By Rachel Fikes, Chief Experience Officer & Director, Workers’ Compensation Benchmarking Study, Rising Medical Solutions
With 30 percent of claims payers achieving top performer status, what steps can the remaining 70 percent take to catch up? This is a pivotal question the Workers’ Compensation Benchmarking Study has continued to ask over its past decade of research.
As with Part 1 of this article series, I use the major drivers of claim outcomes as guideposts to condense 10 years of investigation into four (4) takeaways—the final two (2) of which are featured here. What all these key conclusions have in common is they identify how and what high-performing claims organizations are doing to achieve superior results and, therefore, how others may close the performance gap as well as keep pace with the industry’s overall advancement.
One thing is clear, a strong talent value proposition is critical to operational success across all study focus areas. Given the industry’s growing talent shortfall, to become a top performer, enterprise-wide strategies are essential to do more with less employees in our current and near state. When evaluating high-performing claims organizations (those with closure ratios of ≥101%), their talent practices are fundamental to their ability to excel—which is evident in the third and fourth study takeaways examined here, as well as in the first and second explored last week
Key Takeaway #3: Top Performers Better Equip Staff with Tools & Data
In our 2019 survey of nearly 1,300 frontline claims professionals, 42 percent report utilizing upwards of five (5) or more systems in the daily management of claims. They also indicate their work is highly focused on both external and internal administrative activities (e.g., compliance tasks, claims system data collection requirements). Specifically, nearly one-third of frontline staff report spending 30 to 40 percent or more of their time on external compliance activities. Additionally, half report that internal administrative requirements take 30 to 40 percent or more of their time. Marry these timeframes together, and it leaves little room for strategic responsibilities (e.g., communicating with injured workers and key stakeholders, proactively coordinating return-to-work).
With frontline staff demonstrating the need for efficiency and automation, successful claims organizations address these needs better. No matter what you call it—whether it’s artificial intelligence, machine learning, robotic process automation, predictive or prescriptive analytics, workflow automation, or good “old-fashioned” systems integration—top performers do a superior job of providing tools and data that help frontline staff efficiently and effectively impact claim outcomes.
For instance, in the 2022 survey of claims leaders, 89 percent of high performers indicate they leverage one or more strategies to improve claims professional efficiency (e.g., workflow automation, increased investment in IT resources), compared to 75 percent of lower-performers. They also integrate with more systems/programs (e.g., predictive modeling, case management, bill review), and they use outcome-based data 25 percent more to manage operational performance (e.g., evidence-based guidelines). Additionally, compared to the market (shown below) and lower-performers, successful claims organizations are more likely to leverage system alerts and workflow automation so frontline staff are best utilized and can act on risk indicators quickly.
A final example of high-performance differentiation is in their greater provision of tools to improve frontline professionals’ communication with injured workers (e.g., text messaging, web portals, mobile apps). This expanded tool set makes interactions more efficient and effective, and can increase injured worker satisfaction through more flexible communication methodologies that are now more common and preferred.
Key Takeaway #4: Top Performers Better Facilitate a Whole Person Approach
In the evolution of workers’ compensation, the industry’s transition towards advocacy-based, worker-centric claims models has been a critical step—increasing from a 28 percent adoption rate in 2017 to a 47 percent rate in 2022. Advancing the adoption and integration of a biopsychosocial model of claims management is another critical step in the industry’s transformation, enhancing frontline claims professionals’ ability to impact total worker health and improve outcomes.
Successfully returning an employee to employment and health relies on much more than medical treatments, and higher-performers are more likely to empower frontline staff to address total worker health in an employee’s recovery and return to work. This “whole person approach” involves enabling frontline staff to effectively manage both medical and non-medical aspects of a claim.
For medical interventions needed to treat an employee’s injury, a knee let’s say, top performers have a higher rate of helping frontline staff access and promote quality care by:
- Measuring provider performance and outcomes (e.g., treatment within evidence-based guidelines, total claim costs)
- Using return-to-work and patient functional outcomes to impact provider management (e.g., provider network removal for not meeting quality or outcome metrics, referral and patient channeling consequences)
- Incentivizing providers for quality performance (e.g., fast track payments, higher reimbursement rates, higher referral volume, limited or no utilization review)
For non-medical interventions often needed beyond treatment of the injured body part(s), there are a host of complicating risk factors that are well-known to the workers’ compensation community. For instance, in the study’s 10 years of research, claims leaders and frontline staff repeatedly rank psychosocial issues—such as catastrophic thinking, perceived disability, perceived injustice, and fear/avoidance—as the top barrier to optimal outcomes. Additionally, according to the U.S. Department of Health and Human Services, socioeconomic factors are responsible for approximately 40 percent of a patient’s health, while 20 percent is attributable to medical care. While the industry, as a whole, has ground to cover in these risk factor areas, top performers are further down the road.
Specifically, our 2022 research found 30 percent of claims organizations enable claims professionals to identify/address social determinants of health (SDOH) and higher-performers are more likely to do so, particularly in the areas of leveraging SDOH risk factor data and training in culturally sensitive communication that uncovers barriers to recovery.
In terms of leveraging strategies to mitigate mental/behavioral health issues—which, notably, can be strongly influenced by an employee’s SDOH conditions—top performers also surpass the market. Overall, compared to less successful operations, they are 18 and 22 percent more likely to arm claims staff to identify and address mental/behavioral health issues respectively. Areas of particular distinction include:
- Using questionnaires/screening tools to identify psychosocial risk factors
- Offering behavioral, mental, and/or telehealth specialty provider networks
- Providing Cognitive Behavioral Therapy (CBT) or Progressive Goal Attainment (PGAP) programs
For those claims organizations that choose to close the performance gap, the data is clear. The best claims organizations impact outcomes by better equipping and better capitalizing on their most important asset, their claims talent.
Now in our eleventh year, the annual Workers’ Compensation Benchmarking Study continues to ask, “What makes for exceptional claims management in workers’ compensation?”
The 2023 study carries on this investigation, this year by surveying frontline claims professionals for the second time in the study’s history and the first time since COVID. The 2023 research will not only compare frontline participants’ perspectives to those of the claims executive participants who preceded them, it will also quantify the experience and motivations of frontline professionals in the post-pandemic work environment. The confidential survey is now underway and, as an investment in this industrywide tool, frontline claims professionals are encouraged to participate and claims leaders are encouraged to share this survey link with your team(s).
As always, if you would like to obtain a copy of prior studies, they are available to all industry stakeholders without cost or obligation as a contribution to the workers’ compensation community. They may be requested and downloaded here.
About Rachel Fikes
Rachel Fikes is a 20-year insurance services veteran who leads Rising Medical Solutions’ Workers’ Compensation Benchmarking Study, a national research program she has directed since its inception in 2013. Now the industry’s largest survey of claims leaders and frontline claims professionals, the annual study identifies and quantifies industry priorities, challenges, and strategies. With its potent method of validating how and what higher performing claims organizations are doing compared to industry peers, the study uses its data findings to advance benefits delivery in workers’ compensation.
In her Chief Experience Officer role at Rising Medical Solutions, Rachel is responsible for creating centralized value for the company’s two primary constituencies—clients and employees. Understanding that optimizing the customer experience requires an aligned employee experience, Rachel works collaboratively with all business units, as well as externally with clients, to deliver increased value to all stakeholders and to cultivate a culture of advocacy.
About Rising Medical Solutions | We Make Lives Better.
Rising Medical Solutions (Rising) is a national managed care firm that provides medical cost containment and medical care management services to the workers’ compensation, auto, liability, and group health markets. Rising’s mission is to “make lives better,” by taking the pain out of the healthcare experience for those providing, receiving, and paying for medical care.
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This is NOT a paid placement.