By Jeff Gurtcheff, VP & General Manager, Settlement Solutions, Helios
Years ago while managing a claims organization, I had the opportunity to experiment with ways to improve injured worker outcomes and financial results. The insurer had great programs in place to assure that evidenced-based medical and pharmacy guidelines were followed, utilization review was effective, case managers were assigned to cases they could impact and so on. I’d venture to say they were some of the best programs at the time. But something was missing. Why were the results good but not great?
Our team of experienced claim professionals interviewed our injured workers. Surprisingly, they discovered that injured workers felt a general lack of compassion and empathy from the claims professional and employer. In fact, they felt they had to defend themselves to the people who were supposed to help them. These injured workers were confused by the process, did not understand what to expect, and had no idea why so many people were involved with their claim.
This feedback reminded our team of a few basic facts about most injured workers:
- They did not want to be injured
- Nor did they purposely injure themselves
- They don’t want to be poked, prodded or cut by medical professionals
- They have no perception of the potential cost of their treatment or medications
- They need and want to be employed
We ultimately uncovered that our communication, collaboration, and compassion throughout the claims process was not driven by our understanding of injured workers. Rather, it was driven by the few “bad apples” who repeatedly made claims, committed fraud, and intentionally malingered to “get rich.” Essentially, we were letting the minority shape our behavior.
Little Changes Make a Big Impact
The claims team took this information and created a training program that emphasized compassion, attention, respect, and empathy, to change internal perceptions of the injured worker. These terms were the essence of the core messages we wanted the claims professional to reflect upon before, during and after interaction with any injured worker. We hung signs around the office and placed reminders at each claims professional’s desk. We monitored calls to assure the team took the principles to heart.
Conversations with the injured workers from that day forward changed dramatically. Calls began with questions like, “How are you?” and “How are you feeling?” There was much more explanation, “Let me explain the process to you.” Injured workers were asked what questions or immediate concerns they had. We spent more time explaining the process and reasons for the decisions made about their treatment (i.e., “Here is why I want you to treat here” or “Here is why I assigned a nurse”). All of these changes became our new standard and we closely monitored the impact these made. What we ultimately saw was a significant decrease in attorney involvement, shorter disability durations, and a decrease in medical severities.
Today, at Helios, I manage a Settlement Solutions team that is in a different position than the claims team I previously described. My team handles situations where one or more of the involved parties believe a claim should move to a full and final settlement of all future exposures, the injured worker has been out of work for an extended period of time, and there is no job in which to return. Many times the injured worker is eligible for Medicare. Several cases reach us with the same profile I experienced in my previous position on the payer side — the injured worker lacks trust in the claims process, they don’t understand who is doing what and they feel the need to defend themselves.
Putting the Injured Worker First
My team and I have found that the lessons discovered all those years ago can be applied to settlements with the similar results – greater injured party cooperation and more impactful outcomes. When asked to intervene on cases, our team discusses what is being done and why with the injured party. When we explain to injured parties why we wish to discuss changes to the treatment plan with their treating physicians, we receive amazing, primarily positive, reactions. They are surprised to learn medications are only supposed to be used for short durations, the morphine equivalency dose exceeds a specific threshold, or their body cannot metabolize or process the medications due to their age or comorbidities. This surprise quickly changes to appreciation and trust, simply because the conversation is a result of concern for the injured worker’s safety.
We’ve also found many injured workers DO care about the cost of their treatment. Sure, there are those who believe, like many tort cases, that they need to “run up” their treatment to justify a larger settlement. But, most simply have no idea what their medications cost and the ultimate impact on their employer. For those seeking to settle their case and require a Medicare Set-Aside as part of the process, the conversation is very transparent when it comes to cost. Quite simply, the injured party can easily see whether the adjuster or employer can justify the cost of settlement at the current spend for their medications. Even more importantly, by explaining the impact of why using certain medications for an extended period of time could be detrimental to their health, the injured party usually understands why the employer could not allocate this medication beyond recommended guidelines.
When the injured worker realizes that you are looking to protect their health and move their case in a direction consistent with their desires, cooperation can ensue, driving results. In addition, the conversation with the physician is no longer argumentative. It is about patient safety that is also financially responsible.
Better Communication Equals Better Outcomes
Increasing communication throughout the claims process may seem to take additional time for the adjuster, case manager or vendor partner. And while time is precious to the workers’ compensation professional who is inundated with day-to-day tasks, the long term benefits of open communication will actually reduce the time they spend managing claims and fielding injured party calls.
A recent article in Business Insurance said that the quality of communication with injured workers is more important than the mode of that communication. The article quotes Joseph Paduda, principal of Health Strategy Associates as saying, “The engagement issue is much more about how the employer and the insurance company communicate with the injured worker … in terms of the words they use and the tone they use and how proactive they are, rather than the vehicle they use to communicate with.”1
We spend a lot of our time in workers’ compensation focusing on statistics and costs. This reflection is needed for our businesses to succeed and to uncover trends that improve clinical outcomes. However, we must frequently take a step back to remember that a fellow human being is at the other end of the claim file—someone who likely would much rather NOT be in this situation. I admit that I was initially surprised by the results achieved by implementing something so simple. When I reflect on my own behavior and reactions to people in my daily life, I tend to trust those who are sincere, caring, and knowledgeable. As you think about navigating the complexities of workers’ compensation claims, ask yourself every day if you are actively extending respect, caring, collaboration, trust and warmth into your communication. You’ll find that you’ll ultimately generate better results for everyone involved.
About Jeff Gurtcheff
As the Vice President and General Manager, Jeff Gurtcheff is responsible for all aspects of the Helios Settlement Solutions business, including product development, account management, and driving operational efficiencies to ensure compliance and achieve optimal client satisfaction.
Prior to joining Helios, Jeff served as Regional Vice President of Auto Claims at The Hartford and Director of Workers Compensation Claim Practices where he was responsible for the development of a proprietary internal Mandatory Insurer Reporting tool, claim standards and procedures associated with Medicare Set-Asides, and Structured Benefit Services operations.
About Helios
Helios, the new name for Progressive Medical and PMSI, is bringing the focus of workers’ compensation and auto-no fault pharmacy benefit management, ancillary services, and settlement solutions back to where it belongs – the injured party. Along with this new name comes a passion and intensity on delivering value beyond just the transactional savings for which we excel. To learn how our creative and innovative tools, expertise, and industry leadership can help your business shine, visit www.firstfilltosettlement.com or call 800.777.3574.
Notes
1Goldberg, S. (2014, May 11). TPAs use mobile apps to engage workers in compensation claims process. Business Insurance.