But some claims are different. They require more attention, more resources – and incur significantly more costs. These high-risk, high-dollar workers compensation claims can have lasting impacts on both the injured worker and your business. 

Understanding how to navigate these complex claims can help you better support your employees and protect your bottom line. 

What sets these claims apart, and how can employers manage them effectively? We’re joined by MEM’s Manager of Medical Services Lyndi Barthel and Claims Operations Manager Shannon Fox to answer these questions. Together, they bring decades of experience managing the most challenging work comp cases. 

What makes a work comp claim “high-risk” or “high-dollar” 

High-risk work comp claims stand out from typical cases due to their complexity and potential for significant costs. 

Medical complexity plays a major role. Cases can involve multiple medical providers, extended recovery periods, surgeries, and uncertainty about whether the employee will return to work at all. Medical treatment can extend far into the future. The potential for litigation and the likelihood of prolonged time away from work elevate a claim’s risk level. 

All these factors – medical complexity, potential for litigation or extended indemnity – can cause claim costs to skyrocket. Controlling claim costs is a goal that you, the business owner, share with the work comp carrier, since they can affect your premium calculation. 

A note about complex claims: In this conversation, we’re talking about claims management strategies to achieve the best outcomes for everyone involved. It’s important to remember that the injured workers in these cases have experienced a severe injury – maybe one that will impact them for the rest of their lives. That’s an outcome that no one wants. The absolute best way to protect people and avoid high-dollar claims is to prevent employees from getting injured in the first place with a thoughtful and robust workplace safety program. 

Top cost drivers in complex claims 

What drives costs up in these high-dollar claims? Here are the top factors that contribute to claim complexity and cost: 

• Medical treatment costs: Surgical procedures, extended hospital stays, specialized equipment, and ongoing rehabilitation 
• Lost time from work: Wage replacement 
• Mental health components: Mental well-being affects recovery timelines across many injury types 
• Prescription medications: Multiple medications and specialized treatments can add substantial costs 
• Legal involvement: Attorney fees, depositions, expert witnesses, and litigation expenses 

Fox identified the mental health component as particularly significant. “The mental component that has been added to many of our claims has been significant since COVID,” she remarked. “It seems as if that mental component has just skyrocketed.” 

Common injury types that lead to complex claims 

Certain types of workplace injuries are more likely to result in high-dollar, complex claims: 

• Falls from heights: Consistently rank among the most serious, and can lead to lasting medical conditions like traumatic brain injuries 
• Motor vehicle accidents: Present unique challenges when extensive, affecting multiple body systems 
• Spinal cord injuries: Often require specialized, long-term care and rehabilitation 
• Burns: Include treatment at specialized centers and extended recovery periods 

These injury types share common characteristics: They often affect multiple body systems, require specialized treatment, and may result in permanent impairments that affect the employee’s ability to return to their previous role. 

Complicating factors beyond the initial injury 

While the initial injury determines the baseline complexity of a claim, additional factors can complicate the recovery process. 

Injuries that happen at work can be affected by pre-existing health conditions outside your control. Comorbidities such as diabetes, hypertension, and heart issues can extend healing time and increase treatment complexity. 

Here’s an example: If an employee sustains a foot injury, their healing time and treatment requirements may be significantly extended if they have diabetes or other circulatory issues. This is one reason we advocate for every workplace safety program to include a wellness component. 

Communication barriers can also play a role. Poor health literacy can prevent employees from fully understanding their recovery plan. Language barriers may complicate treatment coordination. Additionally, when injured workers have multiple treating physicians, the coordination becomes more challenging and can slow the recovery process. 

With so many moving pieces, even seemingly straightforward injuries can evolve into complex, costly claims that need specialized attention. 

What to expect from your carrier on high-risk claims 

When a high-risk or high-dollar claim develops, your work comp carrier should respond with additional resources and specialized attention. 

In these cases, carriers typically shift from a single-adjuster approach to involving additional expertise. At MEM, claims representatives work with technical services, and field service managers may be brought in. When appropriate, subrogation specialists ensure all potential recovery avenues are explored. 

“When claims enter into the organization with factors that are extenuating,” Fox explained, “nurse case managers are on top of them, just making sure that they utilize their resources effectively.” This team-based approach ensures that experts from multiple areas examine each claim to make sure important details aren’t overlooked. 

The role of nurse case management 

Nurse case management becomes particularly crucial in high-dollar claims. These registered nurses, who specialize in work comp injuries, help coordinate all aspects of medical care and facilitate communication between the various providers and stakeholders. 

Barthel emphasized the importance of this coordination: “It is critically important to involve experts in each area to help identify and eliminate any risks.” The goal is to ensure injured workers receive appropriate medical care while facilitating their recovery efficiently. 

Centers of excellence for severe injuries 

For catastrophic injuries (e.g. traumatic brain injuries, spinal cord injuries resulting in paralysis), your carrier may recommend treatment at specialized centers of excellence. These facilities provide the highest level of care for severe injuries, even if they’re located far from the injured worker’s home. 

“Although we know it is a higher cost to send individuals to a center of excellence,” Barthel said, “our injured workers do better when we allow them to have the highest level of care at the right time in the claim.” 

While sending someone to a center of excellence in another state adds immediate costs and may mean families need to temporarily relocate, studies consistently show better outcomes when injured workers receive specialized care early in their recovery. 

Early warning signs to watch for 

Recognizing when a claim may be heading toward increased complexity is key to earlier intervention and better outcomes. Fox identified several red flags that indicate a claim is becoming more challenging than initially expected. 

Checklist: Early warning signs of complex claims 

	Employee reports worsening condition despite extensive treatment
	Frequent missed medical appointments
	Poor communication or lack of response from the injured worker
	Confusion about job duties or return to work expectations
	Employee expresses feeling unsupported throughout the process
	Multiple treating physicians with conflicting recommendations
	Underlying health conditions affecting recovery timeline

“If an employee is not improving throughout the medical process,” explained Fox, “if they’re saying that it’s getting worse, even though treatment has been extensive, that could be a red flag.” 

Other critical warning signs include frequent missed appointments and communication breakdowns. When employees repeatedly cannot attend appointments for various reasons or stop responding to inquiries, claims can quickly become more complex. 

Communication is key 

Effective communication throughout the claims process can make the difference between a smooth recovery and a complex, costly claim. Employers should maintain regular contact with injured workers, checking on their progress and ensuring they understand their role in the return to work process. 

Can you ask for updates on your employee’s recovery? The short answer is yes; employers are entitled to medical information about work-related injuries and treatment. Fox noted that in her years of handling claims, she’s never encountered an employer trying to push these boundaries; they typically focus on information directly related to the claim. 

Building and maintaining trust with injured workers is essential. When employees feel supported throughout the recovery process, they’re more likely to communicate openly and work toward a timely return to work. 

Geographic and regulatory challenges 

Location significantly impacts how claims develop and what resources are available for treatment. In rural areas, access to specialty care can mean longer recovery times simply due to the distance workers must travel for treatment. Metropolitan areas typically offer more provider options, but at higher costs. 

Rural vs. metro care considerations 

The work environment also influences claim dynamics. Different industries, like agriculture or trucking, pose different challenges for claims management. A truck driver traveling through different regions may face varying medical costs and regulations depending on where an injury occurs. 

Managing care across state lines 

The laws around an employer’s right to direct medical care vary by state. For example, in Missouri, an employer can direct an injured worker to a specific provider. If the employee declines the directed care, any care they choose is at their own cost. In Illinois, an injured worker has more choice in medical providers but may still be limited within a network. 

Each state also has different rules and regulations for processing medical bills. Some states have fee schedules that determine exactly what can be charged for various services. Other states operate on “usual and customary” billing, where providers can determine appropriate charges based on regional standards. 

These differences between states require careful navigation, but the focus remains on ensuring injured workers receive the best level of care for their specific injury. When providers aren’t available locally, virtual care options may be considered for follow-ups when appropriate. 

So what? The business impact of high-dollar claims 

If your work comp carrier covers these expenses, why should you care how high they rise? 

Because claim costs impact your premium. The premium calculation has three components: payroll, work classifications, and experience modification factor (e-mod). 

Your e-mod represents your company’s claims history. If you have higher claim costs than expected for a typical company like yours – whether from many small claims or one large claim – your e-mod will increase, and so will your premium. 

“For smaller businesses, one large claim can have a real impact on their premium… and their budgeting for years to come,” Fox explained. 

Beyond insurance costs, when an employee is severely injured, it impacts the business in other ways: 

• Lost productivity: Work stops for investigations and incident response 
• Overtime costs: Other employees cover additional duties and shifts 
• Decreased morale: Employees feel less safe at work 
• Higher turnover: Employees leave for safer environments, creating recruiting and training costs 

These broad business impacts are why it’s so important to invest in injury prevention and early intervention. 

Read next: 4 Proven Ways to Reduce Your Workers Compensation Costs > 

How employers can minimize claim complexity 

Luckily, there are strategies to minimize the likelihood that injuries will develop into high-cost, complex claims. 

At MEM, we’ve seen firsthand that investing in comprehensive safety programs provides the best return. If injuries do occur, having strong processes in place can significantly impact outcomes. 

Top strategies to minimize costs: 

• Stay engaged with injured workers throughout their recovery 
• Treat injured workers as people, not burdens 
• Report incidents promptly using proper reporting procedures 
• Direct medical care when possible 
• Implement modified duty programs to bring workers back at reduced capacity 
• Maintain clear communication about expectations and return-to-work processes 
• If recovery progress stalls, consider a second medical opinion 

The success of these tactics boils down to one thing: staying involved. “When you see the employer involved,” Fox explained, “it’s usually followed by an injured worker who wants to heal, a return to work faster than when an employer is not engaged.” 

Navigating complex claims with confidence 

Managing high-risk work comp claims requires understanding, patience, and the right support system. The most important factor in successful outcomes is communication – with injured workers and your claims team. 

“Stay engaged,” Barthel emphasized. “Rely upon the experts that we have here at MEM to help manage the claim, between our claims representatives and our excellent nurse case management team.” 

Remember: Preventing injuries through strong safety programs remains the best strategy. But when complex claims arise, having the right partnership and approach can lead to positive outcomes for everyone involved. 

Prepare your organization to handle complex claims with confidence. Download our free claims management kit so you have it when you need it. 

Frequently asked questions: high-dollar claims 

What should I do if an employee isn’t improving despite ongoing treatment? 

If an employee’s condition continues to worsen or fails to improve despite extensive treatment, contact your claims representative immediately. This may indicate the need for a second opinion, different treatment approach, or additional specialists. Early intervention when progress stalls can prevent claims from becoming more complex and costly. 

Can I stay informed about my employee’s medical treatment without violating HIPAA? 

Yes, because the injury is work-related, employers are entitled to obtain relevant medical information about the treatment and recovery process. The key is focusing on information directly related to the claim rather than broader personal health matters. Your claims team can guide you on what information is appropriate to request and receive. 

How do high-dollar claims affect my future premiums? 

High-dollar claims can significantly impact your experience modification factor (e-mod), particularly for smaller businesses. Your e-mod compares your company’s losses to other similar businesses, and large claims can result in higher premiums for several years. However, investing in safety programs and effective claims management can help improve your e-mod over time. 

How is MEM’s approach to complex claims different from other carriers? 

MEM takes a collaborative team approach to high-risk claims, involving multiple departments and specialists rather than relying on a single adjuster. We focus intently on medical outcomes, provide personalized attention, and provide in-house expertise rather than outsourcing critical services. Our nurse case management and access to centers of excellence demonstrate our commitment to achieving the best possible outcomes. 

When should I consider sending an injured worker to a center of excellence? 

Centers of excellence are typically recommended for severe injuries such as traumatic brain injuries, spinal cord injuries, or complex cases requiring specialized care. While the upfront costs may be higher, studies show that injured workers achieve better outcomes when they receive the highest level of care at the right time in their recovery. Your claims team will evaluate whether a center of excellence is appropriate for your specific situation. 

The post Complex Workers Compensation Claims: High Risk, High Dollar  appeared first on MEM.

But what happens when treatment isn’t progressing, or complications arise that leave everyone uncertain about the best path forward? That’s where a second medical opinion can make a difference. 

On this episode of the WorkSafe Podcast, we explored these scenarios with Shannon Fox, Claims Operations Manager at MEM. With decades of experience managing complex claims, Shannon knows exactly when second opinions become valuable – and how to navigate the process. 

When second opinions make sense in workers compensation 

Second opinions aren’t needed for every claim, but certain red flags signal it might be time to seek another medical perspective. 

Red flag #1: Signs that treatment isn’t progressing 

“The most dynamic situations arise when there is a disconnect between the injured worker, their reported symptoms, complaints and clinical findings,” said Fox. This might look like: 

• An injured worker isn’t improving as expected despite following the treatment plan 
• Treatment recommendations seem excessive or inconsistent with the original diagnosis 

Here’s an example: An employee is treated for a back injury for six months with no improvement. Despite physical therapy and medication, they can’t return to work. A second opinion might reveal whether the original diagnosis missed something or if the treatment approach needs adjustment. 

Red flag #2: Underlying medical conditions that complicate recovery 

Pre-existing health conditions can impact how workplace injuries heal. Fox explained, “an individual who had something fall on their foot, but they have the underlying medical issue of diabetes. That diagnosis can delay medical treatment. It can change the answer to ‘What are we treating for?'” 

Sometimes, underlying conditions aren’t obvious. If a female employee develops carpal tunnel syndrome, a second opinion might determine whether thyroid issues are contributing factors. 

Red flag #3: Extended lost time and stagnant treatment 

When conservative treatment extends beyond what’s typical without progress, consider additional medical input. Fox noted that sometimes treatment for one area evolves to include related body parts, like a lumbar spine injury affecting the cervical spine. 

Pro tip: Don’t wait until treatment has been ineffective for months. Early intervention with a second opinion can prevent prolonged disability and get your employee the specialized care they need sooner. 

Who can request a second opinion 

Who has the authority to request and authorize second opinions? The answer to this complex but important question varies by state. 

State variations in authority to direct medical care 

“In Missouri, the employer has the exclusive right to direct medical treatment,” Fox explained. “That indicates that an injured worker cannot seek a second opinion on their own, and expect the employer or insurer to pay for it. We have to authorize that.” 

However, an employer’s right to direct medical care isn’t universal. In Illinois, injured workers can generally choose their own doctors – typically up to two physicians, though employers with Preferred Provider Programs can limit these choices. Kansas follows a model similar to Missouri, where the employer or insurance carrier selects the treating physician. 

Authorization requirements across different states 

In many employer-directed states, requests for covered second opinions must come through proper channels. Insurance carriers evaluate these requests based on medical necessity. However, every state is different: In Kansas, second opinions are covered up to a certain dollar amount without prior authorization. 

What happens when injured workers seek opinions independently 

If an injured worker obtains a second opinion without authorization, they may be responsible for the cost. But this doesn’t mean the information is ignored. “In instances like that,” Fox said, “we obtain the medical report so we can clarify if it will persuade the decisions that we’re making on the file.” 

For injured workers, the best approach is to stay within the approved provider network and maintain open communication with their employer and carrier to ensure coverage. 

When insurers initiate second opinions 

Insurance carriers can request second opinions when they believe it’s medically necessary. Common reasons include: 

• Confirming a diagnosis when treatment isn’t progressing 
• Evaluating treatment effectiveness 
• Addressing delayed recovery or complications 
• Clarifying permanent work restrictions 

Pro tip: Choosing a work comp carrier with in-house claims management, including nurse case managers, adds value for employers and injured workers. These professionals identify when second opinions are needed, coordinate care between providers, and keep treatment on track – often catching issues before they become major complications. 

Second opinions vs. independent medical examinations 

Second opinions and independent medical examinations (IMEs) serve different purposes in work comp claims. 

IMEs clarify compensability – whether an injury truly arose from a workplace incident. They come into play during disputes about medical issues or disability ratings. “It’s not necessarily for ongoing care, but rather to clarify how a claim should move when there’s litigation or a settlement involved,” Fox explained. 

Second opinions focus on ongoing medical treatment. They address questions about current treatment and determine the best plan of care for optimal outcomes. 

How MEM handles the second opinion process 

When a second opinion is warranted, careful coordination ensures a smooth process. 

Behind-the-scenes coordination 

“We have about 40 claims adjusters at different severity levels who handle files,” Fox noted. The process varies based on adjuster experience, claim complexity, and state regulations. 

We determine whether a second opinion is the best course within applicable state laws through discussions between adjusters and nurse case managers about which physician would be most appropriate. MEM draws on decades of experience working with specialists to make these selections. 

Need help navigating the complexities of work comp claims? Download our claims management kit for practical resources and guidance. 

What employers and injured workers can expect 

Once a second opinion is deemed appropriate, MEM handles the logistics. This includes scheduling, authorizing treatment, and managing communication. “We take care of all of that information and make sure the injured worker knows where they’re going and the employer understands the purpose,” Fox said. 

Geography can be a factor, especially in rural areas. While we minimize travel, accessing the right specialist sometimes requires distance. We balance convenience with getting the most appropriate evaluation. 

After the exam, we quickly assess recommendations. This might involve switching care to the second opinion physician or incorporating their recommendations. Our expert medical management team ensures decisions consider both medical best practices and practical considerations. 

Real-world example: When a second opinion changed everything 

Second opinions can be very valuable. Fox shared a compelling example from her experience managing claims. 

Fox shared a compelling example: “I can recall a claim involving a back injury where the treating physician kept the injured worker on very limited duty for over six months with no improvement.” The injured worker remained unable to work. 

MEM arranged for a second opinion with a spine specialist. “He evaluated the case and discovered that the diagnosis involved a disc issue, which was overlooked by the prior physician,” Fox explained. 

This changed everything. Instead of continuing ineffective care, the injured worker got targeted treatment addressing the actual disc issue. 

The bottom line: The second opinion identified the real problem and connected the injured worker with the right specialist, leading to meaningful improvement after months of frustration. 

When second opinions aren’t recommended 

While second opinions can be valuable, they’re not appropriate in every situation. Understanding when to stay the course is just as important as knowing when to seek additional input. 

Signs that current treatment should continue 

If the treating provider follows evidence-based guidelines and the injured worker is progressing well, a second opinion might only add unnecessary cost and delay. “In those cases, we may stay the course to avoid disrupting care,” Fox said. 

Timing matters. If a provider is early in their treatment plan without adequate time to evaluate results, jumping in too quickly can create confusion. 

Balancing medical necessity with claim integrity 

Carriers aren’t obligated to approve every second opinion request. “We always consider the request, but we have to balance it with medical necessity and the integrity of the claim,” Fox explained. 

Carriers consider factors such as: 

• Medical justification: Clinical evidence supporting additional evaluation 
• Treatment effectiveness: Whether current care follows evidence-based guidelines 
• Cost-benefit analysis: Potential for improved outcomes versus expenses 
• Timing considerations: Whether adequate time has passed to evaluate treatment 

Supporting your injured worker through the process 

When second opinions come into play, employers play a crucial role in supporting the injured worker while working collaboratively with their claims team. 

Staying connected with your claims team 

“My best advice is to stay connected with the claims team; the adjuster on your file,” Fox recommended. “If there’s a nurse assigned to your file, stay connected, because you’re never navigating this process alone.” 

Your adjuster can walk you through the reasoning behind recommending a second opinion, help with timing decisions, and manage logistics. 

Want to understand how different claim types impact your business? Explore our insights on frequency vs. severity in claims management. 

Framing second opinions positively 

One concern employers have is that requesting a second opinion might damage trust. “A second opinion, when handled thoughtfully, is not about questioning the employee,” Fox emphasized. “It’s about making sure we’re doing everything we can to support their recovery.” 

Strategies for positive communication: 

• Focus on clarity: Second opinions are tools for understanding the best path forward. 
• Show support: This is comprehensive care, not questioning their injury. 
• Maintain transparency: Explain the process so everyone knows what to expect. 
• Be a partner: Everyone is working toward the same goal: recovery. 

The bottom line on second opinions 

Second opinions help ensure injured workers receive appropriate care. Whether identifying a misdiagnosed condition, addressing complications from underlying health issues, or clarifying the best treatment approach when progress stalls, second opinions can redirect claims toward better outcomes. 

Seeking a second opinion represents good stewardship, not doubt. It demonstrates commitment to thoughtful care that prioritizes recovery while managing claims responsibly. By staying in close communication with your claims team and asking the right questions early, you can navigate the process effectively. 

At MEM, personalized claims care is one of our top priorities. Learn more about our comprehensive approach to handling claims. 

The post When to Seek a Second Opinion in Workers Compensation Claims  appeared first on MEM.

In the world of workers compensation, loss runs affect a business’s risk evaluation. Underwriters look carefully at a company’s claim history. This process gives them an understanding of how frequently claims are happening, how severe they are, and if a business is putting effort into reducing workplace risk.

Whether a company has had several small claims or one large, severe one, the impact of a workplace incident matters.

Listen to this episode of the WorkSAFE Podcast, or read the show notes below. 

The importance of loss runs

Underwriters who specialize in work comp evaluate the risk a company presents before a policy is written. Part of that process is looking at loss runs. A loss run shows a record of past claims, including dates, descriptions of workplace incidents, and amounts paid.

“We evaluate loss history, or loss runs, when a submission comes to us for the first time to be quoted,” Duello explained. “That’s the first time we’re looking at them.” Underwriters will look at the prior year’s loss runs. Typically, they like to review at least four years of records, but will look further back when needed. This information tells the story of risk and incidents in a workplace.

Frequency vs. severity

Underwriters look for trends in losses. Two patterns stand out in particular in a loss run: frequency and severity. Frequency refers to how often claims occur, while severity encompasses how financially costly a claim is. Duello highlights that severity depends on several factors, including:

• Business type. What industry is the business a part of, and what is the risk level involved in the work?
• Injury severity. For example, does the claim involve amputation, severe burns, or acute spine or neck injuries?
• History. Has the business experienced a claim like this before? Were any steps taken to prevent it? Are the same employees getting hurt?

Duello points out that the answers to these questions don’t necessarily rule out employers from obtaining a policy. “Are they gonna continue having these kinds of losses?” She questions. “And if they are, it’s not a deal breaker for us. The question then is, are we able to price adequately for the expected losses?”

What if a business doesn’t have any loss history?

If a business has never had work comp before, workplace incidents will not have been formally recorded. In these situations, underwriters will look at any work-related losses or expenses.

Brand new businesses won’t have any loss history to review. Consequently, they present their own unique risk. “A new venture is considered a higher hazard type of risk because new businesses don’t always get off the ground,” Duello shared. “They don’t last very long sometimes.”

Frequency vs. severity: What stands out most to an underwriter?

Many employers think that having a large, severe claim is more damaging to their loss history than smaller incidents. But Duello finds that the opposite is true. Underwriters consider several elements, including a business’s longevity, previous losses, pay history, audit compliance, and whether or not a safety program is in place. Each one influences both pricing and renewal decisions. There are important warning signs they look out for.

“A lot of small claims stand out more because any one of those small claims can become a large claim for various reasons,” she shared. “Actually, a motto that’s known throughout the insurance industry is ‘frequency leads to severity’.”

“We’d look to see if frequency, severity, or both have been trending up over the last several years,” Duello added. “That’s a red flag to us as an underwriter. We’ll also look at the types of losses to see what the loss drivers are, meaning which types of losses are occurring more frequently.”

The significance of repeat-injured workers

An important consideration for underwriters like Duello is repeat-injured workers. These employees have been injured on the job multiple times over a span of months or years. It may indicate ongoing issues with that employee. For example, they haven’t been properly trained, ignore safety rules or procedures, or have lasting issues as a result of a previous injury.

A repeat-injured worker has an impact on a business. Underwriters know they present a continued injury risk. “As long as that person is still employed with them, that’s going to continue,” Duello pointed out. “We need to price adequately for that.” For an existing policyholder, this can also play a role in declining to renew a work comp policy.

The role of safety culture in managing claims

Underwriters expect a frequency of claims in some industries and operations. In these cases, the essential task is controlling severity. Where low frequency might be the norm in another business, an increase in claims is a concern. In both situations, underwriters are looking closely for commitment to safety, or a lack thereof.

Management may not enforce current safety policies. Employees may not buy into a safety program that’s in place. “That to us means that losses will continue as they’ve been, and so we need to price for that,” Duello said. But underwriters also seek different solutions where possible.

“It also means we may need to get Safety and Risk Services in touch with them to discuss those options that are available to them to try to bolster their safety program or get their employees to actually buy into what they’re trying to do with safety.”

Solutions of all sizes

Safety professionals at MEM offer solutions of all sizes. Every business has its own needs, may have experienced certain workplace incidents, and will want a solution that works for them and their employees. Underwriters are uniquely positioned to look at loss history, what potential struggles a policyholder may have, and connect them with the right resources. And while many carriers limit personalized services to larger account holders, MEM policyholders can tap into these resources, no matter their size.

Underwriters also rely on safety professionals to serve as their eyes and ears in a business. JA submission and loss history review don’t always tell a full story. A company that appears to be struggling on paper may also be putting all its effort into safety improvements in the workplace. Safety professionals can highlight where employers are doing things right or investing time and effort in getting there.

Agents and underwriters: Partners in reducing frequency and severity

Insurance agents serve as crucial partners for underwriters. During the submission period, the majority of communication flows between them. “They’re ones that provide us with the information we need to price and price not just adequately, but price fairly and all those good things,” Duello said. “And then, you know, we rely upon them to get the information out to the insured.”

In practice, Duello might enlist the help of an agent if a policyholder is putting off complying with safety recommendations. Safety professionals make detailed safety recommendations to address problems that may cause an injury in the immediate future.

“Agents understand the importance of safety just as much as we do,” Duello shared. “And we work together to try to help each other get the policyholder in a good place with safety so that their people are coming home every night.”

How to reduce frequency and severity today

For Duello, employers can reduce claim frequency and severity by starting with a simple step: creating safety rules. Organizational leaders are responsible for leading by example and following safety rules, too. They won’t mean anything to employees if leaders don’t follow them, too.

“I would tell them to implement a set of written safety rules that are specific to their operation,” she explained. That doesn’t mean creating a 500-page document filled with guidance that isn’t relevant to the workplace. “Just a very basic set of written safety rules specific to your operation. Share them with your employees. Have them sign off on those rules. And then enforce them.”

The post Frequency vs. Severity: The Impact of Claims Big and Small appeared first on MEM.

Organizations are always looking for ways to be more efficient. While some of those efficiencies are gained through changing standard operating procedures, others come from technological advancements.

Artificial intelligence (AI) is gaining speed. Many workplaces are now using it to automate and assist with various tasks. Leveraging AI can help companies reduce costs while improving outcomes.

Listen to this episode of the WorkSAFE Podcast, or read the show notes below. 

How artificial intelligence changes the claim process

“Traditionally, the claims process within workers compensation has been a static approach,” Phillips explained. First, an injured worker receives medical attention. A claims representative or adjuster will follow up by reviewing medical records, setting additional appointments, and keeping all parties up-to-date.

Using artificial intelligence (AI) allows for streamlining claims and creating efficiencies. More importantly, it doesn’t take over the process from claim professionals; it acts as a support system. “It’s not taking away any type of decision-making or strategy or critical thinking from our claim staff,” he highlighted. AI serves as a virtual assistant, diving deeper into tasks that take more time.

For example, it can summarize several pages of medical records or highlight inconsistencies in statements. As a result, claim professionals have more time to consult with internal experts, have important conversations with injured workers or policyholders, and create one-on-one connections.

Using developing technology as a tool

While AI is growing in popularity, it’s still a developing technology. “Something I think is really important for folks to understand as it relates to AI, especially in the claims process, is that it’s not a crystal ball, right?” Phillips shared. “It is a tool for our staff and claims professionals to use.”

He compares AI’s work to the way a GPS works on a mobile phone or in a vehicle. It provides a roadmap of the way ahead but may offer more than one route to your destination. An unexpected road closure or traffic jam may require a route change.

“It is ultimately up to the driver to pick which route fits them best,” he said. AI is a tool that’s still evolving; it’s not always 100% accurate. Claim professionals assess the information it provides critically and take all the records and documents they have into consideration before making a decision. This is especially true when considering red flags that may point to work comp fraud. “It’s really there to serve as directional guidance. But it is ultimately the claim professional’s or the adjuster’s role to pick the best path for the claims.”

The importance of efficiency in claims

For a claim professional handling dozens of claims in a single day, efficiency can be a challenge. It’s easy to get bogged down by hundreds of claim activities, or steps in the claim process, that need to be scheduled, documented, or shared with an agent or policyholder.

One of Phillips’s personal mantras is ‘no surprises’. “We don’t want any surprises for any of the parties involved in the claims process,” he explained. “AI allows us to have more time to keep everybody informed on the current status, as well as what they can expect down the road in the claims process.” AI efficiency creates more room for review, and also leads to important outcomes:

• A shorter claim cycle. There is less time between the opening of a claim and its closure.
• More accurate costs. When injured workers get the right care when they need it, less time is spent and money is spent on the wrong type of care.
• Lower litigation percentage. Litigation extends the time and cost of a claim. A more efficient claim process lets an injured worker know everyone cares about them and is working toward getting them back to work.

Predictive analysis: A new benefit on the horizon of artificial intelligence

AI allows users to process large amounts of data and get a broader view of a claim. This view allows trends in claim activity to be identified. Further, the information can be used to forecast what costs or exposures should be expected with certain types of claims. This insight allows claim professionals to deploy resources that may help mitigate the overall cost.

For instance, assigning an adjuster with experience in a particular industry or a nurse case manager to provide extra guidance on medical care. AI provides an estimate of the path a claim might follow – and also provides opportunities to intervene and change that outcome.

Artificial intelligence isn’t a replacement for training

While artificial intelligence is proving to be a powerful tool, Phillips emphasizes that it isn’t a replacement for onboarding and on-the-job training, especially for claims professionals. However, it can be a helpful tool for new adjusters joining a claim in the middle.

For instance, an injured worker currently off work misses a doctor’s appointment. AI flags this as a reason recovery time is delayed. An adjuster just coming into the case can see this highlighted, rather than studying documents and timelines to see what might have been missed and when.

“It helps take out the manual approach to that,” Phillips explained. “It allows the claim professional to look at a couple of different options, potentially talk with a peer about that or their manager or supervisor, and ultimately make the best decision for the claim.”

Always evolving: Artificial intelligence in the future

For Phillips, the goal of using AI is to close claims faster and with better results. Technology is constantly evolving. He highlights that the AI used may look different as soon as tomorrow, and will look different six months from now.

“I think we’re really at the forefront of the next evolution of AI, as we use it for insurance carriers and in the industry, and I’m excited to see where it’s headed,” Phillips said. “I think we’ll be talking more about this in the future, and I would not be surprised if it looks a little or a lot different than it does today.”

The post Claims and Artificial Intelligence: Transforming the Post-Injury Process appeared first on MEM.

Check out this video on how to prepare for and manage claims. 

A proactive and collaborative approach 

MEM’s approach is about more than filing paperwork—it’s about partnership. We walk alongside employers and injured employees throughout the entire claims journey. We’re partners from the moment an injury is reported to the employee’s return to work. Our role is to simplify a complex process, contain costs, and ensure quality care. 

Keeping medical costs under control 

Medical expenses are one of the biggest factors impacting work comp premiums. MEM helps employers manage these costs without sacrificing care quality. Our NurseAid 24/7 work injury line gives immediate access to medical professionals, helping employers avoid unnecessary ER visits and choose the right care from the start. 

What employers can do—before and after an injury 

MEM supports policyholders with practical guidance on both prevention and response: 

• Before an injury: Employers are encouraged to create clear safety policies, offer regular training, implement return-to-work programs, and build a culture where injuries—big or small—are always reported. These steps lay the groundwork for successful claim outcomes and reduce future risk. 

• After an injury: Quick reporting, immediate medical triage, thorough investigations, and drug/alcohol screenings (when appropriate) help keep claim costs down and ensure a smooth recovery process. Employers also have access to fraud prevention resources to protect against system abuse. 

Real people. Real expertise. 

MEM’s claims process is powered by a team of experts who bring professionalism and personal attention to every claim. Each team member plays a key role in delivering results that matter. For example, nurse case managers coordinate care, and field service managers provide on-site support. Investigative staff collaborate to identify fraud.

Confidence through partnership 

Ultimately, MEM believes that every worker deserves to feel confident about their safety. Further, every employer deserves peace of mind knowing they’re not navigating claims alone. Our collaborative process helps reduce financial strain, ensures employees receive the right care, and keeps businesses moving forward. 

To learn more about how MEM can support your business, visit mem-ins.com. 

The post A Support System Employers Can Count On: How MEM Handles Workers Compensation Claims appeared first on MEM.

Several factors, such as medical complications or legal roadblocks, can keep a claim open longer than expected. Some business owners see a claim closed in just a few weeks. Other cases take much, much longer, leaving key questions. Why are claims delayed? What can employers do to help keep the process moving?

Listen to this episode of the WorkSAFE Podcast, or read the show notes below. 

How long will a claim stay open?

For both injured workers and employers, there is one common question after a workplace incident and injury. How long will a claim stay open? Fox points to several factors that ultimately impact claim length: injury severity, required medical treatment, and disputes. No claim has an exact timeframe.

“A simple claim, like minor injuries requiring minimal medical treatment, may resolve in weeks or months, right?” she points out. “But it’s when you get to the more complex claims that may involve surgery and detailed treatment or disputes, it can extend from several months to several years.”

What makes a claim complex?

There are two common types of claims: medical-only and lost time. Medical-only claims only involve medical treatment. The injured returns to work after receiving it. A lost time claim involves time away from work while an injured worker receives treatment and recovers. The claim length on both is shorter, lasting anywhere from 90 days to a few months. Claims often become more complex for the following reasons:

• A detailed investigation is required. If more details are needed to understand how or why an incident happened, then more time is needed to gather them.
• Attorneys are involved. An injured worker may secure representation for themselves, and then an employer may do the same. Attorneys also become involved in cases of subrogation, where a third party may be at fault for causing an incident.
• The resulting injury from a workplace incident is catastrophic. For example, an amputation, spine injury, or severe burns. Multiple payments may be needed for medical procedures, lost time, and continued care.

In some cases, an adjuster or field representative will travel to the incident scene. Fox explained that the larger the loss, the more important it is to have as much information as possible.

Does litigation add to claim length?

When a claim enters the legal arena, time will inevitably be added to the claim length. “Litigation will usually always extend the life of a claim, right?” Fox shared. “And that is because we have another party involved that is working on behalf of the injured worker.”

Litigation delays a claim in two ways. First, a third party enters the claim, wanting to obtain something on behalf of the injured worker. Second, direct conversations with the injured worker can no longer happen. All inquiries must be routed through the attorney, creating a middleman and slowing down communication.

The role of medical uncertainty

Workers compensation laws determine how and when a claim can be considered a compensable work-related injury. The prevailing factor, or the main reason why an illness or injury happened, is an important element in this process. When the prevailing factor is unknown, or extensive, claims adjusters must bring in specialists to help determine it.

In most catastrophic claims, the prevailing factor is essential to determine and may take time to understand. Fox highlights that these cases involve everything from multiple injuries to paralysis, and can extend to traumatic brain injuries and fatalities. The medical treatment required is significant.

“As we gravitate toward the more severe issues, we need specialists to clarify the details of the injury. Is it truly work-related?” she explained. “And a lot of that just adds life onto the claim based on the severity and the details that are involved in it.”

Severe injuries: Does the claim stay open forever?

In some workplace incidents, the resulting injuries are severe enough that the worker may never fully recover. For instance, falling off of a roof could result in several different types of injuries: head, back, internal bleeding or injuries to organs. Even if the injured worker recovers some function, they may never be able to walk or live independently again.

In these cases, the claim is monitored for maximum medical improvement (MMI). At this stage, an injured worker’s physician determines that they have recovered as much as they can. While they may still have occasional appointments or take medication, they are no longer doing it to improve, but to maintain their current state.

“Everything that we do is based on the information we receive from the treating physician,” Fox said. A portion of the claim may be closed if it’s determined no more physical improvement can be had. If the injured worker needs continued medication, therapy, or even lifetime monitoring of medical devices, the claim will stay open to meet those needs.

Claim length: 3 things employers can do to help efficiency

Employers play an important role in ensuring claims get off to an efficient start. Fox highlights that claims move faster when employers take a proactive and supportive approach. What does that look like? Employers should:

Train employees on claims reporting

Employees skip reporting injuries for various reasons. For example, they may not know when to report, fear retribution for ‘causing trouble’, or worry about inconveniencing their employer. However, delaying or seeking out unauthorized treatment can ultimately worsen an injury.

Train your employees on how and when to report an injury. If you can’t be there, ensure they know how to take action without you. First aid training can empower employees who work in rural areas or travel to job sites. Solutions like a triage program allow them to access professional help, even if an authority figure isn’t on-site.

Investigate workplace incidents

Important details are freshest right after an incident happens. Report an incident within 24 hours and start gathering information as soon as possible. Did someone witness the incident? Was the incident caught on video? Take statements and gather any useful evidence.

Support injured workers

If you don’t provide support for an injured worker, then they’ll find someone else to do it. In many cases, this support takes the form of an attorney. Not only does this slow the claim process, but it also creates building resentment between the injured worker and their employer.

Check in regularly on injured workers. “When employees feel valued, they may be less likely to seek legal assistance, and that could definitely speed up the resolution of the claim.”

Another way to support injured workers and shorten the length of a claim is to set up a return to work program. This allows them to get back to work, either on modified duty or as volunteers, as soon as they’re physically able. Not only does it improve their mental health, but it also helps them stay conditioned for a work environment and demonstrates an employer’s commitment to getting them back on the job.

A responsive employer: The biggest impact on claim length

For Fox, the way an employer responds to a claim makes the biggest difference in its length and outcome. This involves three key responsibilities: clear communication, timely medical care, and a supportive approach to injured workers. “A well-handled claim benefits everyone – the injured worker, the employer – because it reduces the amount of money they pay out,” Fox shared. “And it also makes that employee feel as if their employer cares about their overall health.”

The post Claim Length: How Employers Can Improve Post-Incident Process appeared first on MEM.

Planning ahead for workplace incidents is an essential task for any business. Despite safety rules and risk reduction, getting injured on the job is still a possibility. Emotions run high in the immediate aftermath of an injury. Having a plan of care in place ahead of time for an injured worker is an invaluable resource.

Listen to this episode of the WorkSAFE Podcast, or read the show notes below.

The importance of directing medical care

Injuries aren’t just physical – they’re emotional. In the heat of the moment, it’s easy to choose the quickest and nearest kind of care. But this isn’t always the right solution. It may mean an unnecessary trip to the emergency room, or even downplaying an injury that needs more attention than it first received.

Having a plan of care in place has one major advantage for both employers and injured workers: better medical outcomes. Employers have the right to choose where employees get medical care in some states. In other states, they can only make recommendations. In either case, Barthel advises that employers have a conversation with injured workers about post-injury care.

“That gives that injured worker a feeling of confidence in the employer’s ability to manage that medical need in the best and most appropriate manner,” she explained. This chat assures employees of not just physical care, but emotional support and their value to the workplace.

A plan of care: Finding the right care providers

Before employers start making a plan of care, they should determine if they can direct care based on their state rules and regulations. Then, they should start by finding the right providers to add to their plan of care. This is done by looking at the different levels of care injured workers may need.

Lower level care

Many injured workers encounter injuries that don’t require calling 911. For example, back pain, lacerations, or shoulder injuries. A nurse triage program is a great option for early intervention, where experts provide guidance over the phone about where and how to seek the right care.

Outside of a nurse triage program, Barthel recommends selecting a clinic that has comprehensive services. For instance, after an incident, drug testing is often required. A clinic that offers both treatment and drug testing is a more useful addition to a plan of care than one that doesn’t.

Medium level care

If an injury requires more expertise, then the next step is finding a specialist. Most work comp providers, including MEM, participate in a comprehensive medical network. Using medical records and the injured worker’s needs as a guide, a representative then connects them with a care provider who can best meet their needs.

High level care

Some workplace incidents are more serious than others. For example, if an injured worker is unresponsive or too ill to speak, bleeds severely, or has broken or exposed bones. Injuries like these require immediate medical attention. In these situations, employers should never hesitate to call 911. A claims representative will help determine long-term care options, such as burn centers or rehabilitation facilities.

Second opinions

Part of a good plan of care is to ensure the injured worker gets the right and most specific care possible for their injury. However, in some cases, a second medical opinion may be needed or wanted. “We hope to avoid the need for second opinions,” she added. “But they do come up from time to time.” A claims representative will work with the policyholder to determine the best course of action.

Planning ahead for the best care

It’s easy for employees to write off small injuries, like strains or scratches. But even the smallest injuries can escalate into something more serious. Getting the right care as soon as possible helps reduce the risk of complications – and unnecessary costs.

“We know that the earliest opportunity to obtain expertise in most cases is the best thing you can do, and that way the injured worker knows how to manage the injury.”

• Establish if you can direct medical care. If you aren’t sure if you can direct care, Barthel recommends reaching out to your work comp carrier as soon as possible to establish this.
• Pick your providers. Start creating your plan of care. When an employee is injured, who do you want them to call? Where do you want them to go?
• Educate your employees. Ensure your team knows policies and process around reporting and injury and getting help.

“Here at MEM, we want you to prevent injuries. We want to come alongside with you and help you to do that,” Barthel finished. “But when an injury occurs, we also want to come alongside with you and help you to know what to do in that moment.”

The post A Plan of Care: Setting Up the Right Solutions for Injured Workers appeared first on MEM.

Recently, MEM talked with Claims Field Service Manager Terri Sweeten about the importance of witness statements after an injury happens. In her nearly 29 years with MEM, she’s seen what makes a witness statement so important. 

Why are they important?

Capturing information soon after an incident ensures all the information needed to process a claim is available. It can also help businesses identify potential hazards that need addressed. Documenting the information reduces the risk of missing or forgetting key details. As time passes between an incident and the report, – it’s easier to forget specifics. 

When people remember the past, they remember it with varying degrees of clarity according to a study published in the journal Psychological Science. 

That’s why having a witness statement immediately following an incident is so important.  

What makes a good witness statement? 

The purpose of a witness statement is to preserve the who, what, when, where, and how, Sweeten said. The more detailed the statement, the easier it will be to recall the facts when needed later. 

“It should be an unbiased account of what happened at the incident,” Sweeten said. “What we are looking for on that is to preserve the evidence in that unbiased viewpoint.” 

What information should be included besides the events witnessed? 

Witness statements should be collected in written form, because then they can be used in a court of law later. Another reason to have statements in writing is because witnesses may relocate. Include a phone number on the witness statement, an address and a signature. 

How are witness statements used? 

Sometimes it can take years before the statements are used, Sweeten said.  

“Sometimes we find that a person has moved or is no longer employed so  it becomes difficult to find them,” Sweeten said. “If they are a key witness in an incident, the employer really needs to get forwarding contact information.” 

Want to learn more about incident investigation? 

Check out our Eyes on the Scene webinar focusing on incident investigation. 

The post Preserving Memories in Real Time: The Importance of Witness Statements appeared first on MEM.

On this episode of the WorkSAFE Podcast, we sit down with Vickie Egan. She is the Case Management Services Supervisor at Missouri Employers Mutual. Egan has been with the company for six years and has more than 32 years of experience in the nursing field.

First, we’ll talk about two ways mental health plays a role in work comp claims. Then, we’ll explain how mental health issues are addressed and treated. Finally, we’ll discuss the growing role of mental health in the healthcare and return to work processes.

Listen to this episode of the WorkSAFE Podcast or read the show notes below.

Mental health claims: Physical vs. mental injury

When it comes to claims, every injured worker is unique. Their health history, workplace experience, and personal life all play a role in their mental health status. According to Egan, there are two ways mental health comes into play during a claim:

1. Physical injury claims. In these situations, a worker has a physical injury. Factors like their injury type and the length of their recovery period may impact their mental health. Treatment is part of the overall claim.
2. Mental injury claims. In these situations, a worker experiences mental issues from a workplace environment or experience. This is common for those who witness an incident or experience one without being physically injured.

Mental injuries often slip under the radar. For example, involvement in motor vehicle accidents can have a lingering impact, such as anxiety and trouble concentrating. “There’s a lot of post traumatic stress disorder (PTSD) that we see in those type of situations,” Egan explained. “That’s something that we need to treat. It doesn’t have to be a physical injury.”

Not every worker facing injury encounters mental health issues. For some, a workplace injury causes little mental impact. For others, it’s a tipping point.

What does the recovery process look like?

Recovering from a mental health issue is different for everyone. Unlike a physical injury – for example, a broken bone or sprained ankle – determining what is needed to heal is done on a case-by-case basis.

Nurse Case Managers (NCMs) watch closely for behavior or dialogue that may indicate a mental health claim is needed. For instance, changes in attitude, morale, or productivity at work. Employees may turn up late, call in sick more often, or act in unusual ways.

Sometimes employers are the first ones to catch and report these indicators. In other situations, medical providers may be the ones to raise concerns. “There’s a lot of information that can come from different sources,” Egan shared. First, NCMs engage with the worker. Then, they connect with the medical provider. What they learn determines the next step; the need for a psychologist, a psychiatrist, a counselor, or any combination of these.

Step-by-step treatment

After an initial evaluation, injured workers are often authorized to receive six treatment sessions. This allows a mental health professional to better assess their needs and create an updated care plan. If the injured worker needs more help, then more sessions are authorized.

For Egan, it’s important to help the provider understand the goal of returning to work. This includes explaining the demands of the job and potential accommodations for a mental injury.

“That’s kind of an interesting work status to have worked out,” she said. “Sometimes it does take some dialogue with both a policyholder and with the provider to try to get a work status that clarifies things and that people can follow, and  help that process of return to work go smoothly and successfully.”

Resistance to treatment

Not all injured workers dealing with mental health claims are accepting of treatment. The stigma around receiving mental health assistance exists. Although social media and accessibility to care has broken down some barriers, workers of certain ages or industries still resist.

For Egan, an employer’s priorities around mental health should be to educate, support, and encourage. Employees should know what mental health services are available to them. They should also know that these services have been put in place to support them, and that trying to receive help at least once is better than not trying at all. Although some may reject the idea at first, it is worth circling back to the topic – their attitude may change over time.

Mental health claims: Part of the healthcare process

Mental health is more integrated into the healthcare process than ever before. From an emergency room visit to a regular check-up, providers are asking more questions about lifestyle, safety, and emotional stability. “There’s those questions that are part of every assessment now,” Egan shared. “I don’t recall that being there in my many earlier years of working as a nurse, so it is in the forefront. It’s part of the process.”

Attitudes around mental health continue to evolve. Decades ago, admitting to a mental health issue was considered shameful. Now, assessing a patient’s state of mind is an active part of providing treatment. “We want to see it,” she added. Mental health issues no longer hide in the shadows. “We want to address it. We want to make that part of the care.”

Preparing to return to the workplace

Returning to the workplace looks different for every injured employee. They may need modified duty, adjusted work hours, or alternative work while they recover. The same approach applies to mental injury.

“It’s different for everybody,” Egan explained. “That’s where we have to really lean on on the professionals to help us through this.” MEM utilizes a partner to help identify source the right mental health providers. This extends to connecting them with injured workers in the best way, whether that be over the phone or in person. 

Taking a proactive approach to mental health on the job

Not every employer can afford an employee-based mental health program. But showing support, offering resources, and being attentive to employees’ well-being is a great way to start. Talking to work comp carriers about concerns and the resources they can provide is also a great way to stay informed. This way, employers have knowledge of what is available in the event of a mental health claim. For example, telehealth has opened the door to provider access – especially for those hesitant to visit an office.

Mental health matters

When it comes to work comp claims, we often think that clearing an injured worker for the job physically is the priority. However, being mentally fit to return to the workplace is essential. Employees must have good situational awareness and be attentive on the job. This not only help ensure their safety, but the safety of those working with them.

“It’s important to remember that work has such a significant impact on an individual,” Egan finished. “It’s how they define themselves. Many times, it is a big part of their life and it gives them purpose.” Experiencing a workplace injury, or even exposure to an incident, can take much of that away. Employees may experience depression, stress, anxiety, and PTSD as a result. “These are real diagnoses and these are things that we just can’t overlook anymore in the process of recovery.”

The post Mental Injury: How Mental Health Impacts Claims Management appeared first on MEM.

Watch below as Nurse Case Manager Becky Goodyear, shares the challenges employees and employers face and how our Nurse Case Managers can help.  

What is a catastrophic claim?

A catastrophic claim involves a severe injury that often requires multiple medical professionals working together to ensure the best outcome. They often also include extended Intensive Care Unit (ICU) stays. Examples of catastrophic injuries are: 

• Crush injuries 
• Multiple fractures 
• Internal injuries 
• Brain injuries

How we help 

Typically, a Nurse Case Manager meets with the injured worker and their family at either the hospital or in a rehab setting. During their meeting, they ensure the worker is receiving the care they need, along with helping them understand how their medical needs will be covered and how they will be compensated for their lost time from work.  

Events like these are traumatic and overwhelming. As registered nurses, our Nurse Case Managers are there to confirm all medical facilities are receiving the complete information needed for the best care. 

Our Difference

At Previsor, our Nurse Case Managers have more autonomy to approve treatment, equipment, and supplies for injured employees. Catastrophic claims receive their additional attention and guidance. This reduces delays in getting the injured worker is getting the care that they need. 

As our Nurse Case Managers work so closely with the injured workers, we build closer relationships with our policyholders to help earn their trust, giving them the confidence they deserve.   

The post Catastrophic Claims: We’re Here to Help  appeared first on MEM.

Watch below as Nurse Case Manager Rhonda Jones, shares how agents and employers can partner with MEM to ensure injured employees feel supported and cared for.  

Mental Health Injuries 

The World Health Organization estimates that 15% of working-age people have a mental health concern. When an employee is in an incident at work, these mental health concerns can intensify. 

Consider a driver who gets in a serious vehicle incident. What did the employee witness? How does that affect them? The driver may have mental health concerns that need to be addressed. 

How agents can help

Many policyholders aren’t familiar with mental health claims. It’s important to keep lines of communication open. Checking in with injured workers allows you to better understand their status. Often, employees with mental health claims can feel isolated or like a burden on their employer.  

How employers can help 

Employers can make a big impact by keeping an employee engaged and letting them know that they care. Employees need to feel supported and understand that the business wants to get them back to work, while also taking into consideration the overall health of the employee.   

Our Difference 

At MEM, our Nurse Case Managers are equipped to help employees who have a mental health component to their claim. Nurse Case Managers are trained to ask the right questions, assist in finding the right care, and authorize coverage of the care that is needed. They want to be that patient advocate that partners with the employee, employer, and agent to ensure the injured worker is properly cared for.  

The post Mental Health Claims: How You Can Help appeared first on MEM.

At Missouri Employers Mutual and Previsor Insurance, our goal is to help employees get the care they need while keeping costs in check. This means walking together with employers through a claim, every step of the way.  

Here are five people employers may encounter during a work comp claim – and their role in getting workers back on the job sooner. 

Claims Services Representative 

A Claims Services Representative is one of the first professionals an employer will encounter after an incident is reported. They will collect information, assess evidence and witness statements, and authorize payments where necessary. Claims Representatives are in contact with employers during the entire claims process.  

Field Service Manager 

A Field Services Manager (FSM) joins a claim when a Claims Services Representative needs more insight into the incident scene. An employer should collect as many details as they can in the hours and days following a workplace incident. An FSM visits a business to understand more about its operations, take pictures and videos, and talk to any witnesses.  

Their professional experience allows them to tap into additional sources of information, such as local surveillance cameras, that may help resolve the claim. Their insight can also lend a hand in cases of subrogation, where a third party bears some fault in causing an incident. 

Nurse Case Manager 

A Nurse Case Manager (NCM) is a medical professional who will guide the medical aspects of a claim. They coordinate appointments, track the recovery process, and communicate with members of the medical care team. Much of this work is done by telephone. However, depending on the type and severity of the claim, NCMs will join injured workers in-person.  

Primary Care Provider  

A primary care provider is a doctor who oversees an injured worker’s treatment. They will identify the injury type, make referrals for specialty care, and prescribe medication. Claims Services Representatives and Nurse Case Managers will regularly communicate with them during the recovery process. Their professional recommendation will determine when and in what capacity an injured worker can return to the job.  

Return to Work Coordinator 

Return to work coordinators assist injured workers and employers with solutions that accommodate recovery and allow for productivity. Returning to work can positively affect an employee’s morale and financial situation and reduce claims costs. Light duty provides opportunities to work on simpler and less strenuous tasks during recovery.  For example, working at a non-profit organization. 

The post Road to Recovery: 5 People Who Join You on Your Claims Journey appeared first on MEM.