Language of Workers’ Compensation Part One: Understanding Key Stakeholders
An employee is injured on the job. She experiences a sharp shooting pain while lifting a large container from the warehouse shelf.
For the HR department at the company, this employee is now more than a member of the team, she’s an injured worker. For the insurance carrier, she’s a claimant; for the orthopedic surgeon, she’s a patient; for the lawyer, she’s a client; for her family, she’s Mom, wife, sister, cousin, a friend in need of the best recovery and support team.
Each stakeholder comes from a different perspective, has different motivations and uses different language to talk about the injured worker and their injury. A physician, for example, is going to use technical, medical terms that an insured or an adjuster won’t know. An adjuster is going to use insurance terms that the provider might not know.
This is where cases get tricky: stakeholders don’t always understand the driving motivation(s) of other stakeholders. To make things more complicated, each person uses his or her own industry dialect to describe a process already full of acronyms, abbreviations and terms. When messages get lost in translation, mistakes happen, cases get delayed, resources are wasted and all parties suffer.
Here at Viscardi, we’re passionate about simplifying and humanizing the workers’ compensation process. That starts with getting all of us—regardless of where you sit within the process—on the same page.
As part of our Language of Workers’ Compensation series, we’ll be doing just that. In Part One, we’re outlining each stakeholder’s motivations. Knowing WHY each group is interested in the injured worker and his or her injury is critical to creating a collaborative, efficient process and getting the injured worker back to work ASAP (which we’re known for here at Viscardi).
Here’s a brief rundown on the main players in an injured worker case:
Employer: The organization that employed the injured worker at the time of the sustained injury. No employer wants an employee injured on the job. Once an employee is injured, however, the employer wants the claim to resolve as quickly as possible with minimal complications. Also known as the Insured.
Self-Insured Employer: In cases where an employer is self-insured—i.e. the employer shoulders the financial risk for all workplace injury claims—they are known as a self-insured employer.
CFO: The individual at an organization responsible for directing all monetary functions. An important part of this work includes analyzing and managing risk. As a result, the CFO may oftentimes play a central role in the obtainment and execution of a workers’ compensation policy.
Risk Manager: The individual at an employer charged with identifying and managing the risks that a company faces or will face as a part of their operations. A risk manager’s responsibilities in workers’ compensation are varied—from assessing and implementing workplace safety measures to ensuring the claims reporting and handling processes are effectively implemented and optimized for the specific needs of their organization.
Claimant: Also known as the Injured Worker or Employee. The claimant is the central person within a workers’ compensation case. All the stakeholders listed here are focused on doing their part to get the claimant proper care and back to work quickly and safely.
Provider: A doctor or other medical specialist responsible for treating the injured worker. Depending on the severity of the injury, an injured worker might see multiple providers over the course of their treatment. The provider is interested in treating the injured worker within their specialty and ultimately, seeing the injured worker return to full health or reaching Maximum Medical Improvement (MMI).
Nurse Case Manager: Responsible for coordinating an injured worker’s medical care, guiding the injured worker to recovery and ensuring that each stakeholder is accurately informed of an injured worker’s medical status and estimated treatment trajectory.
Claimant Attorney: Assists the injured worker with filing and litigating workers’ compensation claims. The injured worker’s attorney advocates for the injured worker in an attempt to recover compensation for their injuries, in the form of medical or indemnity payments. Also known as Claimant Counsel or Injured Worker Counsel.
Defendant Attorney: Works with the carrier or self-insured employer to settle claims that can’t be resolved through the normal adjustment process. Defendant attorneys want to help carriers defend workers’ compensation claims and minimize exposure to loss. Also known as Defense Attorney, Carrier Counsel or Carrier Attorney.
Carrier: The company that guarantees payment to an employer when a loss occurs as the result of a workers’ compensation claim. The carrier wants to make sure that claims are processed in an efficient and straightforward manner so that costs remain predictable and insureds remain happy. Also known as Insurance Company or Insurance Carrier.
Adjuster: Primary point of contact at the insurance carrier for any workers’ compensation claim. Their main interests are ensuring a claim is appropriately filed, handled as effectively as possible and funding is accurately reserved to support potential medical and indemnity payments. Also known as Claim Handler, Claim Manager, Claim Owner, Resolution Manager.
Third Party Administrator (TPA): An organization that administers insurance claims for a carrier or self-insured employer. When the services of a TPA are utilized, the carrier or self-insured employer still underwrite the risk but outsource the administration of claim processing to a TPA. As a result, a TPA’s interests are similar to those of a carrier: straightforward and efficient claims handling and high insured satisfaction.
Workers’ Compensation Board: A state agency that processes and monitors the administration of all workers’ compensation claims. The Workers’ Compensation Board also provides administrative and judicial services to aid in the resolution of disputes that come about as a result of claims made. Also known as Division of Workers’ Compensation or Workers’ Compensation Division.
Insurance Broker: A representative of an employer (the insurance buyer) that provides guidance on insurance options and acts as intermediary between the carrier and the employer. The insurance broker seeks out and negotiates insurance on behalf of the employer. Brokers want to make sure the employer’s risk is placed appropriately, for the most competitive price and with the highest level of service in claims processing.
Insurance Agent: Different than an insurance broker, an insurance agent acts as a representative of an insurance carrier. The insurance agent’s responsibility is to sell insurance on behalf of one or more carriers. Similar to an insurance broker, an insurance agent is primarily interested in obtaining optimal coverage for an employer’s risk at the most competitive price.