When I think back on the most difficult conversations in my career, I reckon that those with insurers rate pretty highly. I have left many of these interactions feeling frustrated, because of a perceived lack of understanding about the needs of my client or judgment on my clinical skills to help manage an injured worker.
But I am not the only one. I see this reflected on social media platforms with insurers described as “ruthless, “heartless” or “unyielding”. When I am socialising with other professionals , it does not take long for the conversation to take a turn to a recent interaction with an insurer. It is rarely about a productive conversation or favourable outcome.
There are swings and roundabouts working in the worker’s compensation space and it takes a lot of adaptability to keep up with the ever-changing environment. Certainly, compliance and accountability have increased over the years. I remind myself that whilst admin work is annoying and time consuming that it is better to have this level of accountability than going back to the “good ol days”. I look at other countries and think what a privilege it is to have a system that supports our injured workers to regain their lives after injury. It is a flawed system in many ways. As I write this blog from New Zealand, I appreciate that that no one system is anywhere near perfect and has it’s challenges.
The basis of any good relationship is shared understanding. I believe that this where the tension lies between clinician and insurer. Often both parties leave the conversation feeling misunderstood. Consider how much of the conversation is spent on explaining, justifying, or even pleading for understanding? Remember, that whilst we have different approaches or needs from the system, that we are there for the same reason, to help the injured worker sustainably back to their pre-injury hours and duties.
I wonder if you have considered what the working day of a claims manager or injury management specialist (IMS) might look like? Think about all the people involved in a claim: The injured worker, the employer, the medical team, the rehabilitation providers, and the treatment providers. Everyone calling with problems or concerns. These engagements can be challenging. The claims team are often dealing with people that are angry, frustrated, distressed and annoyed. Almost every conversation can be difficult. Understandably they are often on high alert ready for a confrontational interaction before they even pick up the phone. The claims team is also under expectations of outcomes directed from higher up the chain. If you think about that you might not be so surprised about why the attrition rate is so high. It is a tough gig.
Remember that insurance claims managers are people too. Spend a minute or two, interacting with them in a human way. Find out how their day is going? What are they doing on the weekend? You might even establish some common personal ground that will form the basis of an ongoing relationship. A talk with an insurer might turn into a highlight of your or their day.
Here are some tips:
Ensure that you spend some time finding out about the third-party system covering your injured worker. Know about the relevant legislative requirements so that you can engage with a common knowledge base. Understand how the system is set up to support injured workers and what the obligations are of each party. For example, there are important time frames that will have impacts on the injured workers’ pay if they have been certified unfit for a while. It is worthwhile to know that in most schemes, the focus is on helping the injured worker to increase work hours rather than capacity. Understanding some of the core principles of the legislation will mean that you can help your client by supporting them to achieve the goals that are going to result in the best outcome. Directing their rehabilitation in the right way will help to reduce some of the financial stressors that can impact the recovery process. Look for opportunities in your conversations to find out about the legislation and what that means to how the claim is being managed. You will discover that some decisions are not because the insurer is being “bloody-minded” but because they are working under the required legislative framework.
Get on the front foot. Initiate the relationship. Give them a call and introduce yourself. Let the claims manager or IMS know what you think that the worker will need, and why. Often, the NOC or AHRR will not provide enough space to outline the clinical aspects of a more complex client. They are going to need more treatment than the standard 8 treatments usually approved. Tell the claims manager how you are going to address the presentation and any help that you might need, such as a case conference with the rehabilitation provider. These conversations can also help to inform the claim and give the team more information about expected outcomes. Your input might have an impact on other decisions such as the timing of any potential medico-legal examination.
Ask for help: If a treatment request is rejected, a claim denied, treatment approval reduced or an injured worker is moved on to another treatment provider, ask for help to understand the decision. A change in treatment provider can occur if there has been no or poor quality communication from the treatment provider. There may have also been a request from the worker, GP, or employer which you are unaware of. There may be other factors such as a medicolegal direction in the mix. Go into these conversations with an open mind (curiosity) as there are two sides to every story. Ask if there is anything that you could have done differently. Once you have established a shared understanding there may be opportunities for bargaining offering a win/ win to the benefit of your client.
Use your values. The theme throughout these blogs has been the power that instilled values give you. A difficult conversation is a situation when they can help to anchor and guide you. During the conversation, I often ask, How can I be part of the solution? or sometimes even turn it around and say that I do not want to be part of the problem. Ask if they can help you to understand how you can be part of the solution? One value and so many uses! In the spirit of asking for help, I sometimes ask, How can we empower the worker here? or I am wondering if you have any ideas about how we can work together? (As a team) If I discover that the expectations of the insurer are not in line with my values or are not consistent with evidence-based management, I will tell the insurer that I am having difficulty staying true to what I think is best in the situation. This then deflects the emotion away from the insurer, which in turn will help the relationship going forward. Values not only help in the conversation but also act as a personal debrief if it has not gone well, settling your frustration and feelings of stress afterward. Have Courage reminds me that despite the outcome, that I was actually brave enough to have the conversation and that it was better to have a tried. The stay true value is very strong for me as it is about doing the “right thing”. It is very helpful when conversations do not go well as it reminds me that my intent was purposeful and well-intended. The third-party space is one where this value can be challenged and as such, it is a good review value. If you have discomfort after a difficult conversation, use your values as your anchor. Reflect on whether your values have been questioned or whether you have not been able to stay true, to them.
Seek opportunities (Curiosity). Every engagement with a claims manager or injury management specialist is an opportunity to learn or to share. I like to find out about how things work and so will often admit that I either do not know and would like to know more or to ask for a refresher. People love to help.
I like to educate in my conversations by asking: “Would you like to know more about that?” or “Oh yes, we know a lot about this and the evidence shows that…….etc”.
Provide feedback. Follow up any conversation with an email thanking them for their time. Make this an opportunity to summarise your conversation and what you have agreed. Sometimes the outcome is that you have agreed to disagree. As always with email, be mindful of tone and do not forget to save in your client’s notes.
Now to nurture the relationship, follow up on the outcome of the treatment. What worked, what helped, thanking them for their help and support, or what did not work and why. If the worker has had a good outcome, thank the claims manager or IMS for their help. If the outcome has not been optimal because your recommendations were not supported, it is very worthwhile to give them a call and let them know. This will help future engagements with you and other treatment providers.
By the way, I can hear you all saying, “How unrealistic. When do I have time to do all this?”. Sit back and work out whether it is worth your while. Risks versus benefits. Business and Life are based on meaningful relationships. You decide.
I have found that my conversations with insurers, while occasionally challenging, often provide me with considerable satisfaction and I have enjoyed many new good professional relationships as a result of improved understanding.
Dianna Howell Cert Mgr MIML MAPA
If you would like to ask a question or help contact me: email@example.com