View from The Helm

Recovery Roadblock Ahead — How Claims Analysts Can Help Find the Right Detours

Recovery Roadblock Ahead — How Claims Analysts Can Help Find the Right Detours

I think we can all agree that adequate medical treatment affects the prognosis of any disabling illness or injury. But what if we learn the claimant (customer) is experiencing a “roadblock” to following through on the treatment plan? What is the claims analyst’s role in ensuring the claimant is able to follow the prescribed treatment plan? And how can our involvement impact the outcome of the claim?

The Road to Recovery

Health care providers make treatment recommendations designed to improve their patient’s well-being and quality of life. As disability claims analysts, we follow up with our claimant on the outcome of the recommended treatment plan and whether it affects the ability to return to work.

During telephone interviews, claims analysts ask about recent medical treatment, any limitations a claimant may feel are preventing them from returning to work, and what the prescribed treatment plan is going forward. However, in my opinion, there’s another question that should follow: Is there any reason you might be unable to follow the recommendations made by your health care provider? Finding the Right Detours

I believe that claims analysts can assist on the road to recovery by ensuring the claimant has discussed any potential barriers with their doctor upfront. If barriers exist, the doctor can then identify an alternative treatment plan to follow for successful recovery.

Below are some common roadblocks that can arise for claimants and examples of follow up questions the claims analyst can ask to help find the right detours for successful outcomes:

Barrier #1: The cost of a prescribed medication is unaffordable for the claimant.

This is arguably the most common barrier that claimants share with claims analysts.

Have they looked into prescription drug discount cards through their doctor or pharmacist? Did they discuss generic alternatives with their doctor? Is their doctor aware that they have not begun taking the medication or couldn’t continue taking the medication due to cost?

 **These questions can often provide options a claimant was not aware of and prevent a gap in their treatment plan.**

Barrier #2: The claimant was referred for physical therapy but cannot afford the cost associated with the frequency of these visits (often 1 time per week for several weeks, if not months).

Have they attended any physical therapy sessions? Did they discuss the cost concern with the physical rehabilitation center? Can the physical therapist develop a plan that can be carried out at home after an initial evaluation with instruction? Home exercise therapy is becoming more common and this can be an option the claimant was not aware existed.

Barrier #3: The claimant reports they have lost their health insurance and can no longer afford to follow up with their doctor.

Have they contacted their doctor to discuss whether they offer sliding scale payments based on income? Recommend that the claimant looks into community health centers near them  to establish medical care at a reduced rate.

Barrier #4: The claimant explains they are unable to drive and therefore cannot attend appointments with their doctor.

Do they have a family member or friend that could take them to appointments with advance notice? Is there medical transportation in their area and have they looked into whether they qualify?

Barrier #5: The claimant has been referred to a specialist for evaluation (e.g., Neurology, Pulmonology), but they live in a rural area and the office is too far for them to travel to.

Does their local hospital contract with this type of specialist and could they be seen there? Is van medical transportation available that would allow for disabled seating?

These are just examples of follow up questions the claims analyst can ask when a claimant reports a barrier to their medical treatment. The claims analyst should always be aware of the medical treatment plan and prognosis for improvement because this shapes the way we follow up on each claim. By identifying roadblocks, we can help the claimant find the right detours to continue with their prescribed treatment plan.