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Managing Complex Workers' Compensation Claims for Effective Outcomes

Learn about managing complex claims effectively with principles, outcomes, preventative measures, and case studies for improved claims management. Understand why effective claims management is essential.

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Managing Complex Workers' Compensation Claims for Effective Outcomes

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  1. NDS Workers Compensation ForumManaging Complex ClaimsLyn AinsworthGeneral Manager, People, Learning & CultureHouse With No Steps

  2. We will look at: • Why we should manage claims effectively • Types of complexity in claims • Some principles for managing complex claims • Outcomes • Some preventative measures • Case studies • Wrap Up

  3. Why is effective claims management so important? • “Complex” claims = 15% of claims but 70% of cost • At HWNS, 3 yr period: 6% of claims = 75% of cost • Indirect costs: time spent • Every $1 spent on WC premium is a $1 that is NOT available for providing services • We owe it to the people we support to manage claims • We owe it to the community who provide funds to maximise those funds

  4. Why manage claims effectively? • Because we care about our staff and their well-being • Significant impact on people’s lives and livelihood • Reputational risk and impact on recruitment • Impact on our organisational effectiveness

  5. What is a “complex” claim? • All claims have the potential to become complex • Some are inherently complex • Some become complex Tip:Assume all claims are complex and manage that way – then be pleasantly surprised!

  6. Types of Complexity • Injury-related • Psychological injuries • Contributing factors: ageing, disability • Causative complexity • Liability complexity • Legal complexity • Difficult doctors • Number of parties involved • Attitudes and environmental factors • Deemed workers Tip: These may occur concurrently

  7. Injury-related • Serious injury • Complications from an injury • Multiple injuries • Aggravation of existing condition or injury • Pain • Whole person impairment

  8. Psychological Injuries • Primary or secondary • May be difficult to diagnose • Difficult to treat • Take a long time • Social stigma • What is the cause? Event or culture? • Residual propensity

  9. Impact of Ageing, Disability (or both) • Incremental decline -> greater risk of injury • Monitoring of suitability for role • Physical unsteadiness • Diminishing cognitive ability • Physical fitness • Benchmarking

  10. Causative Complexity • Employment was a contributing factor • Not the ONLY factor • Not insignificant • External factors • “Stress” and managing performance • Bullying & harassment • Client aggression / violence • Reasonably excuse – pending investigation

  11. Legal Complexity • S11A – Psychological injury wholly or predominantly caused by reasonable action taken or proposed to be taken by the employer with respect to transfer, demotion, performance appraisal, discipline, retrenchment … • NA to physical injury • Common Law claims

  12. Managing the parties • Difficult doctors • Non-compliant injured worker • Many parties – difficulty in getting together • Conflicting IME/IMC reports • Insurer

  13. Attitude & Environment • Manager and peer attitudes & relationships • Perceptions of suitable duties • IW attitude: “blame” & motivation • Organisational culture and morale • What’s happening in the IW’s life outside of work?

  14. “Deemed workers” • “Lent or on hire” • Agency staff • Certain contractors (not P/L) • Trainers • Little control over management

  15. A complex environment … • Workers’ Compensation is an intersection of legal, industrial, HR and environmental zones which are often conflicting • No-one size fits all • Each case must be considered individually

  16. Some guiding principles

  17. Some guiding principles: • Be prepared for complexity • Care about the injured person – not tokenistic: communication, support • Early diagnosis and intervention of appropriate professional support – rehab provider Tip:My benchmark – any injury that is muscular-skeletal or has possible psychological impact rehab provider is involved

  18. Responsive Strategies • Comprehensive RTW planning – goals need to be clear, incremental, achievable, IW engaged in process • Affirm successes • Thorough investigation and documentation of all injuries (contributes to ongoing prevention) • Engagement of frontline manager

  19. Responsive Strategies • Effective partnering with all stakeholders – requires: • Identification of who the key partners may be (IW, employer, supervisor, rehab provider, NTD, insurer, possibly family) • Clarify respective roles and expectations and how they inter-relate • Timeliness, tone and style of communication

  20. Responsive Strategies • A “person-centred” approach: what important for the individual, what’s important to them • Criticality of effective case conferencing – may need to be multi-level • Vital role of the supervisor and/or manager – often overlooked

  21. Preventative Strategies • Training of frontline managers • Training of RTW staff • Ongoing, multi-level risk management: The more we focus on the preventative aspects of safety and the well-being of our staff, the less likely we are to have complex claims • Pre-employment screening awareness of pre-existing condition or propensity

  22. Outcomes Same role: • Fully fit, PIDs • Permanent modification to PIDs New role: • Fully fit, new position • Permanent modifications, new position RTW – same employer is not possible Termination (Another level of complexity – cost & control)

  23. Failed RTW • Can be a result of: • Lack of effectiveness or appropriateness of RTW plan • Lack of preparation and readiness of IW • Lack of willingness of IW • Lack of support / understanding by supervisor in the workplace • Inappropriateness of suitable duties

  24. Case Studies • IW picked up a washing basket 1/2 full and twisted knee, she was on light duties for over 12 months. Requesting for an operation for the knee was refused - she pursued an appeals process through local solicitor and won. Following operation, while returning to work on light duties, IW was spoken to harshly by a client and left on stress leave. She is still off on stress leave although all shifts were changed prior to taking stress leave so that she did not need to work with the client who had upset her. Now approaching 3 years of light or no duties.

  25. Case Studies • Employee has an employment history of repetitive duties (not disability services related). Commenced working in Disability carer role last year. Within 6 months, had injury to hand by client with swelling and bruising to thumb being bent back. Employee off on WC and returned to work with restricted duties. Resulted in several operations for carpel tunnel etc all covered by WC. Still on restricted duties. Now claiming that other hand is overcompensating for the injured hand and Dr has lodged a new claim related to the initial claim for surgery to other hand. Employee has been on restricted duties with no repetitive duties since the initial injury.

  26. Case Studies • Employee injured on way to work - absent for over one year, post retirement age.  She is now willing to consider a medical retirement - could we have done anything better to resolve this for her in a more timely manner - implications of medical retirement?

  27. Case Studies • IW driving home, had stopped via supermarket, was involved in MVA. Suffered significant “whiplash” injury. Slow progress, and identified some vertebral damage. Failed RTW – too much pain. IW opted for significant surgery, although high risk and not “ essential”. Poor outcome. Requested breast reduction surgery as part of WC to reduce stress on spine – refused by insurer. • Misuse of company e-tag identified while on WC had to be addressed. • In capacity to return to work lead to decision to terminate. • Subsequent request to return to work. • Common Law claim lodged – claiming total incapacity for 24 years at “promotional” level

  28. Checklist • Pre-employment medicals for benchmarking & identification • Thorough investigation of cause of injuries – learn from that • Support & reassure the IW • Prompt medical review – may be supported by employer • Identify rehab provider involvement & other key partners • Maintain contact and communication with all partners • Read the signs of possible complication – especially psychological • Think outside the square when it comes to suitable duties • Train all relevant staff • Monitor the culture and environment of your workplace • Well being programs may improve morale • All staff need to understand key HR principles around managing performance etc

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