While the responsibility of managing a disability claim falls with the specialist it’s assigned to, other key players also contribute to the final outcome. Claim Specialists play the primary role in making the disability determination, but they rely on the expertise of clinical and vocational consultants to ensure their decision is as accurate and sound as possible.
Ideally, disability claims processing is a partnership between these three parties – the Claim Specialist, the Clinical Expert, and the Vocational Consultant – who all work together toward a common goal: to identify the most accurate decision on a claim.
For this partnership to work, each claims team member must possess a broad understanding of the claim decision-making process. At the same time, it’s also important for each to be clear on the specific expectations of their role and the relevant business goals that may come into play. Overall, these claims team partnerships function best when all members are committed to the success of each other on the team.
Claims team partnerships are a critical aspect of an efficient and accurate determination process. The more cohesive the team, the better the quality of the review and assessment of the claim, and ideally the claimant experience. To best position the team for success, disability insurers should have all roles and responsibilities identified up front, along with the process that brings all parties together to do their best work.
Top Factors for a Successful Claims Team Partnership
To start, documenting the expectations of each role is important to the disability claim evaluation process. Above all, they should be transparent and provide a line of sight to the departmental goals they must each meet. However, each role should be committed to the success of the others, with opportunities to offer feedback, coaching, and education to improve their effectiveness as part of the team.
While each role is specialized, they all take accountability for understanding the key components of the disability decision (contract, occupations, functional capacity), yet document opinions only within their areas of expertise and responsibility.
Role of the Disability Claims Specialist
The Disability Claim Specialist determines the claimant’s functional capacity and occupational demands to determine if the claimant meets the contractual definition of disability. This role is the main point of contact for the employer and claimant and is the decision-maker relative to the claimant’s eligibility for benefits under the employer’s plan.
Key Partnership Expectations
- Communicates all decisions to the claimant and employer
- Determines potential return-to-work (RTW) opportunities and initiates contact with employers to discuss job accommodations when appropriate
- Initiates and coordinates the activities of support resources such as the clinical and vocational consultants
- If necessary, reconnects with the clinical or vocational resources to reconcile any response that was unclear or did not answer the questions.
Role of the Clinical Partner
The role of the Clinical Partner includes both clinical support and education to assist the Claim Specialists in their file strategy, without managing the claim. They analyze information from multiple data points to understand the claimant’s level of functionality and related restrictions and limitations. They also identify the likelihood that the claimant will regain additional functional capacity as well as barriers that may impede the claimant’s progress. Ultimately the Clinical Partner recommends solutions to those barriers to appropriate resources and assists Claim Specialists and others in enhancing their own skills at identifying work capacity.
Key Partnership Expectations
- Documents a clear, concise, opinion that provides rationale for the opinion, analysis supporting the rationale and any recommended next steps
- Takes accountability for determining what information would be required currently or in the future to assess work capacity
- Educates the claims staff as appropriate to assist with their overall clinical knowledge and development
- Makes ample informal time available through open hours, walk-ins, or phone consultations
Role of the Vocational Partner
The essence of the Vocational Rehabilitation Consultant (VRC) role is to identify opportunities for the claimant to apply his or her identified functional capacity to work demands within the framework of the disability contract. A significant responsibility of the VRC is to educate Disability Specialists on basic occupational concepts, empowering them to independently determine the demands of common occupations. The VRC also coaches them on more straight-forward RTW support when there is not a need for formal VRC involvement.
Key Partnership Expectations
- At the time of completion of the Occupational Analysis, identifies any modifications or accommodations that would allow the claimant to perform his or her occupation/job with the stated restrictions and limitations.
- Retains accountability on claims that have a high likelihood of RTW to his or her prior occupation/job or any gainful occupation, including documentation and execution of an action plan and proactively engaging the claimant at appropriate intervals
- Creates and executes rehab plans that are realistic and have defined outcomes that are consistent with sound business judgement
- Coaches Disability Specialists on how to engage claimants in discussions around RTW, including how to assess the claimant’s motivation
Shared Roles for the Disability Claims Team
In addition to the distinct roles each claims team member plays, they also share responsibilities in claims processing. For example, all three areas are involved in planning and problem-solving when diagnosing gaps in the actual versus expected outcomes of the claim process. This commitment to coordinating and communicating about claim details also requires the free sharing and receiving of feedback about each member’s performance.
A Quality Assurance program is one means to measure the effectiveness of each team member’s behavior and role in the outcome of a claim. Going beyond the technical accuracy within each individual role, these programs relate the behaviors to expected claim outcomes (i.e., clarity of functional capacity, understanding of occupational demands, appropriate application to contractual provisions).
Supervisors of all three roles can also solicit formal performance-related feedback (from partners with whom their employees have had regular contact) at appropriate intervals.
Forming a strong claims team partnership is a key component of the disability determination process. Without the streamlined integration of these roles, a determination may not incorporate valuable expertise that can guide the decision toward the most accurate outcome. Setting clear roles and expectations are critical to creating the ideal partnership that can help a claims organization work most effectively. Contact a Brown & Brown Absence Services representative to learn how we can support your claims team in achieving this goal.
