In fact, many organizations spend hundreds of hours every year reviewing claims and see very little improvement in their overall workers’ compensation results. Why? Because they focus on the wrong objective. The purpose of a claim review isn’t to manage claims. The purpose is to improve the system that manages claims.
Claims Are the Result of Your System
Every workers’ compensation claim moves through the same process. The injury is reported. The employee receives medical care. The supervisor communicates with the injured worker. The claim is assigned to an adjuster. Return-to-work efforts begin.
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“Workers’ Comp Claims Review Checklist: 9 Must-Have, Serious-Impact Elements”
Every one of those steps is part of a system. When that system performs well, claims generally perform well. When the system breaks down, claims become more expensive. Unfortunately, many claim reviews spend nearly all of their time discussing the outcome instead of asking what caused it.
Looking at Individual Claims Only Tells Half the Story
Imagine reviewing a claim where an employee has been out of work for three months. The discussion may focus on the medical treatment, physical therapy schedule, reserve changes, and anticipated return-to-work date. Those are important conversations. But they don’t answer the bigger question.
Why did this claim become a three-month absence in the first place?
Was the injury reported several days late?
Did the employee wait too long to receive medical treatment?
Did the supervisor never follow up after the injury?
Was transitional duty unavailable?
Did communication between the employer and adjuster break down?
Those are system failures. Unless those failures are corrected, the next claim may follow exactly the same path.
Every Claim Should Teach You Something
One delayed injury report may simply be human error. Ten delayed injury reports usually indicate a broken reporting process. One supervisor failing to contact an injured employee may need coaching. Five supervisors doing the same thing suggests the organization has a training or accountability problem.
This is where claim reviews become valuable. Not because they explain what happened. Because they reveal patterns. Patterns identify weaknesses in the injury management process that employers can actually improve.
Better Systems Produce Better Claims
Many employers try to reduce workers’ compensation costs by concentrating on individual claims. The most successful employers concentrate on improving the process every claim follows.
They ask questions like:
- Are injuries being reported immediately?
- Are supervisors making first-day contact?
- Are employees receiving prompt medical care?
- Is return to work beginning as early as medically appropriate?
- Are communication expectations being followed consistently?
When those behaviors improve, claim outcomes typically improve as well. The system begins producing better results.
Claim Reviews Should End With Action
One of the biggest reasons claim reviews become a poor use of time is because nothing changes afterward. Everyone discusses the claim. Everyone agrees improvements are needed. Then everyone returns to work exactly as they did before.
A meaningful claim review should always end with four questions:
What did we learn?
What needs to change?
Who owns the next step?
How will we measure improvement?
Without those answers, the meeting becomes little more than a status update. With them, every claim review becomes an opportunity to strengthen the entire workers’ compensation program.
Focus on the Process, Not Just the Outcome
The organizations that consistently lower workers’ compensation costs understand an important principle. Individual claims are only symptoms. The injury management system is the cause. Improve the system, and the claims begin improving naturally. That shift in thinking changes the purpose of every claim review.
Instead of asking, “How do we manage this claim?”
The question becomes:
“What does this claim teach us about our workers’ compensation system?”
Answer that question consistently, and every claim becomes an opportunity to improve the next one.
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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