Tag Archives: workers comp

Evolving Health Tech Models in Work Comp

Technology is continuously changing the healthcare landscape. From reshaping ease of access to quality care to improving system efficiencies and interoperability, all aspects are reimagined. Telemedicine and digital health are disrupters that will continue to evolve on-demand solutions and care management significantly.

Three industry leaders from the Alliance of Women in Workers’ Compensation joined us on our most recent Out Front Ideas With Kimberly and Mark webinar to discuss the evolution of healthcare and its impact on workers’ compensation: 

  • Artemis Emslie – CEO of Cadence Rx
  • Dr. Melissa Burke – vice president and head of managed care and clinical at Amtrust Financial Services
  • Ann Schnure – vice president of telemedicine operations at Concentra

Healthcare Reimagined

Access to care has become increasingly on-demand with advances in telemedicine and telehealth. Consumers want to engage with their health more than ever, and these tools put access in the palm of their hands. But from a claims perspective, are workers’ compensation professionals encouraging this kind of engagement from injured workers? Are employers encouraging use throughout their staff? It is essential to consider how useful these tools can be in communicating with an injured worker and in creating healthy trends in the workforce.

Applying consumer data is integral to creating the best healthcare solutions because new healthcare models are personalized, predictive and preventive. Healthcare has historically been viewed as sick care, but, with healthcare becoming more holistic, it covers a range that also includes well care. The range of care has moved to a decentralized model that connects everyone, including, payers, service providers and healthcare providers. While this model provides an easier connection to meet the needs of users, it also makes systems more vulnerable. Because private health data is often the target of cyberattacks, security must be at the forefront of technology advances. 

Throughout all evolutions of health, it is essential to remember that health is human-centric. Technology applications should always be used for improving efficiency and accuracy, shifting how engaged consumers are with their health data.

See also: The Graveyard of Digital Health  

Skills Competition

When developing solutions to advance the needs within the workers’ compensation industry, are you considering what skill gives your company a competitive edge? There is a considerable lack of engagement with digital health in workers’ compensation. Its real-time data could provide critical insights into medication adherence and post-surgery recoveries, and opportunities for an injured worker to speak to a case manager or nurse. Using these digital health advances could alter the engagement for all parties involved in a claim and should be considered when developing a path for a return to work. 

Using our most crucial skills also means leveraging partnerships to develop the best solutions possible. One speaker noted that partnerships occur across all stakeholders, including our patients, and how we are engaging them. Start with the patient journey and then move outward to other stakeholders to keep your solution consumer-focused. Then proceed to use external resources, even engaging with your competitors, because not all solutions can be developed from within one resource.

The Investment Thesis

Investments in new health technologies should always focus on the ability to drive smart, connected devices, personalized healthcare and digitalized guidance and provide 24/7 accessibility to experts. Investors lean toward these ideas because they typically make consumers more engaged with their health. Understanding patterns in consumer behaviors, investors are also aware that technology that links to increased employer-sponsored benefits drives funding and more substantial deals. In 2019, one in three healthcare deals were within the digital space. Notably, women’s health and behavioral health technology earned significant investments last year. 

One of our guests spoke to the critical changes being driven by employers in healthcare, noting that venture capitals and angel funds are explicitly looking to invest in this field of evolution. Investors want to see a real impact on employees. Because blockchain technology protects user data, allowing the sharing of information in a trusted and safe environment, investors are also highly interested in this ever-expanding technology. Blockchain could be used to improve the patient/pharmacy experience and securely share data across a supply chain. 

Payer Perspectives

In creating healthcare solutions, it is imperative to understand the perspective of a workers’ compensation payer and how payers are incorporating healthcare technology into their business practices. One guest noted that the workers’ compensation industry should be incorporating technology and innovation into the foundation of our builds. We should be asking how we can do things differently from the beginning and bring a personalized approach to each injured employee. It is essential to balance these new technologies with human nature and match our resources with the right claim, using them to improve our processes.

Wearables, for example, can be used as a preventative measure and as a motivator. They can be used to stay connected and engaged with an injured employee and track progress. They can provide valuable data regarding who is most at risk in the workforce, or who is taking the necessary steps to prevent injury. Providing experts access to this data maintains relevancy to our goals, allowing a more personalized and aggressive approach to the care of an injured worker.

Mental health has also changed with telehealth and telemedicine, providing us with information on how it impacts a claim. Access to the most updated information on new drugs can provide critical data on drug interactions and reactions, allowing us to make the best decision for an injured employee and improve the outcome of a claim. 

Telemedicine Disruptor

Before the pandemic, telemedicine was viewed as an additional benefit of employer-provided healthcare. Now, there is an urgency to work through all the regulatory issues and make it widely available. There is now a paradigm shift from patients not feeling comfortable with telemedicine, to asking if it is an option, so they do not have to go into a doctor’s office and put themselves at risk. This increased demand is leading to the most dramatic shift in healthcare delivery history.

There are still many regulations on the delivery of care for an injured worker. Everyone in the industry should understand what is permissible in their jurisdictions in the workers’ compensation system to deliver appropriate care. For example, Washington DC regulations have shifted to allow telehealth care within a patient’s home instead of within a medical facility. These changes are part of a group of emergency responses that will expire on July 2, so industry professionals need to keep an eye on how these regulations will shift.

There have also been significant interests in providing telerehab and behavioral health services. With federal-, state- and workers’ compensation-level emergency regulations changing daily, we need to work with regulators to make sure these types of services are reimbursable. Additionally, some companies are offering examinations for quarantined employees so they can be screened before returning to work, ensuring the safety of all other employees, especially those in the essential sector. 

See also: Can We Thread the Needle on the Coronavirus?  

Will You Be the Disruptor or Disrupted?

As health and healthcare continue to be more consumer-centric, evaluate if your company is doing what it needs to create solutions consistently, or if it is becoming stagnant in a data-driven world. Is your model engaging injured workers to custom-fit their needs? Consider retooling your solution to enhance the consumer experience if it does not have customers’ interests in mind. 

As workflow barriers continue to decrease, especially amid the pandemic crisis, it provides more room for growth in technology. Advances in virtual tools and assistance will increase as the need for a telehealth model only increases for at-risk individuals. Most significantly, post-pandemic, expect to see increased requests for telemedicine technology, and requested changes in workers’ compensation regulations.

To listen to the full Out Front Ideas with Kimberly and Mark webinar on this topic, click here. Stay tuned for our special edition Out Front Ideas COVID-19 Briefing webinar series, every Tuesday in April. View the full list of coming topics here.

Impact of COVID-19 on Workers’ Comp

There is much discussion right now on the impact that COVID-19 (Coronavirus) will have on workers’ compensation. Most of this discussion has focused on the potential for claims activity arising from the virus. The determination of whether a communicable disease is “work-related” is a case-by-case evaluation. The large employers that I work with tend to retain risk on both their workers’ compensation and employee benefits programs. Thus, they are not concerned about which financial bucket the money comes from but are prioritizing caring for their workforce instead. Potential claims arising from COVID-19 are not the focus of this column. Instead, I’m looking at how the challenges arising from this virus will affect the workers’ compensation industry.

Individual Claims Costs

In the short term, expect the overall costs per workers’ compensation claim to rise due to the increased duration of claims caused by many factors: 

  • There will likely be delays in treatment as the healthcare industry focuses on fighting COVID-19. That means physicians, hospitals and testing facilities are tied up and that elective surgeries are on hold until this crisis passes. This challenge is not unique to workers’ compensation, as the group health and Medicare setting will be experiencing similar delays. 
  • Modified work will likely be unavailable for many employers, due to the significant downsizing of workforces in many industries, including retail, restaurant, hospitality and airlines.
  • Return to work in any capacity may be a challenge for these same industries. In wage-loss states, indemnity benefits often cannot be stopped without a return to work. 
  • Courts are mostly closed in many states, halting the workers’ compensation adjudication process. 
  • Outside job placement efforts through vocational rehabilitation will be almost impossible, with so many employers idled and a significant percentage of the workforce looking for work. 

Total Claims Costs 

Due to the significant decline in people working in most industries, there will be fewer new claims over the near term. With so many businesses closed or functioning with reduced operations, there are simply fewer opportunities for workplace injuries to occur. 

On the flip side, it is too early to tell what the ultimate impact of compensable virus claims will have on the industry. No one can rule out that the costs from these claims will be as high, or even higher, than what we would experience typically. Specific industries, such as healthcare, some retailers and occupations such as first responders, could see an increase in claims and costs due to the combination of virus-related exposures and the significant overtime hours by their workforce.

Nationally, there is a significant increase in the number of people working from home in response to the outbreak. There is very little case law out there regarding what constitutes a compensable claim when working at home. It will be interesting to see what claims arise from these situations and how courts around the country interpret these situations.

See also: How Coronavirus Is Cutting Connections  

A decrease in total claims may mean less revenue for industry vendors with fee-for-service and per-claim business models such as medical management providers, including utilization review, bill review and case management. Third-party administrators are also often on per-claim contracts, and fewer claims could mean less revenue for them.

Later this year, there could be a spike in claims as things start to return to normal. There will be a massive influx of workers who are both deconditioned and may have forgotten procedures and loss-prevention policies. It will be challenging for employers to ensure their returning workforce is fit for duty and retrained appropriately.

Other Claim Considerations

As many restaurants shift to a delivery-only model, employees who are not usually commercial drivers find themselves adapting to this new role. Could that lead to a spike in work-related auto accidents in that industry? Possibly, but a more significant concern may be that many businesses may not have adequate commercial auto coverage because they did not have drivers until now.

Also, as non-essential businesses close, and many companies shift to a work-from-home model, there should be fewer auto accidents overall.

Industry Financial Implications

The dramatic drop in payroll for many employers may also mean a reduction in the corresponding workers’ compensation premiums they pay. It’s relatively simple; fewer workers equals lower premiums. Look for overall industry premiums to drop sharply for 2020 compared with prior years. Lower premiums also mean lower revenue for state regulatory agencies that are often funded by premium taxes and assessments.

The insurance industry, in general, and workers’ compensation carriers, in particular, depend on investment income as an element in their overall pricing model. With the Fed interest rate at zero and the massive drop in the stock market, those investments will be down across the board. Carriers may have to charge higher rates to make up for the significant decline in investment income.

Like all industries, the workers’ compensation industry is dealing with significant business disruption because of COVID-19. Many offices have closed, and, where possible, companies are implementing work-from-home models. Companies that focused on business continuity planning for such situations have an advantage over competitors that may not have been as diligent in these areas. It is imperative that insurance companies be included as “essential businesses” in any state or local shut-down orders because of the important financial backstop the industry provides to the economy and the workforce in general.

Finally, almost all in-person industry conferences are canceled right now until mid-May and possibly longer, including two of the largest industry events of the year, RIMS and the NCCI Annual Issues Symposium. The conference business is a challenging one because it requires you to invest up-front to secure facilities and resources with the hope you will be able to recoup that investment with sponsorships and attendee fees. Conferences have incurred costs preparing for now-canceled events, and they may not be able to recover those costs. Those unrecouped costs could put a significant financial strain on some event budgets, especially the smaller events that tend to operate with no surplus to tap into year-to-year.

See also: Coronavirus: What Should Insurers Do?  

On a positive note, most workers’ compensation carriers have strong balance sheets that will enable them to come through these challenges. The current crisis is an example of a time when the financial strength rating of your carriers matters most. Injured workers will continue to receive their benefits, and carriers are being very responsive to policyholders, including timely payment of claims. Many claims administrators use electronic banking where allowed, which means even injured workers under confinement receive their benefits in a timely matter.

COVID-19 will affect the workers’ compensation industry well beyond claims related to the virus. However, our industry is strong and resilient, and we will persevere and adapt to these challenges.

Tele-Triage Comes to Workers’ Comp

We are all familiar with the concept of nurse triage to help manage work-related injuries. A new telemedicine concept, doctor triage, takes the idea to the next level.

The telemedicine approach reduces costs, increases flexibility for both doctors and patients and allows for consultations 24 hours a day. Patients speak with board-certified physicians who determine if self-care, emergency room or clinic visits are appropriate and do so more authoritatively than is possible with nurse triage. Early results from our own Doctor Now program find that 99% of the people who were recommended for self-care returned to work without additional treatment. Part of the reason appears to be that, among those who speak with a doctor, self-care recommendations are followed more often.

Doctor triage is part of the growing trend in enhancing telemedicine programs. The number of patients using telemedicine services increased to 7 million in 2018, up from less than 350,000 in 2013. In 2017, about 70% of employers offered telemedicine services as an employee benefit.

Telepresence combined with telemedicine creates saving not just in direct costs for treatment but also in indirect costs. In the U.S., the average total time for a medical visit is 121 minutes, with a minimum travel time of 37 minutes. The average clinic visit is 84 minutes, and the average emergency room visit is two hours, often extending well beyond. Most of the time is not spent with the physician but is spent waiting to see the doctor. By contrast, the average telemedicine visit takes 15 minutes (including wait time); the average time for a doctor triage call is less than 7 minutes.

Adults in the U.S. spent 1.1 billion hours of unnecessary time traveling and waiting for a doctor last year, resulting in additional costs of lost productivity and lost time from work.

Workers’ comp is an area that still remains very much uncharted for telemedicine, and that needs to change. Our young Doctor Now virtual clinic shows the potential. Looking at recent doctor triage sessions: 61% of the calls were for self- care, and 99% of those callers agreed to the self- care and returned to work. Only one person was referred to the emergency room for chest pains. Others were referred to clinics for evaluation and treatment of eye injuries, fractures, lacerations, etc. All received appropriate care, and most returned to work in some capacity.  

The tele-triage approach is especially valuable for those who use our electrodiagnostic functional assessment (EFA). Employers use it to screen employees when they join a company, to establish an objective baseline on physical condition and abilities that can be used as the basis for comparison when an injury occurs — the baseline and comparison let everyone see whether a work incident caused dysfunction, and the baseline provides a goal for treatment.

With EFA, a truck driver who feels he or she sustained a back at injury at work could simply pull to the side of the road and call the 24/7 clinic line. If no emergency care is needed, and there is a baseline EFA for the body part in question, the triage doctor can schedule a second EFA, sometimes for the same day. The triage doctor can also recommend self-care.

If there is no baseline EFA and there needs to be an additional evaluation outside of the triage, a virtual clinic evaluation can be arranged, typically within the hour. The individual can be seen while still at work or in the comfort of his or her home.

Virtual clinic visits offer the injured worker specific analysis; treatment often leads to full-duty release within four visits. Virtual clinic evaluations are typically $150 each. Therefore, with simple musculoskeletal disorders (MSD), a full-duty work release can be obtained for under $1,000, with no narcotics prescribed — telemedicine doctors are not allowed to prescribe narcotics. This is truly a good outcome for everyone.

Even in a state where the employer must give the employee a panel of doctors to choose from, the virtual clinic is one option presented to the employee, along with other panel providers. Insurance carriers are embracing this concept and adding the specialized virtual clinic providers to their panel.

New telemedicine services improve outcomes for not only employees but employers. The return-to-work results and cost savings for employers are dramatic, but the outcome for workers is even better: improved quality of life.

Threats, Openings for Workers’ Comp

Workers’ compensation systems have been a central and meaningful part of our social safety net for over 100 years. This longevity was accomplished despite social and economic change and technology revolutions, through wartime and peacetime, economic crises, etc. Two features have been central to this enviable record of continuity. The first is a fundamental and enduring premise that workers’ compensation systems should provide a fair balance between (1) adequate income benefits and timely medical care for injured workers in their time of need and (2) an affordable cost to employers, which must compete in an increasingly global marketplace. The second feature is a robust, albeit imperfect, process for redressing significant imbalances that inevitably occur from time to time.

What does change look like? When systems stray significantly out of balance, legislators and regulators are mobilized by injured stakeholders to change the laws and regulations to move systems back toward that fundamental balance. Note that the direction is “toward” a better balance — not to some specific “ideal” definition of balance. In this context, “balance” has always been and necessarily remains an amorphous concept. Sometimes, the reform process falls short, and other times it overshoots. Having a reform process that generally moves the systems in the direction of improved balance has been one key to workers’ compensation systems’ successful adaptation to many twists and turns over the course of a century.

A few examples illustrate this. In the early 1970s, the benefits paid to workers were inadequate, according to a report by a national commission appointed by President Nixon. In the ensuing decade, legislatures in many states increased statutory benefit levels. By the late 1980s, the pendulum had swung in the opposite direction. Claims costs were rising at unsustainable double-digit rates; many elected and appointed insurance regulators were unwilling to pass these large cost increases on to their employer constituents; and the availability and affordability of workers’ compensation insurance became a serious concern. Over the next decade, many state legislatures addressed key cost drivers, deregulated insurance prices and created competitive state insurance funds as both the insurers of last resort and as competitors to private sector insurers. Claims costs were reduced, insurance was more affordable for employers and insurance markets were stabilized.

This book examines these questions:

  • Is there a plausible scenario in which many state workers’ compensation systems become seriously out of balance in 2030? And where the workers’ compensation reform process is unable to restore a reasonable balance?
  • If so, what will be the likely causes of the imbalance? Why will the workers’ compensation reform process be unlikely to deliver effective solutions?
  • What might replace state workers’ compensation systems?

When the balance in workers’ compensation systems is disturbed, the causes fall into either of two broad categories: developments outside of the workers’ compensation systems or developments within the systems. Internally generated imbalances typically involve the workers’ compensation statutes and regulations, as well as the incentives and behaviors of the system stakeholders and their agents and vendors. Externally generated imbalances result from forces like structural changes in the economy, societal norms and values, federal government actions separate from workers’ compensation or developments in the larger healthcare system.

Internally generated system imbalances are not unusual. In the past decade, several groups have raised concerns about the performance of state workers’ compensation systems. Some expressed concerns that too many state systems were not serving injured workers adequately. Other groups maintained that the systems were unnecessarily costly for employers and that alternatives may provide better benefits for workers at lower costs to employers.

In the wake of these critiques of state workers’ compensation systems, two groups convened “national conversations” among stakeholders from diverse perspectives. These conversations discussed the strengths and limitations in current state systems (IAIABC, n.d.; 2016 Workers’ Compensation Summit, 2016). Examples of the issues they suggested that should be addressed include:

  • Reducing the complexity of workers’ compensation systems (both groups)
  • Increasing the consistency/uniformity of state programs to reduce expenses (IAIABC)
  • Emphasizing a focus on worker outcomes—e.g., return to work and medical recovery (both groups)
  • Reducing the reliance on adversarial processes (both groups)
  • Ensuring adequate (equitable) benefits (both groups)

These are examples of issues that are typically resolved by incremental changes to the features of existing systems—as has been done in the past. Hence the historic change process has opportunities to address these concerns and improve system balance where needed.

See also: The State of Workers’ Compensation  

The developments discussed in this book are different from these. They originate outside of the workers’ compensation systems. Because of this, they are much less amenable to solutions developed by the workers’ compensation reform process.

Scenario for the 2030s

Workers’ compensation costs triple since 2016, with no real change in benefits to injured workers. Both employers and worker advocates agree that the systems are seriously out of balance. Despite multiple attempts at workers’ compensation legislative and regulatory reforms, too many larger workers’ compensation systems remain badly out of balance.

What are the drivers of this scenario?

Demographic Change

  • Baby Boomers exit the workforce at an accelerating pace, creating historic labor shortages. During labor shortages, employers lower hiring standards. Labor turnover also increases. The shortages extend to healthcare providers, delaying care for injured workers. Claim frequency increases, and disability lengthens.
  • Restrictive immigration policies and practices worsen the labor shortages, magnifying the effects of the shortages on workers’ compensation systems. Automation mitigates the labor shortages but not nearly by what one might expect from reading the headlines about automation “destroying” large numbers of jobs.

Healthcare Reform

  • Accelerating growth of high deductibles in nonoccupational health insurance policies leads more insured workers to shift soft tissue injury cases to the free care alternative—workers’ compensation.
  • As Congress and the administration repeal and weaken key elements of the Affordable Care Act (ACA), more workers lose their health insurance— particularly those covered by Medicaid and nongroup policies. These workers will look for ways to continue coverage for many conditions. For soft tissue conditions, the free care alternative offered by workers’ compensation will be attractive. As the number of uninsured climbs, the number of cases shifted to workers’ compensation will increase.
  • Fee-for-service contracts are being replaced by payment models where provider organizations assume financial risk if costs exceed targets. These contracts cover most of the care paid by commercial insurers, Medicare and Medicaid. Workers’ compensation remains fee-for-service. Providers increasingly shift soft tissue injury cases to workers’ compensation to earn the fee-for-service payments, while not counting the costs of care for these cases against the performance contracts with the other payers. Workers’ compensation claims increase.

SSDI Solvency

  • Congress addresses the solvency crisis in the Social Security Disability Insurance (SSDI) program by abolishing reverse offsets. Moreover, new SSDI set-asides, akin to the Medicare set-asides, are mandated for workers’ compensation indemnity benefits. Workers’ compensation costs increase, as do the expenses involved in resolving claims.

Together, these developments raise workers’ compensation costs significantly—plausibly triple the level of 2016. Both claim frequency and cost per claim see large increases. The large increase in claim frequency is surprising because it is a stark contrast to the falling claim rates that we have come to expect over the previous several decades.

Workers’ compensation systems are seriously out of balance—costs to employers triple but benefits to injured workers have no real increase. In the past, the reform process would have moved the systems back toward balance. Yet this does not occur. Because the large cost increases arise from causes outside of the workers’ compensation systems, the typical workers’ compensation reform process has limited success in restoring balance in the systems.

Other developments outside of workers’ compensation systems also converge to create historic urgency (1) for both historic tax increases and spending cuts in virtually all government programs and (2) to improve the competitiveness of American businesses. This urgency pervades most public policy and strategic business decisions—including the search for solutions to what becomes known as the Workers’ Compensation Problem.

These external developments include:

Widespread Fiscal Distress at All Levels of Government and Millennial Voters Come of Age Politically

  • We begin the repayment of the massive governmental debt and unfunded liabilities accumulated under the Baby Boom generation. This severely limits governments’ ability to maintain many current programs. Privatization and consolidation of government services increase.
  • Because of the inherited public debt, millennials face the prospect of taxes doubling and historic cuts in government programs. Millennial elected officials and voters abandon many of the government budgeting norms and processes that had been used to kick the hard decisions down the road (from Boomers to millennials). Rather, they begin to make hard decisions on government spending to mitigate the impending tax increases. Given the debt that they inherited, millennials are unwilling to incur unnecessary public debt or additional unfunded liabilities that would burden future generations.

Globalization Pressures Intensify

U.S. employers face intensifying globalization pressures, driven by broadening diffusion of telecommunications technologies, especially in a handful of under- the-radar African and Asian economies that account for half of the world’s population growth. As competitors arise in emerging economies, U.S. firms are required to more often choose between aggressively reducing production costs of U.S.-made goods and services, moving production to lower-cost nations and losing business to foreign competitors.

See also: How Should Workers’ Compensation Evolve?  

Sclerotic Legislative and Regulatory Processes

The processes for improving public programs, including workers’ compensation, become increasingly sclerotic. Pragmatic problem-solving and compromise- based solutions become the exception, rather than the rule, in both legislative and executive branches at the federal and state levels. Too often, pragmatic problem-solving is replaced by all-or-nothing processes driven by ideology, camouflaged self-interest, electoral tactics and fake “facts.” This makes it more difficult to move the now out-of-balance workers’ compensation system toward a better balance.

Automation Lets Compassion Scale

The modern workers’ compensation system was devised to provide a guarantee of care and medical treatment to injured workers from their employers. Organizations also are expected to offer guidance on the resources available to injured workers as well as how to navigate issues such as finding the right doctor and taking time off work. In short, organizations are expected to be compassionate toward their injured workers and get them back to a productive and motivated state as soon as possible. The reality, however, is that we’ve shifted very far away from these principles.

Today, claims teams are overwhelmed by the number of cases they are expected to handle, which often hamstrings their ability to service injured workers the way they would like. Additionally, skepticism has crept into the claims process, establishing a more adversarial relationship between organizations and injured workers. Feeling neglected or disrespected, many injured workers then turn to litigation for a remedy. According to a report by the Workers Compensation Research Institute (WCRI), some states now see attorney involvement in more than 50% of workers’ comp claims, which can add significant costs and duration to claims. This is a broken system for everyone — workers, organizations and the claims agents caught in between.

So, how do we get out of the present situation?

The Human Element

The claims process has eroded because of a lack of compassion and awareness. Claims are filed by real human beings — often at their most vulnerable. These are people who are physically hurt, so they are already in pain. They also face the prospect of being away from a job they need to pay their bills and are uncertain of when or how much they will be paid while out of work. Tack on the fear, whether warranted or not, that someone will replace them if they are gone from their position too long, as well as the complications of the claims process. If they don’t hear back from the claims agent handling their case or if bills are taking too long to process, injured workers will turn elsewhere.

At the same time, no one goes into claims adjustment (or at least they shouldn’t) thinking, “I want to make this person’s life as difficult as I can. I want to prove they are trying to milk the system and, therefore, will hold up their claim as long as possible.” Absolutely not. The average claims adjuster likely is dealing with a massive caseload as well as imposed processes and questions that are not geared toward moving claims forward.

That is not to say that corporations are evil. They want their workers back on the job as quickly and safely as possible.

See also: Untapped Potential of Artificial Intelligence  

To remove the distrust and frustration experienced by each constituent in the claims process, recognition of humanity must be present, and compassion needs to be injected. You may be thinking something along the lines of: It’s easy to handle a claim with compassion on an isolated basis. A handful of claims in an agent’s caseload may capture more personal attention, but there is no way to address every claim with such care. I would argue that, even as the number of claims rise, with the next generation of tools it is now possible to provide compassionate care at scale.

The Role of Artificial Intelligence

As odd as it may sound, the way to insert more humanity into claims is by using machines. New technologies, such as machine learning and artificial intelligence (AI), can transform the system.

The end goal of AI is to create the best experience, efficiently and at scale. To do so, AI must be given a precise purpose. In the case of claims, AI can be charged with removing very specific hurdles that get in the way of care.

AI is not about replacing humans with robots. In this case, it is about removing the robot from humans. By automating the mundane pieces of claims management, AI frees agents to address emotional needs. In doing so, AI opens the door for a new model of “scalable compassion.”

Scalable Compassion

Until now, it’s been impossible for teams to deliver compassion at scale without breaking the bank. If AI automates significant portions of claims processing — whether it’s finding the right physician, helping to calculate an MSA, or signaling claims that raise red flags — adjustors can dive much deeper into the details that matter. They can weigh various factors based on data and predictive models to provide better answers to questions and make more informed decisions on a case-by-case basis. This results in a much smoother, happier experience for both injured workers and claims representatives who can spend time engaging with people and using their minds in positive ways.

The scalable compassion model works for businesses, too. If you provide the right experience to claimants, the economics will follow. With strategic use of AI-based technology, claims representatives can help get injured workers to the best doctors right from the beginning. When injured workers get in to see a doctor ranked in the top 50%, companies see a 26% reduction in the overall cost of the claim, even if the upfront costs appear higher. This is because the best doctors expedite recovery. Getting it right from the beginning limits the need for additional procedures and continuing doctor or physical therapy appointments.

Employees who receive the right care early in the life of their claim also return to work faster, minimizing problems for both the organization and the worker. And the increased personal attention and seamless delivery of care dramatically reduce litigation costs — which can account for $35,000 to $50,000 per claim if an attorney gets involved. Scalable compassion ultimately may save companies thousands to millions of dollars each year, while improving relations with and loyalty from workers who feel cared for in their time of need.

See also: The Best Workers’ Comp Claims Teams  

Today, workers’ comp sits at a critical junction. Something must be done to reform the system before it collapses. By implementing new intelligent technologies while embracing the role of advocate instead of adversary, a model of “scalable compassion” makes it possible to finally deliver on the intent and vision for workers’ comp. It represents a bold step forward but one well worth taking.

As first published in Claims Journal.