State of the Nation

The workers’ comp system can be overwhelming for the injured worker, frustrating for physicians, and a non-stop juggling act for claims professionals. Injured workers are bombarded with so much information at the onset of the claim, much of which is state-mandated notifications explaining the rights and duties of the injured worker, the employer and carrier. They may be asked to fill out forms or to have their employer or physician complete forms to initiate their indemnity or medical benefits. The physician is also blasted with state-mandated forms and information as well.

Then the adjuster must process all this information again – all while receiving hundreds of emails, handling high caseloads, and verifying dozens of data elements in the claim file in accordance with the many regulatory requirements.

All of this can be overwhelming and takes away from the adjuster’s ability to actually manage the claim. For those who work in a multi-jurisdictional claims environment, there is the added complication of jurisdictional context switching, which also can slow the process or result in non-compliance with the rules. This is where communication must go beyond the parties to the claim; it must extend to the regulator community, too. 

Occasionally, attorneys and injured workers appear at a public hearing to share their complaints with captive regulators and stakeholder audiences. They will speak about their negative experiences attempting to get treatment authorized or receive late indemnity payments, and it happens because there is a need for better communication.

The complex web of state workers’ comp laws and challenges that adjusters face leaves injured workers in the dark, and that is a recipe for delayed recovery, disputes, and higher claim costs.

Reducing administrative burden on all parties would go a long way to minimizing the time spent on non-essential tasks that do not contribute to improving the injured workers’ experience, allowing physicians and adjusters to focus more on achieving the best medical outcome.

Administrative simplification is not always top of mind for regulators, as they are busy running their agencies, managing dispute processes, and contending with other challenges. But regulators need to hear from our industry about the importance of simplifying administrative processes so we can improve how we help the injured worker throughout the claim process.

Advocacy must happen at the local/state level to be most impactful. Interacting with each other through disputes and problems is necessary for resolving claims, but it is much more important that we find ways to collaborate and communicate proactively, ideally in settings like workers’ comp advisory council meetings, through local events like state workers’ comp conferences, and even via networking and industry trade associations. 

Far too often, regulatory changes are a reactive process, brought on by a long-standing problem which has finally come to a head. Usually, changes are long overdue and sometimes can even be an overcorrection when periodic small refinements might have been useful in the interim. Unfortunately, many regulators do not hear much from industry stakeholders when things are going well. Bringing issues to the table prospectively is a terrific way to not only build connections, but to prevent problems in the future.

Considering that states each have unique politics, economic challenges, and societal issues, it is up to those of us who are actively engaged in the individual states to help drive progress through engagement with the regulator community. I often attend industry events where I hear stories from employers, adjusters, managed care program managers and physicians. There is little chance anything about the workers’ comp system will change for the better without continuous, transparent and thoughtful policy discussions.

This is more likely to occur when regulators and system participants are mutually engaged in tackling issues. I have observed regulators to be open to productive input, but more than that, they welcome proposed solutions. As one of my earliest mentors once said to me, “Don’t bring me a problem without bringing me a potential solution.” This is true for regulatory agencies as well. They often hear from injured workers or other stakeholders when problems occur, yet they are less likely to hear constructive ideas of how they can simplify the system.  

One of the challenges to working in a 50-state system (plus more, if you include Federal/U.S., Black Lung, Longshore and Jones Act) is the vast difference in terms of who chooses the authorized medical provider, how lost time and permanent impairment benefits are determined, and even how much interaction the state regulatory agency has within the day-to-day claim process. Some states require every milestone on the claim be communicated to the state, including details such as wage statements, authorizations for treatment, and even reporting of all medical bills – even when those bills are not the subject of a fee dispute. Other states have minimal involvement, capturing only the first report of injury, medical and indemnity payment data, and the claim closure. It is unclear why so many regulatory agencies require the capture of so much detailed claims information, even when there are no issues in dispute between parties.

In a recent regulator roundtable where more than half the states were represented, several questions were posed to these agency leaders including:

Regrettably, these questions are mostly met with silence, as regulators are faced with solving the problems in front of them, not guessing what is on the industry’s minds. This is where engaging is so important.

We like to actively communicate with regulators so that we know our perspective is heard. And since the pandemic, it has become easier to get engaged as so many states have moved to virtual meetings. As a result, there seems to be an uptick in overall industry participation, which is an incredibly good thing.   

However, it is important to understand the local and regional politics and economic differences in state workers’ comp systems prior to engaging in policy discussions. Without some knowledge of these underlying influences, it is difficult to anticipate what challenges public administrators face. These factors are often a huge barrier to adopting new regulations.

One example is the issues with physician dispensing in the southeast region. It has been long known this is a systemic problem, yet politics and economics have impeded progress in overcoming this challenge. That is not to say there is no hope, as long as the industry remains engaged and vocal at the local level. Persistence is the key to progress.

So how can we all do better? One way to increase your engagement is to join a trade association that brings together others who have the same interests. Many regulators like to hear from those working day-to-day in the workers’ comp system. Getting involved with organizations like the International Association of Industrial Accident Boards and Commissions (IAIABC), the Southern Association of Workers’ Compensation Administrators (SAWCA), or the National Association of Insurance Commissioners. In organizations such as these, regulators and industry experts sit side by side, working on projects and committees to address issues in the system.

At Healthesystems, we not only participate in organizations such as these, but we also engage regulators at the local and national level, as that is where we know we can help improve the system for all participants.

For more information on our local engagements, sign up for our weekly Regulatory Recap email by visiting www.healthesystems.com/advocacy-compliance.