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Best Practices Automation Can Shorten Claim Duration And Improve Outcomes For Return-To-Work Claims

By Robert B. Kuller

There are many questions that the return-to-work (RTW) industry grapples with on a daily basis. These include questions such as how can we automate a notoriously labor intensive function, how can we focus on abilities rather than disabilities, how can insurers adjudicate claims based on medical facts rather than opinions, how can we improve claimant/injured worker outcomes and how can employers better promote a return-to-work culture and make RTW as easy as possible for their current/former employees? We are really looking for that nirvana where we find common ground between the claimant/injured worker, the employer, the insurer and the physician. If we broadly look at the three categories which encompass the vast majority of Return-to-Work circumstances, one bucket would include claimants that have a legitimate short-term condition that will allow them to return to work in days rather than months or years. The second bucket includes claimants with legitimate long-term conditions that will render them permanently disabled and very unlikely to return to work at all. We are left with an indeterminate bucket in the middle; the pool of people that are “partially abled” who can be truly impacted by a robust, best practices, automated return-to-work process.

Best Practices Automation Can Shorten Claim Duration And Improve Outcomes For Return-To-Work Claims

Best Practices Automation Can Shorten Claim Duration And Improve Outcomes For Return-To-Work Claims

As a senior executive who has spent a good deal of my career involved with identification of poorly designed processes, business process improvement (BPI) and change management, It should be noted that BPI focuses on “doing things right” more than it does on “doing the right thing”. In essence, BPI attempts to reduce variation and/or waste in processes, so that the desired outcome can be achieved with better utilization of resources.

I believe the current processes that I have observed in the RTW field must be remediated in order to achieve better outcomes. Achieving this starts with the use of assistive technology to address every constituent’s needs, to expedite the collection of pertinent data, and to standardize best practice methodologies. This way, every aspect of the RTW process is consistent and repeatable, using the “right” labor component to gain efficiencies while significantly enhancing outcomes.

Capture the Right Data

Best practices automation starts with a comprehensive online job analysis library that would allow employers and insurers to easily capture or modify the physical and mental/nervous system based job specifications. The next step involves obtaining detailed physical/mental capacities via an online physical/mental capabilities form (PCF or MCF) from the medical provider detailing exactly what the claimant has the capability to do, measuring things such as how long the person can stand and sit, how much weight they can lift, whether they can bend to pick something up, their cognitive abilities and their Global Assessment of Functioning score. Capturing this data rather than what is currently collected on a standard manual APS form changes the focus of RTW analysis from “disabilities” to abilities, takes physicians out of the claims adjudication business and properly positions them to be medical rather than insurance experts. In addition, the collection of this data provides consistency, helps reduce the subjectivity of reviewing the text driven APS and medical records and provides a basis of future predictive analysis.

Compare the Data

The use of automated technology makes comparing the claimant’s original job requirements and their current physical/mental capacity (PCF or MCF) data (completed by the medical provider) a much more accurate and less labor intensive exercise than ever before.  This results of this comparison, when matched against the online job requirements library, easily identifies specific RTW opportunities for the claimant’s existing job with accommodations, provides recommendations for transitional work assignments, provides, where necessary, recommendations to continue on a path of medical rehabilitation and makes recommendations for an occupational change based on the claimant reaching maximum medical improvement (MMI) and the employer not having an open position when it is time to return to work.

Assist in the Vocational Rehabilitation Process

Should a claimant require an occupational change, assistive technology has been developed to build a comprehensive catalogue of online career compatibility and motivational assessments, job skill building/profiling tools, as well as cognitive, sensory, psychomotor and physical inventories. This individualized claimant catalogue when used in conjunction with a set of online tools such as online resume and cover letter builders, online interactive interview training, builds out the claimant’s comprehensive training, education and experience (TE&E) profile. Finally, the claimant’s catalogue is matched against an up-to-date national job pool database, filtered by geographic and salary preferences, to aid in the placement process leaving time for career transition coaches and case workers to use their time with the claimant much more effectively and efficiently.  The combination of Including the claimant in his/her personalized RTW plan, using career transition coaches to motivate and guide while working in an assistive automation environment has been shown to lead to more successful RTW conclusions and is a “best practice” fundamental.

Actual Results

This set of advanced RTW best practices using assistive technology is currently in use at major insurers and has produced outcome results that far surpass existing manual RTW methodologies. Outcomes thus far show over 80% of physicians completing online PCFs on the first attempt, which has led to the identification of over 18% of cases which were previously deemed as “unable to return to work” as “can return to work in own occ,” and over 21% of cases previously deemed as “unable to return to work” as “maybe can return to own occ and likely to qualify for any occ employment.” Actual placement rates for those individuals exceeded 30% when required to secure employment in a new occupation. The reserve release associated with these results are significant for any insurance organization and these results foretell a very promising future for those organizations that grasp the power of an automated RTW solution rather than staying with the status quo.  Most importantly, a proactive RTW program allows a disabled employee with the ability to successfully return to work in a safe manner sooner, which is a true ‘win’ for all parties involved!

Robert Kuller is currently Senior Vice President at FastTrack RTW Services & Solutions. He has more than thirty years of experience in top and senior management positions at companies such as, Process Powered Consulting, Real Media, Liquent, Siemens Medical Systems, Quest Diagnostics and Solvay Pharmaceuticals. He has spoken internationally and taught over 50 courses in an array of management disciplines at the University of Phoenix School of Business. 

Global Banking & Finance Review


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