Managing the Labor Challenge: Clinical Services

Tom Kerr (TK): In part two of our podcast series on integrating new adjusters to the industry, Tammy Bradly, senior director of clinical product marketing at Enlyte, joins us to discuss clinical solutions for proper decision making. So, Tammy, what are some major concerns about turnover in the insurance industry?

Tammy Bradly: First, Tom, I think it’s important to look at some key stats here. According to a survey by the Bureau of Labor and Statistics, the overall median tenure for workers in the insurance business today is only 4.1 years, and that’s pretty startling to me. Overall, though, they are anticipating that the employment of claims adjusters and related occupations will actually decline over the next 9 to 10 years. But despite the declining employment, they’re still expecting there to be over 23,000 openings year over year for claims adjusters and, again, those related‑type occupations.

And these openings are expected to result in the need to replace workers who transferred out of the insurance industry into other occupations and also exit the labor force, which I think is a lot of what we are seeing — people retiring that have been longtime claims professionals.

So, this means we have a large number, or are going to have a large number of inexperienced professionals entering the field and, likely, will not have the tenured bench strength they may have traditionally had to mentor them when they’re new in those positions.

So, with new adjusters, there’s always going to be a learning curve. Even if you come in with some experience, you still have to learn a claim system, company policies and procedures, and perhaps one or more client special handling instructions. Unlike years past, turnover is not necessarily a seasoned adjuster moving from one job to another. It’s new professionals coming into the industry.

So now on top of the usual things you learn when you change jobs in similar professions, these new professionals coming in have to learn about workers’ compensation, all the rules and regulations associated with the comp industry. Now we’re asking that new claims professionals with no experience also know when’s the right time to refer a claim for clinical intervention and take the time and even know how to make that referral. So, I think all of this is going to be certainly things that the newer claims staff are going to struggle with as they acclimate to their new positions.

TK: And that statistic you offered about insurance professionals staying in the field just 4 years really is quite a shift for us. There has been some stickiness to our industry that, once people enter it, they usually stay for quite some time. So, with fewer experienced professionals in the ranks, what are some of the major issues new adjusters face in handling clinical decision making?

Bradly: Well, I would say first and foremost, perhaps over or underutilization of clinical resources. perhaps using the wrong intervention at the wrong time. perhaps approving of medical treatments that aren’t necessarily supported by nationally recognized utilization guidelines. And any or all of these things can delay that injured employee’s recovery and, ultimately, return to work.

TK: Would case managers be considered part of the solution in helping guide new adjusters?

Bradly: I would say yes, but to a degree. I think first and foremost, every claims organization expects their staff to manage their claims and really only engage clinical resources when we can enhance the outcome. We’re not there to do their job, nor do we even have that expertise, but we are there to provide that additional level of medical or vocational expertise on claims when they need it.

Claims professionals can certainly learn about diagnoses and treatment plans from the case manager. We can explain technical terms in a manner that they understand and that, in turn, is going to help them manage their claim better.

It’s also our job to alert the claims professional when it’s time to close a case, whether we’ve achieved our goal or perhaps we feel we can no longer impact the claim. I certainly think that streamlining documentation and processes is really key to helping claims professionals.

One way to make the job of the claims professional easier is to streamline the claims process as much as possible. This can involve automating certain tasks or providing easy‑to‑use software that simplifies data entry and communication. Leveraging technology and partnering with the case management firm who utilizes life-of-claim risk identification, to identify those claims that actually are predicting or demonstrating risk, is very helpful in that decisioning and making sure that that adjuster is using the clinical resources at the right time.

It really does kind of help to take that decisioning out of their hands and use data to drive timely interventions. Technology also allows us to transmit case management notes and reports, right into the claims system. That’s a huge time saver for claims staff.

Also, providing ongoing training and access to resources can truly help claims professionals stay on top of the changes within the industry, learn new skills, and handle complex cases more effectively. And, in many states, adjusters have licenses and need CEUs to retain these licenses or certifications. Enlyte provides national CEU webinars on a regular basis to support this effort. And I’ll say that the turnout for this is really phenomenal.

This year, we geared a lot of these CEU trainings to focus more on those newer adjusters and more of a back-to-basics type of content, that really does help that new adjuster learn more about case management services, when to intervene with case management, as well as learning about diagnoses, treatment plans, etc.

There’s also opportunity to deliver client‑specific training to help educate those new adjusters as well. We’re focusing on an e-book that’s really, again, going to be geared towards that newer adjuster and really educating them around the basics of case management. And I think that’ll go a long way as a great resource to help them, if they’re new in their job.

Certainly, adjusters should take advantage of case managers who they are working with on claims. And, by this I mean, if they’re working with a case manager on one case, maybe they have a question about another case when they’re on the phone with that case manager, or they can pick up the phone, give that case manager a call and get some free advice.

And, kind of to that same point, just having conversations with the case manager and what I refer to as staffing of a file, that goes a long way to really help and educate adjusters on the claim process and the things that clinical can do to impact a claim.

And, lastly, I would say encouraging communication between the adjuster and the case manager, and really figuring out that claim professional’s preferred method of communication is very important. For the case manager, it’s really important on our part that we don’t just regurgitate a medical record. We really need to interpret those findings for the adjuster in a manner that they can understand and also compare the treatment to nationally recognized guidelines, so that that adjuster does understand that that particular treatment is medically appropriate for that claim.

TK: And what should adjusters who are new to comp expect from working with case managers?

Bradly: Yeah, that’s actually part of our e-book; but anytime an adjuster makes a referral over to their clinical partner, they should expect to receive an outreach from that case manager within a day or so of that file being assigned unless, of course, it is a rush referral where a truly immediate response is required. But to get a response back from that case manager and make sure they can connect and talk about the claim, the adjuster’s particular needs. The case manager at that point in time can clarify what is the adjuster’s preferred method of communication.

Claims professionals should also expect to receive timely updates both via communication as well as reporting from the case manager. And typically the initial evaluation report is usually done within 10 to 14 days of the case being opened. Even sooner if it’s a telephonic case. They should expect regular updates anytime there is a change in the claim status, such as, surgery is recommended, the injured employee was released or is returning to work, the employee reached maximum stability ...

Again, reporting typically is done at least on a monthly basis, so they’ll have that written documentation or those nurse notes at least once a month updating them on the happenings of the claim.

TK: Tammy, let’s talk about another clinical component, the independent medical exam. For new adjusters, I would think this would be an area where it would be helpful to know what to look for in an IME partner. Can you talk about that?

Bradly: Yeah, and I think a lot of the same factors apply for both case management as well as IME. Adjusters should look for obviously a reputable partner.

Well, how do you know you’re getting a reputable partner? I’d suggest that they ask questions when they’re trying to make a selection.

• Do they have the coverage I need?
• Do they have the provider specialties that I need?
• Are those providers credentialed and qualified?
• Do they hold any national accreditations?
• Does the company itself hold any national accreditations?
• What is their quality process?
• How long have they been in business?
• Will this partner make my job easier?

And you may not know the answer to the last question until you make that first referral, but you usually can figure out pretty quickly if you’ve engaged with a partner that’s going to make your job easier. Certainly, I would say as a minimum, looking for a company who is URAC accredited is a really great starting point. URAC really sets the standards that any certified entity must adhere to.

TK: Thanks, Tammy. In the next part of our series, we’ll talk about what new adjusters need to know about provider networks. Until then, thanks for listening.