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 of 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 and that the claims process itself is quite complicated. 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 in a positive direction for claimants.
That is not to say that corporations are evil. They want their workers back on the job as quickly and safely as possible.
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 rises, with the next generation of tools, it is now possible to provide compassionate care at scale.
The role of artificial intelligence
As ironic 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 up agents to address emotional needs. In doing so, AI opens the door for a new model of “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 a Medicare set-aside or signaling claims that raise red flags — adjusters can dive much deeper into the details that matter. They can weigh various factors based on data and predictive models in order 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% cost 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 ongoing doctor or physical therapy appointments.
Employees who receive the right care early in the life of their claim also return to work faster, minimizing negative impact on 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.
Today, workers’ comp sits at a critical junction. Something must be done in order 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.
Jayant Lakshmikanthan is the founder and chief product officer of CLARA Analytics. This entry first appeared in Claims Journal and is republished here with permission.
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