Early Claim Intervention: The Key to a Healthy Claims Experience
Apr 12, 2018

Health care is one of the largest and fastest growing service sectors in our economy. Statistics show that hospitals are one the most dangerous places to work with incidence rates being nearly double the rate for private industry as a whole. In 2011, U.S. hospitals recorded 253,700 work-related injuries and illnesses, which compute to a rate of 6.8 work-related injuries and illnesses for every 100 full-time employees. 


Is working in healthcare inherently unhealthy?

While healthcare workers face a number of unique “dangers” in their job, such as exposure to blood-borne pathogens, diseases and hazardous materials, even the most commonplace type of workplace injury becomes unique in the healthcare environment. 

Combine a lifting injury with the challenge of repositioning a non-responsive or unruly patient, and the potential for serious injury increases.  And while most workplaces face slip and fall risk, compounding that same slip and fall with a biohazard exposure could create both physical and mental injuries, leading to even greater claim severity.

In hospital settings, slip and falls represent about half of all accident types, with exertion (lifting, pushing, or pulling) representing a quarter of healthcare employee accidents.  The sprains, strains, and tears from these common accidents are the most frequent natures of injury among all types of hospital workers.


Challenges that Confront Healthcare Administrators and Risk Managers.

With 47% of hospital workers aged 45 or older and with co-morbidities and barriers to post-injury recovery, those minor injuries became severe, resulting in 31 or greater days away from work.  With limited light-duty position availability, injured worker absence creates both a financial and administrative challenge. The director must backfill and move personnel to cover the absent employee’s shifts.

Thus, healthcare clients find common injury types which start off as simple no lost time claims, may later become complex, resulting in lost time, surgeries, litigation, or permanent disability. The resulting absence management component impacts morale and patient care quality.


The Benefits of an Early Claim Intervention program.

Early Claim Intervention is a post-injury claim management strategy which uses data to identify those claims with potential adverse development over the life of the claim.  Through analysis of data, claims are directed to a Resolution Manager. They are guided to resources to help mitigate the severity of a given claim, or even types of claims within a geographic region.

Examples of trigger elements in an early indicator program are:

  • Common injury types, such as sprain/strain injuries to backs, knees, shoulders, necks
  • Specific jurisdictions or reporting locations within the program with  high incident rates of severe or complex claims
  • Late reported claims or those with only a few days on the job, or other “red flag” identifiers.

In an Early Claim Intervention program, those claims meeting the established criteria for the program will be handled by an indemnity Resolution Manager, even if there is no exposure for indemnity at the time of assignment.  Early communication with the injured worker and investigation on these claims is key, even if there is no lost time or question of compensability. This early communication leads to greater confidence in the claims process and affects cooperation throughout.

In an analysis of 3 years of PA Workers Compensation claims for healthcare clients, we found that average incurred on Early Intervention Claims programs was $3,887, 27% below ODG Best Practice Guidelines*.  Closure rates were also more favorable on the Early Intervention claims.

PA WC Claims Data 2014-17

Average  Incurred


Early Intervention Claims Program



All Other



*ODG Best Practice Guidelines for Average Incurred (PA): $6,519

Additional resources, such as Telephonic Case Management could be leveraged early, mitigating claim severity by identifying complicating factors and proactively assigning qualified resources to lessen their impact. This is particularly helpful in spotting and addressing those co-morbidities which can delay recovery.  With early nurse intervention, like PC 365, we have seen promising cost and duration reductions:

Through data analysis, focused and early communication, prompt referral to specialists and helpful resources applied, Early Claim Intervention is ideal for the challenges facing our healthcare clients. 


Lisa Faith has over 25 years of industry experience. You can find her on Twitter and LinkedIn.


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