Claims Advocacy, Problems and Solutions

The shift that continues to transpire within the industry is real. Carriers, Employers and TPA’s that continue to keep moving forward with the same archaic process denying to accept a change will be left in the past. The time to adapt with keeping an open mind for change is now. The system in place today is not cost effective and has been failing all parties for years.

Let’s take Starbucks for a moment. Can you argue with over $50 million in reserve savings and a 50% less litigated claims rate over a three year period?  This is only the beginning for the utilization of a less adversarial process. To my belief, there are so many more components left out of this model, but what a great start.

Being a past claimant personally for over six year’s vs a fortune 100 insurance carrier really opens your eyes. As a prior entrepreneur, starting my first company at the age of 15 and by 18 building a second company into six states with national franchises, I have clearly seen and identified numerous issues within the workers’ compensation system which has become my life’s mission to solve these problems for all parties.

What if the claimant was your Brother, Sister, Mother or Father? Would you feel comfortable with the way they were being treated within the current system and be happy with the service or process you provided?

You should be able to answer yes to the previous questions, if not you already know there are a number of major issues needing to be addressed and that should keep us all up at night. To my belief, if the care provided and resolutions for a claim is not good enough for your own family, we are not doing our jobs. We must strive to do better, there are no exceptions. Anyone can have a work related injury at any time.

The current system today requires improvement in many areas though you must look at the whole picture, not just from the carriers, employers, or TPA’s view but the claimants view and experience as well. Unless you have had the experience of navigating your own claim for years within the system itself, you may never fully understand a claimant’s mindset and problems that plague the system without being able to put yourself in the claimant’s shoes.

Is your staff the catalyst for claimants to seek counsel?

The communication breakdown that occurs with the majority of claims leaves the carrier, employer, and TPA’s being the catalyst for the claimant to seek legal counsel.

Has your staff been trained and educated on how to address a claimant with concerns when utilizing a less adversarial approach when a dispute arises?

For Example:

Claimant attends a physician appointment and disagrees with the treatment option provided, believing its way to invasive.

The adjuster just listening to the claimants concerns for a less invasive treatment, instead of calling the claimant non-complaint and defiant, therefore cutting off all indemnity and or medical benefits dictates the direction the case will take.

The Carrier, Employer or TPA become the catalyst for the claimant to seek counsel with increasing administrative costs.

Carriers, Employers and TPA’s invest so much in the training of employees, setting protocols to be implemented helping to understand and connect with the claimant. Don’t let your company become the catalyst for claimant litigation.

The number one solution for reducing administrative costs is being proactive with claim resolutions. There is no reason a majority of claims should be open and outstanding after two years. When working towards final settlement of claims, it should not take more than one day and one meeting to finalize claims with an amicable resolution for both parties.

Utilizing unique private mediation to settle claims and connect with a claimant will reduce your administrative expenses, expedite the time frame for resolutions, mitigate risk, and improve reserves all while helping the claimant obtain benefits to move forward with their life.

Paul Gold

Founder & CEO

PG Resolutions Group