November 5, 2020 • Education

Professional Administration Key Performance Indicators

There’s a relatively new trend in the workers’ compensation space that puts more focus on the injured worker. For years the industry has looked at ways to reduce costs and increase efficiencies, without realizing that the most effective way to do both is to ensure the injured worker gets the best and most appropriate care.

Advocacy based claims models are becoming the new normal, as companies realize that the injured worker should be a key part of the claims handling and recovery process. Treating the injured worker with compassion and making his needs the top priority results in better engagement from the employee, which speeds recovery and return to function and work. 

While making the injured worker central to the workers’ compensation system is a win-win for all parties involved, what happens after the injury claim settles? Organizations committed to their workers take steps to ensure that these efforts continue after the claim is closed. 

Post-Settlement Issues Which Prevent Settlement

Injured workers who’ve been covered by workers’ compensation benefits for any length of time have much to lose when they settle. For example:

  • Setting up medical appointments. When an injured worker is in the workers’ compensation system, they are typically given a choice of providers. While they may not necessarily be happy with the medical personnel available to them, they at least know there will be someone they can see. Once they have settled, injured workers can see any providers they want. The problem arises when the worker doesn’t know what providers are available, how to make appointments, and how to get to and from them, especially if their injuries physically or logistically limit them. Navigating the healthcare system can be overwhelming when there is no longer a claims adjuster and/or nurse case manager to help.
  • Paying for care. Injured workers go to providers, get their prescriptions, and undergo medical treatments without having to pay anything. Their medical care is funded entirely by the employer/payer. Once they’ve settled the claim, the injured worker is on his own to pay for all his medical care. Typically, he becomes a cash payer, and is paying ‘retail’ for this care, since he doesn’t have discounts available. If he is not familiar with the medical fee schedule of his jurisdiction, he may even be paying more than necessary. That can easily and quickly eat up the money he received from the settlement.
  • Compliance issues. Many injured workers who’ve settled their claims find they must adhere to strict government requirements, especially if they are or will soon become eligible for Medicare. Money received through the workers’ compensation system must be used for any Medicare-eligible medical care related to the injury. Many injured workers who settle their claims have Medicare Set-Asides set up to protect Medicare’s interest as secondary payer. Having a Medicare Set-Aside includes a plethora of requirements that must be met. The money must be spent exactly the way Medicare allows, and the injured worker must report his expenditures each year. 

These and other issues often prevent injured workers from settling their claims. Those who do agree to settle need to know their concerns will be fully addressed after the paperwork is signed. Getting legacy claims off the books is often dependent on allaying the fears of the injured worker.

Professional Administration Key Performance Indicators (KPIs)

Professional administration is a concept that has evolved in recent years. It has become very affordable and, most importantly, puts the injured worker’s needs first.

The most trusted professional administrators are those that create a positive experience and provide continuous support for the injured worker who has settled. Several key performance indicators demonstrate the effectiveness of a professional administrator.

  1. Discounted Medical Costs. The biggest fear of injured workers who want to settle their claims is running out of money. Professional administrators can offer discounted pricing; for providers, pharmacies, treatments, durable medical equipment and other medical-related issues. Those with wide networks can help injured workers reduce their spending. These companies should be able to reveal the savings to their members on an annual basis.
  2. First call resolution. How quickly and effectively does the professional administrator respond to questions or problems from injured workers post-settlement? How often is the issue resolved with the first phone call? The company should be able to show proof of this, either anecdotally from members or with statistics showing the percentage of single vs. multiple calls for the same issue.
  3. Customer satisfaction. Perhaps the most important KPI is how injured workers who have settled their claims rate the professional administrator. Savvy companies constantly issue surveys and seek feedback from their members to see how they are doing and areas for improvement. The professional administrator should be willing to provide statistics showing the satisfaction levels of members.


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