Claims Handling

Reposition Role of Claims Adjusters to Maximize Outcomes

Facing a continued increase in complex claims, organizations need to change the way their adjusters manage claims to achieve the best outcomes.
By: | November 23, 2015 • 4 min read
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There’s been a significant shift in the types of workers’ comp claims over the past couple of decades. Because of that, organizations need to change the way their adjusters manage claims to achieve the best outcomes.


That’s one of the key takeaways from a new claims benchmarking study. Where the majority of claims in past years were high frequency/low complexity, there are now fewer but much more complex claims that require a shift to be resolved successfully.

“Executives really emphasized that where we want to focus our attention is repositioning the claims adjuster as the role of an advocate,” said Denise Gillen-Algire, director of managed care and disability for corporate risk management at Albertson’s Safeway Inc. and the author of the report. “If you think about what claims examiners do, they really are facilitating benefits and affecting millions of people.”

The Workers’ Compensation Benchmarking Study is the third annual report sponsored by Rising Medical Solutions that delves into the challenges facing claims managers. However, this year’s report goes a step further and includes insights from industry practitioners on ways to address the challenges.

“The study report is based on the qualitative research conducted through focus groups and interviews with 40 industry executives, including directors, vice presidents and executive-level leadership from every major type of workers’ compensation payer organization,” the report explains. “The focus groups yielded in-depth qualitative research data on experiences, perspectives, insights and opinions as well as potential solutions related to claims operational challenges. The use of focus groups increases candor, probe, and the thinking behind participants’ opinions, and can generate data that would be inaccessible without the interaction of group participants.”

Outcomes Management

Where many organizations talk about outcomes management, in reality they focus more on cost containment. The change requires a commitment throughout the entire organization.

“The point is, if we say we want to focus on outcomes then it’s important that our internal metrics — key performance indicators — and how we measure performance also supports focusing on outcomes,” Gillen-Algire said. “The messaging we give to claims staff through internal performance metrics and how they prioritize their time must be focused on outcomes.”

A consistent theme echoed by the industry executives was the need to focus on claims examiners as creators of value through outcomes management and as holding positions of power. That means that in addition to process compliance, claims adjusters must also focus on outcomes management.

“Adjusters today are required to make various key decisions throughout the life of the claim,” said Srivatsan Sridharan, senior vice president for workers’ compensation product management at Gallagher Bassett. “The quality of these decisions has a significant impact on the results — from employee health, to the claim cost, to how long these claims remain open.”

Sridharan and Gillen-Algire were among the participants in a recent webinar produced by Risk & Insurance® Magazine.

The key to driving ultimate claim outcomes is to tie performance measures to core competencies. The outcomes, the webinar panel explained, rely on the successful execution of interdependent core competencies.

“Taking the discussion from measuring core competencies to how we drive those measures to deliver outcomes is really the question here,” Gillen-Algire said. “For example, a common outcomes measure is claims resolution.”

Most companies want a ratio of more than 100 percent, so more claims are closed than open. To ensure that goal is achieved, companies must look at the core competencies that actually drive that.

“For example, if you don’t execute the initial investigation appropriately, downstream it will affect the outcome,” Gillen-Algire said. “Another example is looking at the execution of return-to-work activities. If you don’t execute them appropriately, than claims resolution will be affected.”

Reverse Engineering

Starting with the desired outcome of a claim can lead to a better result, the report indicated. It’s what is called reverse engineering.


“It’s thinking about the outcome we want to achieve and then about each step that gets us there,” Gillen-Algire said. “Looking at the steps most likely to have the greatest impact, then putting the most resources on those core competences that will drive ultimate outcomes.”

Several core competencies can affect a claim’s outcome such as the compensability investigation, disability and return-to-work management, and litigation management.

“So it’s important to pay close attention to all the factors that truly influence outcomes such as psychosocial issues, retirement claims, comorbidities and how those impact the ultimate claim outcomes, which is really driven by successful execution of core competencies,” Gillen-Algire said.

Companies that invest in claim outcomes measures and use reverse engineering over the next couple of years will see the greatest impact on outcomes, Gillen-Algire suggested.

Nancy Grover is the president of NMG Consulting and the Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at [email protected]
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2015 NWCDC

Best Use of Nurse Case Managers

Nurses with soft skills can significantly improve outcomes on complex claims.
By: | November 13, 2015 • 2 min read

Nurse case managers can vastly improve outcomes for injured workers and save a bundle for payers. The trick is to understand which claims will benefit from intervention and to use nurses with the right skill set.

“If an injury occurs from lifting equipment or falling from a height, the claim needs a nurse,” said Stephanie Perilli, senior director of medical and health management for The Home Depot, during a session at the National Workers’ Compensation and Disability Conference® & Expo on November 12.

In a comparison of claims more than 24 months old, the company saw a 12 percent savings on paid medical dollars and a 28 percent reduction on paid loss dollars for claims with nurse involvement.

For non-catastrophic cases, the company uses a model to determine whether to involve a nurse.

“Our results have significantly improved over the last three years,” she said.

In a comparison of claims more than 24 months old, the company saw a 12 percent savings on paid medical dollars and a 28 percent reduction on paid loss dollars for claims with nurse involvement.

But not every claim is appropriate for nurse intervention. A recent study determined that 25 variables, especially when some are in combination, can serve as triggers.

“If you’ve got an injured worker who is over 35, has no college degree, has injured a certain body part and undergone certain medical treatment, get a nurse as soon as possible,” said Mary O’Donoghue, VP of medical services for Helmsman Management Services.

In addition to the complexity of a claim, the nurse’s skill set can determine the value of involvement. Those nurses who are trustworthy can make the most difference.

“They can identify problems, educate folks, and redirect where needed,” O’Donoghue said.

Helmsman has found the most effective soft skills needed to move claims forward are communication with all parties involved, including family members; empathy, to establish trust with the injured worker; and collaboration, to make sure there is a plan in place and everyone involved is on the same page.

Nancy Grover is the president of NMG Consulting and the Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at [email protected]
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Sponsored: Aspen Insurance

When the Going Gets Rough, the Smart Come to Aspen Insurance

Aspen’s products liability team excels at solving tough problems and building long-term relationships.
By: | November 2, 2015 • 5 min read

Sometimes, renewals don’t go as expected.

Perhaps your company experienced a particularly costly claim last year. Or maybe it was just one too many smaller incidents that added to a long claims history.

No matter the cause, few words are scarier to hear this time of year than, “Renewal denied.”

But new options are now emerging for companies that are willing to tackle their product liability challenges head-on.

Aspen Insurance’s products liability team – underwriters, loss control engineers and claims professionals – welcome clients who have been denied coverage from other, more traditional carriers.

“For our team, we view our best opportunities to be with clients who have specific problems to solve. In these cases, we leverage our deep expertise and integrated team approach to help the client identify root causes and fix issues,” said Roxanne Mitchell, Aspen U.S. Insurance’s executive vice president and chief casualty officer.

“The result is a much improved product or manufacturing process and the start of a new business relationship that we can grow for many years to come.”

“We want to work with insureds as partners, long after a problem has been resolved. We seek clients who are going to stick with us, just as we will with them. As the insured’s experience improves over time, pricing will improve with it.”
— Roxanne Mitchell, Executive Vice President, Chief Casualty Officer, Aspen Insurance

Of course, this specialized approach is not applicable to all situations and clients. Aspen Insurance only offers coverage if the team is confident the problems can be solved and that the client genuinely wants to engage in improving their business and moving forward.

“Our robust and detailed problem-solving approach quickly identifies pressing issues. Once we know what it will take to rectify the problem, it’s up to the client to make the investments and take the necessary actions,” added Mitchell. “As a specialty carrier operating within the E&S market, we have the ability to develop custom-tailored solutions to unique and complex problems.”

For clients who are eager to learn from managing through a unique, pressing issue, and apply the consequential lessons to improve, Aspen Insurance can be their best, and sometimes only, insurance friend.

The Strategy: Collaboration from Underwriting, Claims and Loss Control

Aspen offers a proven combination of experienced underwriting professionals collaborating with the company’s outstanding loss control/risk engineering and seasoned claims experts.

“We deliver experts who understand the industries in which they work, which is another critical differentiator for us,” Mitchell said.

Mitchell described the Aspen underwriting process as a team approach. In diagnosing the causes of a specific problem, the Aspen team thoroughly vets the client’s claims history, talks to the broker about the exposures and circumstances, peruses user manuals and manufacturing processes, evaluates the supply chain structure – whatever needs to be done to get to the root of a problem.

“Aspen pulls from every resource we have in our arsenal,” she said.

After the Aspen team explores the underlying reason(s) and root cause(s) producing the client’s problem in the first place, it will offer a solution along with corresponding price and coverage specifics.

“We have a very specific business appetite and approach,” Mitchell said. “We don’t treat products liability as a commodity.”

As noted, a major component of Aspen’s approach is that they seek to work with clients who are equally interested in solving their problems and put in the work required to reach that end.

Aspen_SponsoredContentMitchell cited two recent client examples of manufacturers of expensive products that could endure large claim losses but had some serious problems that needed to be solved.

A conveyor systems manufacturer had a few unexpected large claims and lost its coverage in the traditional insurance market. The manufacturer never managed a product recall in the past, and Aspen’s loss control engineers dug into why several systems failed. Aspen also helped the company alert customers about the impending repairs.

Another company that manufactured firetrucks had three or four large losses, when telescoping ladders collapsed, resulting in serious injuries. The company’s claim history was clean until this particular product defect. When Aspen researched the issue, it found that the specific metal and welding used to make the telescoping ladders didn’t have the required torque to keep the ladders from collapsing.

Both companies worked with Aspen to correct the issues. Problem solved.

“It is so important that our clients are willing to actively engage in finding out what is causing their losses so they can learn from the experience,” Mitchell said.

Apart from the company’s problem-solving philosophy, Mitchell said, the willingness to allow qualified clients to manage their own claims is the second biggest reason companies come to Aspen.

“We are willing to work with clients who have demonstrated the expertise to handle their own claims — with our monitoring — rather than hiring a TPA,” she said. “It is a useful option that can save them money.”

Mitchell explained that customers who stay with Aspen for the long-term can be confident that Aspen will help them – whatever the challenge. For instance, if they need a coverage modification for a new product that they bring to market, Aspen can help make it happen. Mitchell noted, “We pride ourselves on the ability to develop custom-tailored solutions to address the complex and challenging risks that our clients face.”

Long-term Relationships

Aspen_SponsoredContentAspen’s desire to help solve difficult client problems comes with a caveat, but one that benefits both Aspen and the insured: It wants to move forward as a true partner – one with clear long-term relationship potential.

In a nutshell, Aspen’s products liability worldview is to partner with a manufacturer who is facing a difficult situation with claims or coverage, help them solve that problem, and then, engage in a long-term, committed relationship with the client.

“We want to work with insureds as partners, long after a problem has been resolved,” she said. “We seek clients who are going to stick with us, just as we will with them. As the insured’s experience improves over time, pricing will improve with it. This partnership approach can be a clear win-win.”

This article is provided for news and information purposes only and does not necessarily represent Aspen’s views and does constitute legal advice. This article reflects the opinion of the author at the time it was written taking into account market, regulatory and other conditions at the time of writing which may change over time. Aspen does not undertake a duty to update the article.


This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Aspen Insurance. The editorial staff of Risk & Insurance had no role in its preparation.

Aspen Insurance is a business segment of Aspen Insurance Holdings Limited.
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