Case manager whistle blower says workers deserve better  

Anonymous Claims Adviser

“I would hate for an injured worker to hear how they’re spoken about in the office,” a NSW claims adviser tells Return to Work Matters.

Ed: Earlier this year, Return to Work Matters was contacted by an anonymous source who said they worked in the NSW workers’ compensation system. We’ve since spoken with this person over the phone twice and received written material from them, combining our conversations with the written document to produce the article below. As a small, not-for-profit organisation, Return to Work Matters lacks the resources to independently verify that this person works where they say they do, whilst also respecting their desire for anonymity. However, we have no reason to doubt the genuine nature of the opinions and observations offered below. If you want to take the article with a grain of salt, you’re welcome, however, we formed the impression that we were speaking with someone who wanted to be fair and do the right thing: a genuine, balanced and well-intentioned whistle blower.

The quest for “outcomes” drives case management practice

I manage a book of tail claims, about 75 to 80 claims on average. All of the injured workers I look after have at least 21% whole person impairment (WPI). Some are physical claims, some are psychological. Some of the claims have been on the books for more than twenty years. With these claims, it’s just about maintenance and monitoring costs, making sure we’re not spending too much. Other claims are high priority, we’re trying to generate outcomes that save the business money.

The biggest driver of my activities overall is cost control and “outcomes”. Outcomes are things that generate payments for the company - things like moving someone into retirement or upgrading their capacity, for example when a worker goes from being certified as being totally unfit for work to having a capacity to work suitable duties, or when they return to pre-injury duties. Work capacity decisions are a big priority.

Outcomes drive everything: no matter how small or big, we are pushed for outcomes. They can be as small as a ½ hour upgrade in capacity, to declining major surgery, to making a work capacity decision on someone that does not even have a job but has some capacity to work.

Fortnightly we have a select five to ten claims that we are to review with our leadership triangle, made up of a leader, a technical advisor and an injury management adviser. In this review we identify outcome goals and set activities and timelines to reach these goals.

The worker has no idea of what the goal is. The treating practitioner has no idea, it’s all decided in-house.

Once we’ve decided on a goal and strategy, we push pretty hard to get that outcome. In-house, there is support for the claims adviser throughout. Your supervisors really try and get in behind you and try and help you achieve those goals. If they’re not met, there are team meetings to look at different strategies – where can we work extra hard to achieve the goals. Throughout our whole book of claims we’re told to target the ones that we can get outcomes on quicker than others. Ones where you can gain work capacity decisions, ones where we think they have capacity and they’re not showing it, we have a collaborative approach to get the upgrade, or work capacity decisions.

However, it still puts extra added pressure on the claims adviser. I take it very personally. I try and make a connection with the workers and try and help them when I can, but sometimes the approach taken doesn’t take into account them as a person, as an individual.

Outcome goals are sometimes set in-house, without stakeholder buy-in. This can cause friction later.

With the injured worker, the doctor, the claims adviser, it can become a real dog fight – they’re saying no we want this, but the claims adviser has been asked to achieve something different.

I understand that, from a business point of view, my employer is there to make money, but sometimes the human approach gets lost in that.

If I do not reach a certain base line of reaching these targets continuously this will in turn cost me my job. Reaching my targets at any cost to the worker is a must and is expected. To reach these outcomes we are to look at all different ways and workers are treated as guilty until proven otherwise.

Outcomes drive revenue and more outcomes deliver more contracts. The people (injured workers) become just claims to drive more outcomes.

KPIs place pressure on case managers

To meet my monthly KPIs, I must make two-way contact with each worker in my claim portfolio, as well as their employer if the worker still has an employer that wants updates. I have monthly targets to reach in respect of number of upgrades, work capacity decisions, medical case conferences, claim closures and outcomes achieved. Not reaching targets continuously can jeopardise my employment or bonus chances. If I don’t meet targets, I also run the risk of getting put on a performance plan.

We have set activities that we need to complete each day. If we fail to complete something on the designated day, it’s known as a breached activity. There’s an expectation that we don’t have any breached activities.

For example, I’m expected to make a minimum 15-20 outbound calls per day and keep up with all the admin work related to my claims. Personally, my first priority is ensuring my workers are paid when they should be. I have to manually process all make-up wages paid by the insurer and answer any questions from the payment team. That accounts for about 25% of my working day.

Incoming mail takes up another 25% of my time.  Day to day management of my claims is a constant revolving door of contacting all parties involved: the worker, employer, lawyers, rehab providers, doctors, hospitals, physiotherapist, psychologist, psychiatrist and all treating professionals, whoever is relevant to that claim. I deal with huge amounts of incoming mail (things like medical certificates, treatment requests, follow up information, clinical notes, reports and invoices) take case notes, approve and decline treatment requests and make referrals to rehab or other programs.

Then I call my workers. Again, it’s about 25% of my day, maybe a little more, just touching base, answering questions and always thinking about the outcomes I’m meant to achieve, for instance whether the worker has given even a small sign that they have some capacity to work.

The rest of the day is spent doing whatever else needs to be done, including completing any remaining activities due that day. Regular training often takes an hour out of the day too.

The pressure is intense. It gives you sleepless nights. I’ll wake up at 3am and all I can think about is my workload. I’ll be thinking, I should have done this or that. It stresses you out. They’re not physically standing over you but you can feel the pressure from the leaders because it’s on them too.  The pressure rolls downhill. I see it all across teams, but the pressures put on us claims advisers is the worst because we’re at the bottom. I’ve seen psychological claims from claims advisers that can’t deal with the pressure.

I have worked in a lot of pressure and deadline driven jobs that deal with the safety of people and property, but I have never felt the pressure from above management like this job.

Responsibility for treatment decisions intensifies the stress

It is a claims advisor’s role to gather all the required information to make decisions. This includes working with rehab providers to gain evidence of capacity and labour market analysis to prove that a job deemed suitable is possible even if it’s not necessarily available. As claims advisors, we are trained and guided to use rehab, treating professionals and independent medical examiner reports as tools to seek upgrades / outcomes and as evidence for declining requested treatment.

All decisions that are made on a claim carry the name of the claim’s advisor (first name only), even though in reality the decisions are often made by people higher up the organisational chain. I have no medical training or work injury rehabilitation degree but my name is given as the decision maker on all outcome decisions including surgery requests, medical treatment requests, work capacity decisions, all declines and approvals no matter the nature.

If you have a claimant that has had a lot of treatment declined, it makes it a hard sell to build respect and trust as their claim’s advisor. As the claim’s advisor, all decisions, good or bad, we must explain that decision to the worker as if we had made it. So when you’re talking to this person on the other end of the phone, you’re trying to build rapport but you’re in control of their life, their treatment, their income. It’s too much.

Sometimes, I’ll talk to people that are in tears because they’ve been told they need a surgery, but we’ve declined it. That’s a tough conversation to have.

During my time in the claim’s advisor role, I have seen a massive turn over in people. From the workers we serve to the business we work for, the role is very demanding in all areas: physically, mentally and emotionally. By the end of the week, you are both physically and mentally drained to the point of exhaustion.

Attitudes to injured workers are toxic

The overall business culture is particularly good where I am based, but the attitude towards the workers we represent is toxic. The language used to talk about people that we never meet, only speak to via phone calls or email is downright disrespectful.

When you’re in the office, people share stories. No names are used, no privacy is breached but the talk is really negative. Injured workers are lazy, they’re liars, they expect everything. The portrayals of the customers that get thrown around the room, I would hate for any of these injured workers to hear how they’re spoken about in the office culture. You wouldn’t believe it unless you hear it.

I have seen firsthand that some workers are very disrespectful and think they are entitled to everything. But it has never been taught throughout any of the training given to us claims advisers that these people are suffering loss and grieving. We are not trained in mental health. As far as mental health training, all we get is how to talk to someone who is suicidal.

In my role I must be friend, doctor, counsellor, doctor, specialist, lawyer, family councillor and claims advisor all in one. I deal with people with all levels of anger, depression, addiction, suicidal thoughts, family break ups and stressors. All because of a workplace injury.

We are taught that we must build rapport and show empathy but must not make it personal. We are taught that it comes down to customer service. We’re also taught that we must work towards outcomes as they lead to the business making money.

Does this stuff affect the recovery of injured workers? In my view, yes it does.