrsoftware.com/

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