The Benefits of Worker’s Comp Claims Triage

Medical Case Management (7)

When a worker is injured on the job, it can be stressful for the worker, the employer, and even the claims adjuster or manager as they consider the right response to the injury, managing the care needed and time off required, the unknown costs, and the possibility of long-term effects. A lot is at stake in those first few hours after an injury, both in the actual care of the injury and financially.

The average worker’s comp claim in the U.S. costs $41,353, with some claims reaching $100,000 or more. There are about 4.9 million worker’s comp claims made each year by both private and government employees, costing employers a total of $100.2 billion in 2021.

Furthermore, recent years have seen the number of worker’s comp claims increasing.

This is likely the result of several employment market and social trends:

  • ● The aging workforce. Many experienced workers are retiring and being replaced by inexperienced workers with less training.
  • ● Employers’ increasing use of independent contractors rather than employees.
  • ● Labor shortages prompt businesses to upskill and reskill workers, who may find themselves in unfamiliar jobs.
  • ● Return to the office. More workers in the workplace = more claims overall.
  • ● Increasing numbers of mental health claims post-pandemic.
  • ● Workplace violence. This phenomenon is on the rise in several sectors – education, the transportation industry, healthcare, law enforcement, and retail.

In the face of this increasing pressure, one way to reduce costs is by effectively triaging claims as they come in. Claims are incredibly varied, encompassing everything from bumps and bruises to multi-trauma accidents. They are also sometimes not as simple as they seem. Sometimes an injury can seem minor, even to the worker, yet have long-ranging effects that are unexpected.

What is Claims Triage?

The process of gathering information about the incident, assessing the situation, and then determining and directing the worker to the right level of care is called claims triage. Much like triage works in the emergency room, data is gathered, the situation is evaluated, and then the patient’s status is categorized by severity and treatment needs. We see this all the time, and it makes sense that a heart attack victim is seen by a doctor sooner than someone with a minor injury.

Triage is a valuable technique when it comes to processing worker’s comp claims, both for treatment effectiveness and cost containment. For example, if a worker experiences a minor laceration injury that needs stitches, but reports to a busy emergency department – he or she may be waiting while in pain for hours, and the cost of care will be significantly higher than it could have been. With the proper guidance, that worker could have been seen in an urgent care clinic, received the same level of care, and been in and out in an hour.

Conversely, if a worker is involved in a serious injury that needs emergency care, but instead reports to their local doctor’s office – that provider will likely send them directly to the ER anyway, maybe by ambulance. By not following the right care route from the beginning, precious time is lost and the patient experiences more pain and frustration.

How is Triage Handled?

There are several ways companies choose to handle the triage process. Most require that workers see a medical provider that is approved under their plan, with pre-authorization. Therefore, the worker should communicate along the proper channels of the company to find out the next steps.

Most organizations have a designated leader who is the decision-maker, or an employee health representative. This person may or may not have medical training. Some organizations try to triage claims with a set of rules, a decision tree, or a set of policies. Others have used automated systems equipped with data analytics software.

Another option is to contract with a nurse triage hotline that the worker, leader, or even a claims adjuster or claims manager calls to report and discuss the injury. An experienced nurse assesses the severity of the injury and uses their knowledge and insight to calm the caller, provide some first aid advice if needed, then direct them to the appropriate care setting. The nurse hotline can then document the case, follow up with the patient, leader, or adjuster, and refer the case to a case manager, if necessary.

The Benefits of Claims Triage

Telephonic nurse triage programs deliver a host of measurable benefits to all stakeholders in the claims process. One benefit that affects the whole team is that the nurse line encourages prompt reporting of injuries, which can improve outcomes and prevent complications. It also provides fast documentation and communication with employers and insurers – the first report of injury (FROI) document gets sent out immediately. This efficient process keeps everyone informed of progress and next steps. This makes claim management and resolution much easier for all stakeholders.

Worker and Manager Benefits

Workers specifically benefit from a nurse triage line because it is convenient and accessible for workers to call – 24 hours per day, 7 days per week. Many businesses aren’t able to provide that type of coverage, so it makes sense to use a service that can. In a work setting like a factory or a hospital where workers are busy around the clock, accessibility is crucial.

Handling claims with a nurse is also known to boost employee satisfaction with the claims process and the care received. Employers can convey their concern for the well-being and recovery of their workers by providing easily accessible care and service. This experience of speaking to the nurse and receiving a compassionate response to an upsetting incident often deters litigation down the line.

Nurses that work triage services are experienced and skilled at handling stressful situations, while keeping a calming and compassionate presence while they offer assistance. Many companies use nurse advice or assistance lines in conjunction with health plans or telehealth services. This type of treatment modality is increasingly common, and the convenience and peace of mind are big benefits for employees.

Without this type of service, a worker may, for example, hit his/her head and not report it because they think it is fine. A nurse may be able to do an initial assessment and decide that it is necessary to seek treatment for a possible concussion. Similarly, sometimes workers may seek treatment when it is not needed, or even be pursuing a fraudulent claim. The nurse can also act as the first line of defense against such costly claims.

Triage services lower worker’s compensation costs by reducing unnecessary medical visits and directing workers to the most suitable provider and level of care. One source suggests that an average triage service could help avoid 25% of overall claims!

Benefits for Adjusters

By making the worker’s comp claim process as accurate and efficient as possible, adjusters can more exactly gauge risk and offer lower premiums to employers in response. Claims triage helps insurance adjusters to prioritize the most urgent and complex claims that require more attention and resources, while fast-tracking the less urgent and simpler claims that can be resolved quickly and efficiently.

Claims triage can have several benefits for insurance adjusters, such as:

  • ● Saving time and costs: Claims triage can help reduce the expenses associated with hiring, training, retaining, and managing claims staff, as well as investing in infrastructure, equipment, and technology. By adjusting the claims resources to match the claims demand, insurance adjusters can avoid overstaffing or understaffing their claims department, as well as overinvesting or underinvesting in their claims infrastructure.
  • ● Increasing revenue and quality: Claims triage can help increase the revenue generated by optimizing the cash flow, reducing denials, improving collections, and enhancing the customer experience. By increasing the claims capacity to handle more claims, insurance adjusters can capture more revenue opportunities. By improving the claims quality to handle claims more accurately and efficiently, insurance adjusters can reduce revenue leakage and increase revenue retention.
  • ● Creating competitive advantage: Claims triage can help create a competitive advantage by enabling faster and better decision making, innovation, and adaptation. By leveraging technology, insurance adjusters can gain more insights into their claims’ performance, identify trends and issues, and make data-driven decisions. By accessing specialized talent and expertise, insurance adjusters can adopt best practices and innovations in their claims processes. By responding quickly and effectively to changing market conditions, customer expectations, and regulatory requirements, insurance adjusters can differentiate themselves from their competitors.

Claims triage can involve various factors and criteria to determine the urgency of a claim, such as:

  • ● The severity of the injury or damage
  • ● The complexity of the liability or coverage
  • ● The potential for fraud or litigation
  • ● The availability of data or evidence
  • ● The customer satisfaction or loyalty

Claims triage is a vital process for insurance adjusters that can help them manage their claims effectively and efficiently. By using claims triage, insurance adjusters can save costs, grow revenue, improve quality, and create competitive advantage.

A company culture of safety is important, but a culture of prompt and accurate response to injury is equally important for reducing overall costs. These cost savings in turn can get passed to employers, making their business more affordable and cost effective.

Who Should Consider Setting up Triage Services?

Some companies, especially small businesses, think that triage services only pay for large companies, or they look at their historical claims records and may think that nurse triage services are not needed. It is important not only to consider the number of claims per year, but the cost of those claims, and the risk for future claims.

Data shows that the average claim is around $41,000. For an average business with five claims per year, that could amount to over $200,000. Nurse triage services that can demonstrate measurable claims savings can easily provide considerable return on investment.

If your business is supporting any of the 10 highest-risk professions, then a nurse triage service is almost a guaranteed benefit. These types of positions require manual lifting, equipment handling, and bodily risk – representing 38% of total claims.

  • ● Nursing assistants
    ● Registered nurses
    ● Laborers
    ● Truck drivers, heavy and tractor trailer
    ● Stockers and order fillers
    ● Licensed practical and licensed vocational nurses
    ● Retail salespersons
    ● Personal care aides
    ● Production workers
    ● General maintenance and repair workers

Triage services can benefit businesses of all sizes, in many different industries. It is dependent on each employer and insurance adjuster to discuss the facts, risks, and benefits of the case while assessing the need for triage services.

Ready to Get Started?

As with any important business decision, it is important to weigh options and determine the needs of your business and clients. Nursing triage services price plans differently, so it is important to understand the comparisons. It is also important to request information about their quality benchmarks, such as average response time. Some services also handle case management, which may provide more continuity of care for everyone involved.

Are you ready to implement evidence-based approaches for reducing claims costs and improving employee outcomes? We are available to show you how to protect your business, establish processes that work, and support your growth. Contact us to learn more and discuss your workplace claims strategy.


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