In today’s marketplace, finding the competitive advantage whileensuring best-in-class products and customer service is whatdifferentiates one insurer from another. In the world of workers’compensation (WC), industry-leading insurers have identifiedpre-claim nurse triage programs as the newest competitive edge.First-aid screening by telephone results in many benefits,including better care for employees and lower workers’ compcosts.

As we observed with other innovations over the years, theadoption curve of pre-claim nurse triage programs resembles what weexperienced in the 1990s with return-to-work (RTW) programs. Theinitial adoption is slow, but when the benefits of a new serviceare recognized, implementation moves quickly. Today, we’reapproaching the tipping point at which pre-claim triage is rapidlygaining greater market acceptance. Consider the fact that thelargest WC insurers are in the process of implementing a triageservice or evaluating one with the intent to install such aprogram.

As a former insurance underwriter and then an agency owner, Irecall many business owners who resisted launching RTW programs.Over time, however, data clearly showed such programs reduced costsby helping employees get back to work faster. Early adoptersexperienced significant advantages over their competitors, and RTWprograms are now the norm with proven results.

I’ve seen the same pattern with pre-claim triage. Initially Isaw how my WC clients benefitted from this new risk mitigationtool, convincing me to become an early champion. As I watched myclients’ WC costs go down because of pre-claim triage, I alsowatched their employees embrace the spontaneous conversation withan “instant warm” nurse.

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Data tells the story

Compelling data is the proof that allows an insurer to evaluatea relatively “new” concept such as pre-claim triage, and adoptionrates are rapidly increasing. Decades of data clearly show theimpact triage has delivered to employers, injured workers andinsurers, including the following:

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

Getting an injured worker the right care at the right timedoesn’t necessarily mean calling 911, except in cases of potentiallife-threatening incidents. For minor injuries, workers usuallyagree to treat themselves when a proper assessment has been madeand they are supported through the process. That avoids anunnecessary claim because the first-aid screening anddecision-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 reducingexcessive lag times. New tools, such as pre-claim nurse triage,deliver the right balance by avoiding prematurely entering workersinto the medical system, while not sacrificing the timeliness andquality of medical attention an injured worker needs. Additionally,following the effective adoption of pre-claim triage, underwritersrecognize improved risk scoring of individual accounts attributableto 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 shouldrequire of their collaborative partner, at a minimum:

• A system that assures the first-aid screening is anevidence-based medical recommendation, objective and consistent, nomatter which registered nurse answers the phone;
• The pre-claim triage partner should operate a UtilizationReview Accreditation Commission accredited 24/7 call center staffedby registered nurses, which is a nationally recognizedaccreditation validating an organization’s commitment to qualityand accountability in healthcare; and
• The pre-claim triage partner should be free of conflicts ofinterest, with no incentive to increase revenue by processing moreclaims or creating extra transactions.

Pre-claim nurse triage programs are transforming the insuranceindustry’s workers’ compensation model. As the adoption ratecontinues to increase, more carriers are offering—and in some casesrequiring—pre-claim triage. It will be the norm in the next fewyears, just as RTW has become. The results are beneficial forinjured employees, supervisors, employers and carriers alike.

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