With almost 30 years in claims/case management, I have managed thousands of claims and not one has been identical to the other. They have similarities but that’s it. When you are dealing with claims, there are individuals that makes each case unique – the employee, the doctor, rehabilitation professionals, and of course either WSIB or an insurance carrier and each one of their adjudicators, case managers and so on. You should never apply a cookie cutter approach to addressing an illness or injury. As individuals, we all have nuances that need to be addressed upfront if you are looking for a speedy resolution. Now granted, not all claims can be closed quickly, but I have found 99% close relatively well within an appropriate time frame with a few tips found below.
1. Communicate, Communicate, Communicate
I can’t stress this enough. Talk to everybody – have face-to-face meetings – get everyone in the same room, write summaries of the meetings to share with group. Keep the communication frequent and transparent. It is crucial to take the time to converse with all parties. In a world where computers have taken over, where we are tight for time, where our schedule is overwhelming – always take the time to have a conversation with a sick or injured employee. I have closed thousands of cases successfully with taking the time to listen first, talk second, with employees and parties involved in the case. You will find with ample communication, the claims don’t linger or become complicated.
Also as a claims manager, I have never closed the case by myself. Like health & safety in the workplace, I believe an injured/ill worker is the responsibility of the entire organization. When someone gets hurt or is off sick, it should be a collective effort to effectively manage the situation to successful resolution. It should never, ever be one person in your organization managing the claim. In the best case scenario, the employee, the supervisor, and the claims manager (whether you have a dedicated staff for this which is highly recommended) or a health & safety professional, should be present in all meetings. The supervisor’s manager and Human Resources should always be in the know and should attend at least the first meeting so the employee understands and knows this is a team approach. Too many companies make claims management the responsibility of one person who is already overloaded with various other job titles and work.
In today’s world I notice that we all tend to get somewhat reserved to act when it comes to all the regulations and legislations. Being cautious so that you don’t overstep the regulations and legislations is good, but don’t let this stop you from communicating to resolve the issues.
2. Respect for each other
Despite the fact that you may think the employee is malingering or dragging his feet in regards to returning to work promptly, it is crucial that we remain respectful at all times during the claims process. It makes for much easier communication.
Even if you believe there is an element of over exaggeration or lack of motivation, there may be another very real reason why this employee is not back to full time work. Find out what it is because if you don’t deal with it, your problem continues and continues.
This is what I say in my community training programs for a very simplistic view of managing claims – look at it like a 10 pin bowling game. Every time you address or communicate with the employee, you have potentially 10 barriers (or 10 bowling pins) to knock down. If you don’t find the reasons why your employee is not back at work, this will be a very long claim that will frustrate you both.
What most people fail to understand is the injury/illness did not just occur because of a physical issue. Attached to the injury/illness are numerous mental health components that need to be addressed as soon as possible. There are many reasons why employees do not go back to work right way – find out which one (s) are keeping your employee from work or regular duties. Ask the question and be prepared to deal with the issue. Over the years the reasons are rooted from a variety of different scenarios – things are heating up at home, conflict on the job is common, and how we treat someone can sometimes make them dig in their heels and they are now in it for the long haul. We all lose at this point – time, money, productivity and sometimes our patience.
Treat each other with the utmost respect. Who cares what you know, or what you think you know. At the end of the day, you want your employee to return to full duties as soon as possible. Antagonizing the situation with a lack of respect for him/her and the situation will get you nowhere.
3. Be diligent
In order to be diligent, your claims manager must know more than the employee, the doctor (not necessarily medical knowledge), more than WSIB/insurance adjudicators and definitely be on top of the legislations and regulations to avoid further complicating the case by not addressing the duty to accommodate, not returning to work or forcing the situation at hand by adding discipline and/or termination to the already frustrated parties.
You the employer, in my opinion, need to be in control. Don’t wait for WSIB or the doctor or the employee to tell you how they are going to manage your claim. Be prepared, be proactive and get involved with all parties. Be the force and strength behind the claim that helps the employee and interested parties find resolution in a timely manner.
Makes sure you close each case in the best way possible – the employee is back to full duties and you have the doctor’s sanction. The number of times I have seen a case get overturned with WSIB and/or the insurance carrier is frightful, and extremely costly to an organization and the ill/injured worker. When others have closed their books, don’t close yours until you know you have resolved all the issues and your employee is safely back on the job.
Bonus Tip
Keep it simple. Try not to get too technical while managing claims. Don’t key in as the heavy but work in coordination with the injured employee and his team of health professionals. Follow the regulations and legislations so you don’t contravene the employee’s rights but don’t let this deter you from managing the claim within minutes of its occurrence. Do have face-to-face conversations, phone conferences with the physiotherapist, written communication with the doctor – obviously with permission. Be respectful to all the parties involved in this case and be diligent in finding a lasting resolution to the claim as soon as possible. Everyone wants the same thing you do – to get the employee back to regular work yesterday. Don’t waste time – get on it!
FOURNIER Health has been helping organizations for over 15 years to manage their disability claims to successful resolution with an average ROI of 1:7. For every dollar paid to us, we save you $7.00 for a full case management of your claims. Sounds to me like a free resource that you should try. Check out our website for further details at www.fournierhealth.com.
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