Sedgwick Reports on Future Expectations for WC Claims Administration

Memphis,TN (WorkCompAcademy) - In this commentary paper, Max Koonce, Sedgwick chief claims officer, details the aspects of workforce changes, healthcare and legislative/regulatory reform in his article "A view of workers’ compensation: past, present and future."

The events and activities of the last few years have caused society to pause and consider many things from a cultural and political standpoint. Although workers’ compensation is generally not one of the headline considerations, the question remains as to what we can and should learn from past events and how it can influence the construct or functioning of workers’ compensation in the future.

The pandemic brought on heightened legislative and regulatory activity at the state and federal level. During 2020 and 2021, 18 states established COVID-19 presumptions for workers’ compensation via legislation, directives, emergency rules and/or executive orders. Two additional states -Tennessee and Washington - established a more general "infectious disease presumption." At the time of this publication, only seven states have presumptions still in effect, although this was still a topic of conversation within many states through proposed legislation even in 2022.

It has been argued that "socialization of risk" occurred during the pandemic through the expansion of coverage under workers’ compensation for COVID-19 by presumption legislation/executive orders. Some contend that broadening workers’ compensation coverage beyond employment-related risks to those which employers have no ability to control or prevent seems not only counterproductive but also counterintuitive. Others contend that broadening such risks is supported, since society is a third interested party to the grand bargain of workers’ compensation, with the role of balancing protections for the employee with the critical role of business to a well-functioning economy.

Telehealth utilization increased dramatically during the pandemic, which brought to light its viability and function in supporting the continuity of medical treatment.. From a workers’ compensation perspective, Sedgwick saw an increase from less than 1% prior to the pandemic to a height of 17% for initial or subsequent physician visits. Although this has stabilized over the most recent 12 months, it maintains an average of roughly 10% of all initial visits.

Healthcare monitoring by mobile/ wearable devices continues to grow, with a greater percentage of consumers expecting these devices to be incorporated into their overall healthcare.

But the pandemic did not enthrall society with confidence and/or support for health-related institutions. The Robert Wood Johnson Foundation, in conjunction with the Harvard TH Chan School of Public Health, published a survey in May 2021 on the public’s perspective of the United States health system. Two points that were noted:

- - Positive ratings of the public health system declined, from 42% in 2009 to 34% in 2021.
- - The public currently trusts nurses, healthcare workers and doctors more than public health institutions and agencies.

With regard to claims administration, technology is driving the evolution of many long-established workers’ compensation claims handling models.

- - Auto-triage systems that evaluate early claim data elements and combine the data with historical patterns to accurately place a claim into a particular “bucket” for processing
- - Auto-adjudication systems that allow for "simple" claims to be processed without human intervention
- - Predictive modeling using historical data patterns to predict the future
- - Consumer self-service tools designed to eliminate the frustrations often associated with workers’ compensation claims due to lack of understanding and expectations of the process

Integrating workers’ compensation and disability/sick leave has been a topic of consideration for several years. Some employers have found ways to seamlessly integrate these benefits for their employees, yet this approach has not gained significant traction as a standard throughout the industry.

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