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Reducing the Burden on Claims Adjusters via Expectation Management and Objective Data

It is well-known that the workers’ compensation industry is very complex as it covers a variety of professions including medical, legal, and customer service. At the core of this multidisciplinary field is the claims adjuster. Adjusters shoulder the management of workers’ compensation claims and often handle hundreds of claims at once to help injured workers get back to baseline health while driving a claim towards resolution. The rest of us that make up the workers’ compensation industry strive to help claims adjusters carry this burden by providing partnerships, products, and expertise as tools. The greatest of these tools is simply the management of global expectations in both duration timeline and financial risk.

Establishing Timelines with Evidence and Data

ODG Solutions for Claims AdjustersManaging expectations is a vital part of the claims adjuster’s role as it allows them to proactively plan the claim with all parties involved and set a series of checkpoints on the path toward claim resolution. One method for accomplishing this is by using evidence-based medicine to establish an estimated timeline of the claim. Treatment guidelines are an invaluable resource for reacting to the sudden changes and recommendations that come up in a claim, but they can and should be utilized proactively at the start of the claim as well. Setting a timeline for return-to-health and synchronizing it between all stakeholders, including the injured worker, will avoid unnecessary conflict from the misalignment of expectations and combine all efforts towards a target recovery date.

While setting a global expectation of recovery is vital in managing the claim, the basis of the timeline itself is equally as important. ODG by MCG provides target timelines for durations at the diagnosis and claim level through the Max, Average, and Best Practice values (or M, A, and B) through our ODG duration tools. These data-driven duration predictions can be used as the core timeline expectation of the claim. The claims adjuster can use the M, A, and B values to communicate expectations of lost time, or treatment duration using the M value as a proxy for Maximum Medical Improvement (MMI), to all parties involved in the claim. Setting injured worker expectations for recovery will add a level of trust through transparency and will lead to improved outcomes in both return-to-health and cost-mitigation.

Managing Financial Expectations with Data-Driven Reserves

In addition to duration timelines, adjusters also manage financial exposure through the appropriate and timely setting of reserve funds. Generally, reserves are set at the onset of the claim when preliminary diagnosis information has been received. This is the perfect opportunity to base the strategy toward resolution on an objective, evidence-based guideline. Doing this allows for the setting of treatment duration and cost threshold checkpoints for strategy re-evaluation which should then prompt proactive reserve reviews. In addition, doing so will remove any opportunity for bias by eliminating the need for anecdotally informed timelines and decisions.

Managing reserves accurately is a core pillar of adjusting and, as it often requires justification using objective information at the claim level, can be a very time-consuming process. To help support adjusters, the ODG Reserving/Cost Modeling tool contains data-driven reserve estimates at the claim level that directly correlate to the M, A, and B values on the aforementioned ODG duration tools. Adjusters can utilize the duration timeline and the associated set checkpoints to reevaluate reserves using the ODG reserve calculator. Benchmarking current reserves against the ODG estimation will allow for proactive management of reserves through regular reviews and adjustments. Reserving proactively with data-driven justifications will allow adjusters to strategically lead cost-mitigation efforts and keep all stakeholders apprised of the most likely financial outcome of the claim.

Claims Adjusters’ Time Matters

With the inherent chaos of managing hundreds of claims and their unique risks based on expertise provided by a team of professionals across many fields, every minute of an adjuster’s time matters. Setting global expectations for both durations and financial exposure will create built-in checkpoints and each threshold allows for proactive management of the claim in an objective, unbiased way. ODG supports claims adjusters towards these goals by providing data-driven recommendations that streamline workflows, automate strategic checkpoints, and build a foundation of transparent justifications for claim decisions.

-Kayleigh O’Brien, Implementation Specialist, ODG by MCG. Published July 19, 2022.

The information contained in this article concerns the ODG guidelines (or solutions) as of the date of publication, and may not reflect revisions made to the guidelines (or solutions) or any other developments in the subject matter after the publication date of the article.

Image courtesy Shutterstock/create jobs 51


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