ORLANDO, Fla. – Workers compensation claims that deteriorate into costly, prolonged cases often show warning signs early, putting pressure on employers and claims organizations to identify disengagement, behavioral health concerns and other barriers before a claim goes off track.
That message emerged across several sessions at the Workers’ Compensation Institute’s Workers’ Compensation Educational Conference last week, where experts discussed communication failures, psychosocial issues and other factors that can delay recovery, as well as the growing use of data and artificial intelligence to identify troubled claims sooner.
Changes in communication can be among the earliest indicators of trouble, said Joseph Sousa, deputy director in the risk management department for the City of San Diego.
Late claim forms, missed or rescheduled medical appointments and reduced communication with supervisors and coworkers can signal that an injured worker is becoming disengaged, he said.
“The communication ends with the department and the worker is just isolated out there,” Mr. Sousa said, describing one of the earliest signs that a claim may be drifting.
Employers can play an important role in preventing such isolation.
Injured workers can become fearful and disengaged when they do not understand the workers comp process or receive conflicting information from adjusters, medical providers and employers, said Justin Romine, Bethesda, Maryland-based vice president of global claims services for Marriott International.
Those problems can become particularly important when a medical-only claim becomes an indemnity claim and a worker is taken off the job, he said. Another critical point comes when a worker decides to hire an attorney.
Marriott has encouraged managers to maintain contact with injured employees after research reviewed by the company found that a lack of concern from a direct manager was a significant factor in workers deciding to hire attorneys, Mr. Romine said.
“Getting your direct managers of these injured workers involved, and perhaps coworkers, is also key to avoiding that fear that they may have in returning to work,” he said.
Behavioral health and other psychosocial issues can also significantly alter a claim’s trajectory, particularly in catastrophic cases.
Paradigm data from thousands of catastrophic cases showed 74% involved two or more psychosocial or behavioral health issues, said Kathy Galia, Fernandina Beach, Florida-based president of workers compensation solutions at the specialty care management company.
Among Paradigm’s catastrophic claims, 35% of injured workers had unstable housing, 21% had pre-existing substance abuse issues, 18% had a pre-existing behavioral health condition and 15% lacked family support.
Those factors should not be automatically interpreted as worker noncompliance, she said. Language barriers, cognitive difficulties and other circumstances can cause workers to miss appointments or fail to follow treatment plans.
“We have to be careful because that can be a runaway train,” Ms. Galia said.
The financial consequences of behavioral health issues can be significant.
Pam Bloom-Pugliese, Tampa, Florida-based director of product management at ODG by MCG, presented workers comp data showing that the average duration of a back pain claim increased from 25 days to 81 days when a single mental health comorbidity was present. Costs doubled, while maximum claim duration was nearly four times higher.
Missed appointments and difficulties getting to physicians may be early indications that something besides a physical injury is affecting recovery, said Dr. Michael Lacroix, Sarasota, Florida-based medical director at The Hartford.
How employers respond also matters, he said. Employers who effectively turn an injured employee over to the workers comp system and wait for the worker to return can miss an opportunity to maintain engagement.
“Do they basically cut him off, send him off somewhere until he’s ready to come back, or do they keep in touch?” Dr. Lacroix said.
Some employers have developed programs that designate someone within the organization to maintain contact with injured workers and help them navigate treatment and rehabilitation, he said.
Technology is increasingly helping claims organizations spot problems that might otherwise be buried in claim files.
Experts said AI models can analyze structured and unstructured claims data to identify patterns linked to delayed recovery, including comorbidities, behavioral health issues, prescribing patterns and other indicators.
Mike Theis, assistant vice president of product analytics and business strategy at Tampa-based Healthesystems, said pharmacy data can provide early signals through such factors as early prescription refills, rapid increases in dosage and prescribing patterns.
“There are a lot of signals there,” he said.
Brook Rosenbaum, Boston-based general manager, property and casualty, at Gradient AI, said newer AI models can take the analysis further by examining information contained in unstructured claim notes that may not be captured in traditional data fields.
“A lot of the models … the AI is able to take that one step further,” he said, adding that AI can process unstructured notes to identify additional risk indicators.
The goal is not to automate claim decisions, speakers said, but to use those signals to identify claims that may benefit from earlier intervention.
Shannon Ford, Marion, Iowa-based senior vice president of case management solutions at Paradigm, cautioned against creating “false confidence” in technology, while Tom Veale, Long Beach, California-based president of TRISTAR Insurance Group, said human involvement remains essential.
“We are always going to need the judgment of the adjuster,” Mr. Veale said.
Mr. Theis said the challenge is prioritizing interventions when models identify numerous potentially problematic claims.
“If every claim is high risk … where do we find the right balance?” he said. AI, he added, is helping claims organizations segment claims so resources can be directed where they are most needed.
Identifying the right claim sooner can allow employers and insurers to deploy nurse case management, behavioral health resources, return-to-work assistance or other interventions before problems escalate.
“If we catch this stuff early,” Mr. Veale said, “the savings are tremendous.”
