Insurers should "hold doctors to account" for workers' comp claims delta

Insurers should "hold doctors to account" for workers' comp claims delta | Insurance Business

Insurers should "hold doctors to account" for workers

The chief executive of a global claims administration firm is calling on workers’ compensation insurers to start holding doctors to account for what he describes as the “defined delta” between workers’ compensation claims and private health or non-occupational disability claims.

This so-called “delta” – raised with Insurance Business by Charles Taylor TPA president and CEO Christopher Schaffer – embodies the trend where workers’ compensation claims are costing more and taking longer to resolve than private healthcare claims in the non-occupational environment.

“There’s just no reason for that,” said Schaffer. “If you’re injured at work, there’s no reason why it should cost more or take longer to recover than if you were injured outside of work – and yet, that’s what’s happening. It’s a delta that’s easy to identify, and the workers’ compensation doctors are complicit in that delta. I think we as an industry have to try to close that delta and hold doctors to account.”

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One way the insurance industry can do that, according to Schaffer, is by promoting evidence-based medicine and using claims data to challenge the workers’ compensation status quo.

“We can use scientific and evidence-based data to challenge workers’ compensation doctors if their treatment is not performing as well as their peers and colleagues in the wider healthcare industry,” Schaffer said. “It’s important to highlight that. If doctors are only treating workers’ compensation claimants, they might not see or feel the differences that have emerged [versus claims in the non-occupational environment]. We can provide that information and challenge that delta not only with medical opinion but also with stats based off our claims data.”

Education lies at the heart of this problem, and again, the insurance industry has an important role to play in that. Insurers can help to educate the medical community about the delta, why it’s occurring, and what practical steps they can take to mitigate the issue.

“I think there are some systematic things like the way states reimburse claims that incense all the wrong things,” Schaffer commented. “Moving forwards, are states going to reimburse on a guideline basis or are they going to reimburse on an outcomes basis? Certainly at Charles Taylor TPA, we want doctors to make more money by getting people back to work quicker rather than making more money by keeping them out of work for longer.”

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Another issue at play is what’s known as secondary gain, which is a physiological motivation for injured employees reporting symptoms or complaints or pain. In the workers’ compensation environment, injured workers don’t always have much incentive to recover and get back to work as quickly as possible. That’s a dynamic that’s driving up costs in workers’ compensation and is something that can only be beaten with the help of medical professionals who are delivering evidence-based care, according to Schaffer.

“It’s not only about educating doctors. It’s also about educating the workers’ compensation commissions and the courts about the benefits of evidence-based medicine,” he added. “At Charles Taylor TPA, we’re trying to embed data into our operations in a number of different ways, whether it’s using official disability guidelines as part of the adjusting process, whether it’s triaging claims to nurses more effectively, or whether it’s developing the data that we have so we can present doctors with counter views.

“This is an emerging trend in the workers’ compensation industry that I think will continue for the next several years. Insurers have so much data at their fingertips, so instead of having competing medical opinions by qualified experts, now we can advance a position that is not only backed by a qualified expert but also by the quantum of statistics from the medical community. That can be very powerful and effective when utilized properly.”