Effective Claims’ Management

Unfortunately, by definition, claims management indicates that an event has occurred (or has been alleged to have occurred) and is tied to a potential loss (cost).  Best claims management practices start with a comprehensive investigation identifying:

• What occurred?
• Why it occurred?
• Who was involved?
• What damages or injuries resulted?

Investigations should be sufficient in gathering and documenting information that is fair, factual, free of emotion and complete. 

Ultimately, investigations will lead to root causes and corrective actions to avoid reoccurrences.  However, when it comes to effective claims management, they are the foundation in which claim management strategies are rooted based on the facts and details obtained and documented.

Regarding workers compensation claims, the investigation may help the claim be managed by taking advantage of cost limiting rules within workers compensation (such as safety rule violations) or may even indicate the injury is not work related.  

Beyond the investigation, effective claims management in workers compensation includes pre-incident items such as:

• Clear written procedures
• Orientation, Training and Safety Meetings
• Designated medical providers
• Modified duty (Return to Work) opportunities

Best practices may also include:

• • Employee fitness for duty programs
  • Pre/Post-employment screening to identify best employee candidates for their position and obtain baseline information such as ability to perform essential functions, range of motions, etc.
  • Dedicated claims managers
  • First aid measures for muscle skeletal injuries

After an incident occurs and a claim is process, effective claims management includes:

• Continued communication with your employee
• Active engagement with the medical providers and claim adjuster (carrier or Third-Party Administrator)
• Working with your insurance agent’s risk/loss control team
• Returning the employee to work as soon as possible (RTW) program within the doctors’ restrictions.

There are numerous variables, and no two claims are the same.  By having a strong foundation in place and appropriate resources, claims management will provide a greater return on the employers’ investment.

Although it may not always appear to be so, all involved are on the same team and desire the best outcome for the employee’s health.

Looking for opportunities to improve your claims’ management process? Contact your Innovise Risk control team!