The One Thing That All Great Workers' Comp Claim Managers Do

Despite new regulations and workplace safety initiatives across industries, workplace injuries occur at job sites. With 2.6 million nonfatal workplace accidents and injuries occurring yearly across the nation's private employment industry, about 2.8 people out of 100 get injured at work, according to the U.S. Bureau of Labor Statistics.

Faced with these statistics, companies must decide how to best deal with this reality. Having a proper workers' comp program in place is more than just a cost of doing business. When implemented correctly, it is a strategic investment that protects the company's workforce and financial performance.

At the center of the workers' comp program is the workers' comp claim manager. Their job is to oversee all aspects of a worker's comp claim from start to finish. This means having a solid plan to manage the claim so that the employee can return to work as soon as possible while preventing costs from ballooning while they are away. Great workers' comp managers are stellar communicators who work closely with injured employees, case workers, and healthcare providers to achieve a favorable outcome.

The Best Workers’ Comp Claim Managers’ Process

The one thing that the best workers' comp claims managers do is consistently manage claims - and all the steps in the process - proactively. That is because claims that are not proactively managed can balloon with unnecessary costs and delays that benefit neither the employer nor the injured employee.

Claims managers can drive the best results of the claims process by proactively managing these steps along the way.

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Step 1: Promptly Report On-The-Job the Injuries

Your workers' comp claims management process begins when a worker claims they were hurt while working. After getting a formal report, you need to confirm that there was an accident and collect evidence about how it affected the claimant.

That means recording statements from the injured employee and any witnesses, taking photos of the scene, videotapes, and every piece of evidence available at the scene.

The time you take to report and investigate the issue after the accident is critical for gathering factual information. Most states demand the supervisor make a report as soon as possible and up to 24 hours.

Step 2: Provide Immediate Medical Attention For A Workplace Injury

For serious injuries, call 911 to secure immediate medical attention. If the injury is not too serious, arrange for appropriate onsite first aid treatment. In this case, you can submit a report-only claim to your insurance carrier.

Job-related injuries vary from state to state. In some, the employer designates an approved doctor from a list of network medical providers. In Minnesota, injured employees choose the doctor they want.

A claims adjuster works with the claimant throughout the claims process to avail proper medical treatments and ensure a timely settlement.

It's always best to emphasize positive outcomes from everyone involved to reduce claim costs.

Step 3: Notify your Insurer Of The Injured Employee

Workers' comp claims managers are also responsible for notifying your organization's workers' compensation insurer about the injury after gathering details and documentation about the incident. Here is what you need to do:

Provide the appropriate paperwork. The information should include the date of the incident, where it occurred, the time, and circumstances surrounding the incident.
Interview witnesses and have their order of events recorded in a statement. Pair the statements with all supporting documents.
File the completed form and supporting claim documentation with your insurer.
Submit a first report of injury form to your state's workers' compensation board if necessary.

Again, this process may vary depending on the state. It's safest to begin by reading the rules of worker's comp claims in your state before filling or submitting any forms to your insurer.

Step 4: Investigate Any Reported Workplace Injuries Thoroughly

The investigation phase involves compiling evidence that the claimant was hurt while working.

For example, if an injured worker says their arm broke during duty, the insurer will find evidence that the claimant was physically active. Should the insurer find out that the claimant played tennis, rugby, or other activity that involves intense hands use, the evidence would significantly reduce their chances of getting medical benefits.

Sometimes, insurers may reconstruct the incident to determine whether the claimant's story adds up or their injuries can result from what they say happened.

In other instances, insurers conduct background checks into the claimant's work history to see whether they've claimed workers’ comp insurance before and the circumstances surrounding it.

The opposite is also true. These investigations may prove that the claimant was injured at work. This evidence serves to determine how much compensation they should receive.

Step 5: Gather Documentation about the Workers' Comp Claim

Collect useful evidence for the workers' compensation management process:

Medical Records. Collect medical records info before and after the injury. These details show where the employee was hurt and the extent of the injury.
Accident Reports. If you wrote a report after the accident or the police came on sight to write a report, keep the report as part of your claims documents.
Witness Statements. Gather statements from coworkers and other people who may have seen what happened.
Medical Receipts: These show the amount the employee has spent on out-of-pocket medical expenses, including medication bought over the counter.

Written documentation is the best because it's irrefutable and, in most cases, hard to alter.

Step 6: Determine Eligibility

Follow the legal guidelines that make an employee eligible for worker's compensation. Some eligibility criteria are standard –such as:

The injury must be directly related to work.
The claimant must be disabled for five full or partial calendar days to file a claim for workers' compensation benefits.
The claimant has four years from the date of injury or realization that your injury or illness is work-related to file a claim.
Employees who are disabled for less than five full or partial calendar days can file a medical-only claim. These are reported to the workers' comp insurer.

Different jurisdictions have other additions to eligibility. For example, the injured worker and their employer must have had an employer-employee relationship when the injury occurred in South Carolina to qualify for the workers' comp.

You can use employment records to confirm that the worker is an employee and not hired under casual or other unrecognized terms.

Step 7: Ongoing Communication with Employees and Medical Providers

Employees who suffer work-related injuries develop stress and anxiety that worsens should employers stop communicating with them.

Filing a workers' compensation claim can also be confusing. Guide them on how to do it and update them on the claim status.

Contact them and offer assistance early to help them maintain a positive connection to your workplace. For example, assure them you want them back and are looking forward to it. Discuss the formal return to work formula to help them understand what to expect.

Help the medics involved to understand what kind of work the employee used to do to help them create treatment plans that would help the employee get back to work.
Communicating with medical providers and everyone else involved is also crucial for improving the claims process for the claimant.

It also helps gather evidence and speed up recovery so the worker can return to work. Communication also makes the employee feel valued and makes it easier to cooperate and close the claim without litigation.

You can make communication even easier by educating employees on what to do when an injury occurs during onboarding.

Step 8: Facilitate Return to Work For An Injured Employee On Workers' Comp

A good return-to-work program can help reduce the psychological difficulty injured workers go through.

For example, it should clearly define your organization's return to work goals and be shaped by clear and consistent policies.

Those policies should be communicated and evaluated regularly to measure performance and allow favorable adjustments.

Consider your program might help after recovery -having employees recovering at home a workers' compensation, such as in returning employees return on temporary nonphysical or lighter physical duties.

If this idea is impossible for your organization to execute, arrange with your insurer to get temporary light-duty jobs at organizations that need volunteers.

Step 9: Manage Rehabilitation And Recovery Of The Injured Employee

Beyond having a standard return-to-work policy, work with a vocational rehabilitation specialist, the injured worker, and the treating physician to develop a tailored plan based on their after-injury situation.

Also, monitor progress when the injured employee returns to work. Monitoring is best done by a TPA or insurer who suggests reasonable provisions that may help the injured worker return to the former position.

Further, the insurer should identify and solve any problems that arise as the employee returns.

Step 10: Review Cases And Manage Reserves

Accurate claim reserves ensure financial stability when workers' compensation claims occur.

Experienced adjusters understand best how certain injuries will play out. But ideally, avoid an underfunded reserve and one that's adjusted after doctor visits.

Although insurers have the final word regarding maintaining sufficient claim reserves, these ideas help ensure reserve accuracy.

For instance, communicate with all parties. Keep everyone updated on the claim status, including the insurer, the injured employee, and the medical provider.

Also, consider working with claim representatives to engage in routine, organizational claim reviews. This activity reveals typical claim costs in your organization and whether past reserves satisfied past claims.

If you run into claim reserve issues, hiring an independent auditor is the best route to follow. This specialist investigates current reserve practices and offers necessary guidance.

Step 11: Manage Compliance

Worker's comps compensation is mostly handled at the state level, and some states may have different compliance regulations. In most states, however, you must comply with these laws as part of your workers' compensation and return-to-work obligations:

Have an up-to-date workers' compensation insurance policy that covers all your workers.
Submit claim forms to your insurance provider within three days of receiving them from an injured worker.
Disburse payments as instructed by your insurer.
Ensure you avail suitable duties after injury to the claimant.
Have a record of your wages for the past seven years.

You can negotiate a quick settlement if you manage the process well and if the case is simple. The idea of well-managed workers' comps is to reduce the payout and prevent hearings.

The Final Key to Effective Workers’ Comp

The key to an effective workers' comp program is proactive claims management. This ensures the best outcomes for impacted employees and protects the company from ballooning costs due to malingering cases or claimant fraud.

The challenge is that most companies do not have the time or staff available to provide this level of attention. Or, if they have hired a third-party partner to help them manage their workers' comp burden, it is often the case that interests aren't aligned. Instead, partner with a company who takes on the financial risk associated with workers' comp and are therefore incentivized to manage any claims to the best possible outcomes.