By Melissa McGarry, Director, Product Implementation, Coventry & Apricus
By now, most of us have heard about the Great Resignation — a trend in which millions of employees across the nation are leaving their positions for better opportunities. COVID-19 was the catalyst, as the pandemic led many people to look for better pay, enhanced benefits and improved work-life balance.
Even before this trend, the workers’ compensation industry had been experiencing a shortage of claims professionals due to baby boomers retiring. Now even more vacancies have been generated in what The New York Times has termed a “turnover contagion.”
Claims departments are being hit hard, and an increased workload is falling on those who are left behind. Many of these professionals were already burdened with a high caseload. Now, there are added pressures — and from multiple sources.
For instance, employers are dealing with their own labor shortages. Stretched thin, workers may be scrambling to keep pace with the demands of their jobs and put themselves at higher risk of accidents and injuries. This could lead to more claims, which then gets added to an adjuster’s plate. The health care industry, which treats injured workers, is also experiencing a severe nurse and physician shortage due in part to burnout from treating COVID-19 patients.
All of this can lead to a compounding effect: adjusters are forced to shoulder more work, while also dealing with delays and other inconveniences. Eventually, this could lead to more burnout and additional resignations.
Claims managers must take proactive actions now, championing strategies that provide their staff with support. One approach that can offer immediate relief is working with a specialty network that provides adjusters with assistance in several ways:
1. Ease their workload.
Oftentimes, adjusters are handling well more than 100 claims at a time. These claims represent various types of injuries — all with varying levels of medical complexity and with injured employees who all have a unique set of medical, social and psychological factors that could impact their recovery and return to work.
Needless to say, adjusters are managing a lot, and they need help. Partnering with a specialty network provides much-needed assistance as many adjusters don’t have the time, bandwidth or expertise to identify and schedule the best specialty services that would foster optimal outcomes.
The right partner would be a specialty network that has a broad geographic reach. This network would offer a care-coordinator model, which would help assess the injured employee’s needs and would be able to deploy a broad range of services, including:
- Durable medical equipment
- Home health
- Diagnostic imaging
- Transportation and translation
- Home and vehicle modifications
- Discharge planning
By handing off this function to care coordinators who spend their time focusing in these areas, adjusters will experience a tremendous relief in their workloads. Selecting the right partner can provide a claims team with additional expertise in areas such as medical and pharmacy management, independent medical exams and data analysis. And because the network has established relationships with specialty vendors, such as prosthetic manufacturers and equipment suppliers, it can actually expedite the delivery of these services. Finally, the specialty network assumes the administrative and logistical burden; this is a huge advantage for adjusters who are inundated with cases and tasks.
2. Provide in-depth expertise in specialty services to help fill the knowledge gap.
When claims organizations lose team members, there’s a worry that remaining staff or new recruits will not have proficiency needed to acquire the necessary specialty services. For example, an experienced adjuster understands that recovery from an injury will not always unfold in a straight line.
Injured employees may need an array of specialized services to achieve optimal outcomes. Nearly half of workers’ comp claims result in medical expenses ranging from $10,000 to $500,000 with high-cost claims accounting for a larger share of spending. Specialty services represent 20% of this spend. These services can’t be categorized simply as “ancillary,” as they often play a pivotal part in the injured worker’s recovery.
Toward that end, a specialty network becomes a foundational resource, which when combined with physician networks, can add up to a more inclusive resource for adjusters. When the network lens is expanded to include specialty services, adjusters gain further support that can streamline patient care. This type of integrated model offers a single point of contact for all specialty equipment and services, scheduling and clinical oversight. This provides added reprieve to the adjuster’s workload.
These examples show how a specialty network’s in-depth expertise can assist the adjuster:
- Durable medical equipment can include anything from wheelchairs and supplies, such as bandages, to modification services, rehabilitation equipment and electrotherapy units. From an adjuster’s perspective, the inner workings of securing the right equipment is often a mystery, especially because there’s a wide range of equipment that differs in nuanced ways. Adjusters need to rely on knowledgeable specialty network coordinators to review orders on their behalf, select the best vendors and bring concerns to their attention.
- Amputations are the costliest type of injury in workers’ compensation, both in terms of lost time and long-term expense. Working with an experienced specialty network for prosthetics is critical to controlling costs and achieving the best-possible outcome for each injured worker. Working with a robust specialty network will ensure a wide array of potential prosthetic providers. In addition, injured workers must receive comprehensive evaluations to assess their needs, and to support not just their return to work but also their hobbies and lifestyles. The specialty network should be prepared to arrange for this evaluation.
3. Assist with the increased number of common, everyday injuries.
With the Great Resignation, employers across all industries have felt the pinch. A shortage of staff can lead to an increased incidence of injuries, especially in physically demanding jobs, such as manufacturing and construction.
In addition, new employees tend to be more prone to injury. A 2015 report found that 40% of workplace injuries are attributed to new employees in their first 90 days of work. The most common type of injury is a sprain or strain. For example, a new employee may be more likely to incorrectly lift a heavy object, resulting in a pulled shoulder or injured back. Or, a new recruit unfamiliar with a workplace’s layout might trip and hurt a knee or wrist.
These are common, everyday injuries, but adjusters need help to deal with the sheer volume of cases and their specialty needs. Requests for equipment — such as crutches, braces, or wraps — can be efficiently secured by a specialty network, allowing adjusters to focus on providing personalized service to the injured employee, so they feel as if they’ve received the attention they need and are ready to return to work.
4. Expertly coordinate the myriad of specialty services needed on catastrophic cases.
Catastrophic injuries occur with relatively low frequency, but when they do, they require specialized experts to manage all aspects of these complicated claims.
Many payers have their own catastrophic claims team, so their most seasoned professionals would ordinarily manage these cases. However, many of these experienced adjusters have retired or have been recruited away. As such, many catastrophic claims teams are also short-staffed and in need of assistance, especially because these cases often require a significant number of and various types of specialty services.
A best-in-class specialty network offers a catastrophic injury response team, which collaborates with the payer’s case managers and provides care coordination so injured employees receive the right services at the right time.
By having a specialty network involved, claims adjusters are free to focus on their portion of the claims process. At the same time, they have the peace of mind in knowing specialty services will be managed by a network that can optimize service, results and costs. Proactive care coordinators will facilitate seamless coordination and communication, so injured employees have all the essentials ready and available at each stage of their care and recovery.
Some claims organizations may prefer a more integrated approach that combines a broad-based network, case management and specialty services. Having one partner coordinate all of these aspects can have a profound, positive impact on the costs and outcomes for these highly complex claims.
Specialty Networks: Providing Adjusters with a Great Assist
Each time an adjuster handles a case, there’s a high likelihood that it will require some form of specialty service, and the ability to secure those services must be made convenient to adjusters — essentially available at their fingertips. Perhaps a claim requires a translator. An adjuster shouldn’t have to spend half a day trying to identify and schedule that service. A specialty network is coordinating these types of services all day, every day.
Claims managers looking to provide overstretched adjusters with a much-needed assist should forge a partnership with a strong specialty network. Does your organization have a partnership? Is the existing network fulfilling your adjusters’ needs in a timely manner?
Your organization must ensure that a specialty network has processes in place to deliver not only savings, but also superior service to your claims team. The network should also utilize digital strategies to streamline the specialty service process and provide full visibility into the actions being taken, facilitate oversight to ensure nothing falls through the cracks and have an integrated clinical-management approach to ensure optimal outcomes.
About Melissa McGarry
Melissa McGarry has been with Coventry for more than 10 years and oversees multiple network products including its Outcomes-Based Network program, Exclusive Provider Program, Telemedicine networks and Auto network. She is also product manager for the Apricus specialty network. Melissa has more than 30 years’ experience in the health care industry with deep knowledge of networks, network products, utilization management, and behavioral health. Melissa holds a B.A. in Psychology from the University of Texas at Austin and a Master’s of Education in Counseling from the University of North Texas.
Apricus, an Enlyte company, is the combination of two industry-leading specialty networks offering durable medical equipment, diagnostic imaging, physical medicine, home health, transportation and translation and more for the casualty insurance market.
Enlyte is the parent brand of Mitchell | Genex | Coventry, a leader in cost-containment technology, independent medical exams (IME), provider and specialty networks, case management services, pharmacy benefit and disability management. The three businesses have recently aligned their joint industry expertise and advanced technology solutions into a combined organization of nearly 6,000 associates committed to simplifying and optimizing property, casualty and disability claims processes and services.
Enlyte is a WorkCompWire ad partner.
This is NOT a paid placement.