By implementing a proactive pre-injury strategy to reduce the frequency and severity of claims, employers can better prepare and manage absence and benefit management programs. However, it is also critical that organizations build a successful post-injury claim management model that is flexible and adaptive to change.
Employers that take steps to gain a thorough understanding of their workforce and how they utilize various health and disability benefit programs can customize a post-injury claim management response model to facilitate better outcomes on claims and reduce costs as a result.
While the claims administrator has a significant role, the employer should still “own the process.” Starting at the time of the reported event, employers are often in the best position to gather critical facts which can foundationally support pre-loss measures related to safety, prevention and root cause analysis, as well as post-loss initiatives related to the claim compensability process and return to work coordination.
Adopting an Advocacy-Based Model
The first initiative employers should consider involves the adoption of an advocacy-based model, one which considers the needs and concerns of the injured or ill employee as the priority. At the time of the reported event, it is important that an employer guide and educate the employee proactively through the process of what to expect, how the process will work, what benefits are available, how an employee gets paid and where medical bills should be sent.
Even under favorable circumstances, early communication from an employer to an employee can be invaluable. Managing considerations in simplest terms, such as through a frequently asked questions document with key information and points of contact, at the time of the reported event can be very impactful. Additionally, reducing lag time and improving the benefit coordination process is vital to minimize disruptions, support the compensability decision and sustain an effective post-injury management response.
An advocacy model – with proper fact-finding and analysis – also eliminates the hazard of making assumptions, such as:
- The injury is fraudulent or the event was purposefully staged
- The employee is malingering or delaying the recovery and return to work process
- The employee is “gaming the system” or is skilled at navigating the system
Assumptions such as these can prompt suspicion and, subsequently, detrimental behavior. For instance, immediately assuming that an injury is “fraudulent” and confronting an employee following the report of a work-related accident can not only damage the relationship your organization has with an employee, but also greatly raises the likelihood that that employee will become fearful of reprisal and retain counsel to preserve their rights when they do have an injury or illness.
Implementing an objective process as an employer is a key foundational step in effectively managing pre- and post-loss objectives while building a culture of safety and oversight.
Creating an Effective Post-Injury Framework
Employers that manage obligations without an integrated team will likely face obstacles and be vulnerable to missteps, increased loss costs and consequential legal action. Focus should be placed on creating a management framework which is consistent, compliant and administered by an integrated team with defined connection points.
The post-injury team should be comprised of representatives with responsibilities in, among others, Safety, Claims, Risk Management, Human Resources, Health and Benefits, and Legal. Additionally, vendors – such as third-party claim administrators or carriers, medical providers, vocational experts and legal panels – need to work effectively in their roles to help mitigate exposures and support the continuum of the targeted objectives.
The primary functions of the employer in a post-injury process includes:
- Implementing a management process with actionable policies which support communication from the time of the reported event through the continuum of injury and absence management with all key stakeholders, starting with the employee.
- Building a process which guides the management process for key stakeholders in a manner which expedites and qualifies the process, rather than adding unnecessary administrative burdens.
- Executing proper fact-finding techniques during the initial reported event and post-analysis process for both pre-loss and post-loss elements are part of a critical foundation – who, what, where, how and why can drive results when properly applied. This approach is critical in the current COVID-19 pandemic environment and particularly relevant as jurisdictions throughout the US begin to implement required COVID-19 related incident reporting.
- Overseeing the claim management and benefit coordination process to support proper claim adjudication decisions and benefit payments to avoid unnecessary litigation.
- Coordinating productive return to work options to include a comparison of the capabilities of the employee to objectively measured physical demands to support the alignment of temporary transitional duty tasks and potential reasonable accommodation processes in accordance with the Americans’ with Disabilities (ADA).
- Identifying overlapping obligations across occupational health and non-occupational health and pre and post-loss objectives can drive the shift in an organization to a more effective model across each department with improved outcomes and compliance.
- Developing a practical management framework among departments to guide operations and foster cooperation across an organization while relieving administrative burdens regardless of whether an event is related to occupational health such as Workers’ Compensation, or non-occupational health such as Short-term Disability (STD) or group health. In addition, Family Medical Leave (FMLA) and the ADA apply regardless of the source of the disability or absence and should be designed in a collaborative manner with stakeholders.
- Performing regular reviews of the transition duty work assignments in comparison to regularly updated capabilities outlined by the recognized medical provider, can assist employers with avoiding unintended consequences as they navigate the continuum of injuries, illnesses and management practices.
For an employer to manage obligations and properly satisfy multiple objectives (including pre- and post-loss initiatives and the continuum of absence), breaking down organizational silos internally and retaining vendors who strive to drive measurable results can be invaluable. A thorough understanding of the nature of an employer’s operations and exposures, along with the development of clear action plans, can be extremely important to mitigate and manage loss cost, and the total cost of risk (TCOR).
As industry trends continue to emerge, employers will need to enhance their workers’ compensation best practices to help improve compliance and outcomes while building a consistent management process across their organization. Changes in federal and state laws have added to the complexity of navigating employer obligations and require a thorough redesign of policies and procedures. As the need for productivity continues to drive organizational objectives, employers that create an effective and integrated model will be better positioned to realize outcomes with measurable results.