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Data tells the story

Compelling data is the proof that allows an insurer to evaluate a relatively “new” concept such as pre-claim triage, and adoption rates are rapidly increasing. Decades of data clearly show the impact triage has delivered to employers, injured workers and insurers, including the following:

• Workers feel their employer cares more about their well-being by giving them access to a nurse.
• Employers take better care of their employees with immediate first-aid screening.
• Workers’ comp expenses are reduced by eliminating unnecessary claims costs up to 25%.
• “Soft channeled” referrals increase the use of preferred network providers up to 20%.
• For every 2,000 calls $1.5 million is taken out of the WC spend.
• Pre-claim triage provides data necessary for carriers to add to their predictive modeling projects.
• A 6-to-1 return on investment is the average reported economic gain.

Getting an injured worker the right care at the right time doesn’t necessarily mean calling 911, except in cases of potential life-threatening incidents. For minor injuries, workers usually agree to treat themselves when a proper assessment has been made and they are supported through the process. That avoids an unnecessary claim because the first-aid screening and decision-support service is the best known method for the worker, the employer and the insurer.

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Improves risk scoring by underwriters

The workers’ comp industry continues to struggle with reducing excessive lag times. New tools, such as pre-claim nurse triage, deliver the right balance by avoiding prematurely entering workers into the medical system, while not sacrificing the timeliness and quality of medical attention an injured worker needs. Additionally, following the effective adoption of pre-claim triage, underwriters recognize improved risk scoring of individual accounts attributable to the measurable reduction in lag time, incurred but not reported (IBNR) incidents, overall frequency and claim severity.

To maximize the impact of pre-claim triage, carriers should require of their collaborative partner, at a minimum:

• A system that assures the first-aid screening is an evidence-based medical recommendation, objective and consistent, no matter which registered nurse answers the phone;
• The pre-claim triage partner should operate a Utilization Review Accreditation Commission accredited 24/7 call center staffed by registered nurses, which is a nationally recognized accreditation validating an organization’s commitment to quality and accountability in healthcare; and
• The pre-claim triage partner should be free of conflicts of interest, with no incentive to increase revenue by processing more claims or creating extra transactions.

Pre-claim nurse triage programs are transforming the insurance industry’s workers’ compensation model. As the adoption rate continues to increase, more carriers are offering—and in some cases requiring—pre-claim triage. It will be the norm in the next few years, just as RTW has become. The results are beneficial for injured employees, supervisors, employers and carriers alike.

Brian Cullen is managing director of triage with Medcor, the industry leader in pre-claim nurse triage and pioneer of innovative outsourced health services to improve outcomes, service levels, and access to care, while reducing costs for carriers and employers. He is risk mitigation specialist, a CIC, ARM and veteran of more than three decades in the insurance industry.