White Paper Examines Work Comp Claim Tipping Points: GENEX

A newly released white paper highlights the value of early case management intervention for optimal return to work in workers’ compensation claims.

GENEX Services, a national provider of managed care services for employers and insurance carriers, explores the question of where the tipping point lies in routine workers’ compensation claims in its latest white paper.

“Every adjuster or workers’ compensation program manager has more than one story of a simple sprain or strain that somehow, someway escalated from a claim that should have been resolved in a month for a few thousand dollars to one that spiraled out-of-control,” says Pat Chavanu, senior vice president at GENEX. “It’s costly for employers and carriers and can be devastating for the injured worker. We have to find ways to stop it.”

The white paper noted that the longer the delay in intervention, costs rose and returning injured workers back to work took longer. In addition, the white paper revealed that the first 30 days is critical in identifying referral indicators. Case management utilized within the first three months of an injury were twice as likely to achieve successful RTW than those claims that were referred three to 12 months after an injury.

Analyzing industry research, as well as its own database of thousands of claims from close to 400 of the nation’s leading Fortune 500 corporations, GENEX revealed no single tipping point, but rather claims characteristics indicating the likelihood a claim may “tip” and then rapidly escalate into excessive costs.

The findings supports the premise regarding the value of earlier case management intervention. The company’s latest analysis of 46,000 claims over a 12-month period shows that the longer the delay in intervention, the higher the costs and the longer it takes to return workers to their jobs. The return-to-work rate can drop by close to 20 percentage points when delaying case management for a year. In addition, claims that utilize case management within the first nine months of the injury are twice as likely to achieve a successful RTW as those that are referred three years after the incident.

Some common characteristics of claims that may tip include:

1. poor initial physician diagnosis;
2. doctor hopping (e.g., three or more specialty physicians);
3. lack of modified work duty options;
4. poor employee/employer relationships;
5. psycho-social factors including poor family support;
6. pre-existing conditions;
7. alcohol or drug dependence.

The challenge, Chavanu notes, is that often employers and carriers aren’t aware of contributing factors, until the claim has already started to spiral. By then, excessive delays and costs have already kicked in creating additional resolution challenges.

“One of the most important steps employers and carriers can take is to analyze claims and to engage telephonic case management for even routine injuries when two or more red flags are identified,” says Chavanu. “As an industry we have to move away from setting arbitrary dollar figures for when to bring in case management; we need to utilize it earlier when it can make a difference in terms of costs, outcomes and the well-being of the worker.”

The white paper emphasized the value in operationalized data analytics to aid insurers in identifying the tipping point in a workers’ compensation claim.

Source: GENEX