In at the deep end

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As companies wake up to the benefits of rehabilitation, there are calls for front-line claims handlers to be given more training. However, Lynn Rouse warns, care must be taken to avoid them getting out of their depth

To date, the debate surrounding competence and qualification in the rehabilitation arena has centred on rehab providers and case managers. As members of a fledgling industry, the lack of benchmarks to judge their quality and cost-effectiveness is an understandable concern.

What about the training needs of front-line liability claims handlers within insurers? The top echelons of management may have bought into rehab but will its benefits be hampered if those on the front line cannot quickly identify appropriate cases to refer to providers? Surely the instruction of rehab experts will be subject to delay or unsuitability without a baseline of knowledge, awareness and understanding from claims handlers. As such, what are the fundamental training requirements and is there a danger of providing claims handlers with excessive knowledge?

Andrew Pemberton, director of Human Focus Return to Work, comments: "It is essential that claims handlers should have some knowledge and understanding - to what degree remains the contentious element of the debate."

Helen Merfield, chief executive of HCML, says she has been aware of the issue for some time: "It's hard for claims handlers if they don't receive training because it would be like asking a medical practitioner to handle a claim. Why should we expect them to automatically understand?

"Major training for all claims handlers is needed; it is not enough for claims handlers to simply be told from the top-down that 'we are going to do rehab'."

Ian Fulton, managing director of Proclaim Care, agrees. "Early identification of cases that are suitable for rehab is important and that means that some knowledge and training is essential. The difficulty lies, however, in the fact that insurers have different practices and levels of experience at the early stage."

So how in-depth and detailed should training be? "It's difficult to suggest a ready-made answer, especially when you consider the pressures of work and additional early case tasks that claims handlers have to conduct," Mr Fulton says.

Nick Patterson, managing director of Corpore, is also concerned that training claims handlers to take significant responsibility on the rehab front could over-burden them. "Claims handlers have many cases on the go, as well as heavy caseloads dealing with liability, causation and quantum. So if you are asking them to look at rehab on top of that, it's an additional burden that they will struggle to deal with."

Mr Fulton says that insurers are devising their own screening forms to assist those on the front line. These will simply identify suitable cases - without requiring in-depth knowledge - using a system of 'red flags' based on factors such as severity of injury and the likelihood of future work absence. "In the short term, these indicator forms identify claims as potential rehab cases that handlers can refer on for advice to determine their suitability."

Graham Dickinson, partner and head of catastrophic injury at Davies Lavery, agrees that the red flag route is proving popular. He points to four typical terms that insurers are using for this purpose - head injury, spinal injury, amputation and hospital in-patient status.

Level of intervention

Several commentators support this use of set protocols and red flags. "In a front-line rehab environment, referrals can be based on protocols, building in basic checks to ensure an automated process," says Mr Pemberton. For example, Human Focus devised a computer-aided telephone interview to guide claims handlers through the process and establish not only appropriate cases for rehab but also the level of intervention required.

Four scores result from the interview: a score of one indicates the person is happy with their progress and no intervention is needed; two indicates the case is light on rehab or physiotherapy; three signifies full rehab or physio; and four means a higher level of desktop review is required by a rehab practitioner or case manager who can analyse the answers and interpret them accurately.

"At this point, a case may be elevated to more thorough intervention - that's the beauty of the script," says Mr Pemberton, "it's low-cost, rapid and quickly conducted as part of the first notification procedure and the front-line members of staff can deliver it with modest training because it uses predominantly closed questions."

So far, a total of 700 cases have been put through this process. It is currently being trialled in the claimant solicitor environment, although Mr Pemberton reports he is in discussions with a large insurer to put it into practice with staff.

Dr Edmund Bonikowski, chief executive of Kynixa, is one commentator firmly opposed to the upskilling of claims handlers to the point where they "erroneously believe they are experts in rehab as well as claims management". He is not against introducing a basic level of awareness but is adamant that "there is no need for claims handlers to know everything - they just need to know how to ask the right questions".

"The essential issue is where the knowledge base should lie for running rehab as part of claims management, and insurance claims handlers and managers can get out of their depth." He says insurers must accept that, in rehab providers, they are buying expert services from a multi-disciplinary team stemming from years of broad-ranging experience.

He adds: "Let's not educate claims handlers about the intricacies of rehab but just about what these services can do. If you drive a car and the engine begins to smoke, all you need to know is where to find the shop that fixes engines, plus how long the repair is likely to take and delivery standards. That's where the industry needs to move to."

John Higgins, employers' liability claims manager at AIG Europe, would also like rehab decisions to remain in the hands of the experts. However, he is in a slightly different situation to most insurers as it can call on the resources of sister company AIG Medical and Rehabilitation.

"The issue of whose call it is to make should lie with the case manager - they have the specialist knowledge, not the insurance company," Mr Higgins says. "As the paying party, we need to be involved but if employees can't go back to work or achieve pre-accident levels, the case manager should proceed."

Philosophical drive

In Mr Dickinson's view, what is needed is a philosophical drive by insurers that makes spotting potential rehab cases more efficient. "This is a much better way of dealing with training needs than some one-hour mandatory course on what to look out for."

Ms Merfield may disagree with these sentiments - at least to a degree. HCML has devised a modular educational programme that it uses with insurer clients and has submitted it to the Chartered Insurance Institute for consideration in the hope the programme can be endorsed.

Ms Merfield believes it is important that front-line claims handlers understand some of the fundamentals of rehab, whatever their scope of responsibility may be on a day-to-day basis. For example, being able to differentiate between clinical case management and vocational rehab, as well as becoming aware of how bio-psychosocial factors can impact on effectiveness.

"Ideally, a module should be part of every liability claims handler's training, with input from experts, such as the case managers who deliver rehab and the practitioners. Training should also cover the different models, benefits and measurement of success."

Ms Merfield is worried that limiting the training of claims handlers to simple box-ticking exercises could be detrimental. "It does not empower people and we should be upskilling claims handlers, not deskilling them. It's important for them to understand what the reasons are behind using rehab and there is nothing more demoralising than ticking boxes and then failing to know the answer to questions that arise."

Bearing this in mind, what should training ideally incorporate? "All claims handlers would have a good level of knowledge about the more commonly found, serious types of injuries, as well as the normal clinical pathways a person would need in terms of recovery," says Mr Fulton. "A base level of knowledge would be great but we have to be realistic - rehab recommendations are only one of a number of tasks that claims handlers are faced with and have to perform."

"I am not sure that claims adjusters need to have in-depth technical knowledge - that's what you pay case managers for," adds Mr Higgins. "As long as they can recognise that a person may require rehab and know who they should refer the case to that ought to be sufficient."

So how are individual insurers dealing with the issue of rehab, the training needs of claims handlers and their level of authority?

David Lee, senior liability adjuster at Brit Insurance, explains his company has run a pilot for one year, working with independent provider Kynixa. As Brit outsources its claims, workshops have been run for its external adjusters covering not only the Brit philosophy, liability and quantum issues but also the role of rehab. Kynixa is invited to explain the services on offer, what works and what does not.

For its part, Highway has just concluded a three-year study, looking at more than 100 cases tracked from first intimation to settlement. Peter Gallagher, Highway's claims director, explains that the findings of this study have helped dictate the way training is approached. The result is a questionnaire that illicits where rehab is necessary and what type is appropriate - something he refers to as the 'magic phone call'.

"When claims handlers receive a case they obviously look at liability and the surrounding circumstances. However, they also specifically ask about rehab and follow the path provided."

So is this a 'red flag' script? "We try not to be too regimented or prescriptive as that can lead to not capturing sufficient information," he says. "The point is to illicit as much information as possible to consider suitability."

Matthew Scott, head of liability claims and professional services at Axa, uses the insurer's whiplash pilot - put in place with sister company Axa PPP Occupational Health - to illustrate the type of training given. Both teams visit each other's working environments to understand the context of the work carried out, workshops are run and crib sheets made available to help front-line claims handlers.

Speaking of the need to change the cultural mindset of the latter group, Mr Scott says: "Their background has been more adversarial and focused on investigating claims and establishing liability. So we need to get them into the reflex of asking about rehab; whether the client has considered it; whether it has been mentioned by other medical professionals; and having the capability to explain objectively what we can offer and respond to any challenges.

"However, what that shouldn't stray into is our people trying to become case managers themselves. We need to ensure there are boundaries to what claims handlers can decide and where their range of expertise should start and end. For example, if a solicitor questions what sort of rehab is appropriate for their client, that's where our nurse case managers or other experts step in."

Steve Maddock, claims technical director at Royal and Sun Alliance, explains that its new pilot, RSA Care, uses a blend of medical staff and claims handlers at the front line. "The insurance person makes the initial assessment with questions identifying whether a person has been injured or has ongoing symptoms.

"Every one of those cases will then be referred to a medical practitioner on the team to conduct a more detailed health assessment and they then direct the person to the most appropriate treatment. We do not want to create part-time, pseudo health professionals," he says.

Allianz Cornhill is currently working on selection criteria - based on injury, age and job type - with teams split into handling whiplash, mid-range and serious injuries.

Bob Rabbitts, technical claims manager at Allianz Cornhill, says: "For serious injuries and those in the mid-range, we are looking to develop case selection guidelines and hope to finalise these by the end of the half-year." He adds that the 50-strong team handling whiplash claims received training at the start of the year.

FoC courses

Should the Faculty of Claims and the CII be looking to devise an industry-wide basic qualification or training course on rehab for front-line claims handlers?

"We have a claims training manager, Damian Wonfor, and it is through him that we co-ordinate our training programmes," explains David Southwell, Zurich's personal injury claims manager. "We also have Bill Paton as our representative on the FoC board. I have highlighted this issue with him and he is going to raise it to determine whether there is an appetite within the market to develop something. There is clearly a case to have something on the syllabus, somewhere. However, to try and say what form that should take would mean going outside my sphere of expertise."

Asked whether this issue is already on the FoC's agenda, Fiona Andrews, faculty manager, says the board has identified liability claims handling and investigation as a priority and is hoping to develop a liability claims handling module in the next six months.

This would cover quantum/settlement arrangements as well as the investigation side, she explains. Furthermore, the FoC hopes to mirror the priorities identified with a programme of masterclasses, allowing for a dedicated session on rehab. "If the industry expresses a desire for a benchmark on rehab knowledge and skills, we will happily respond," Ms Andrews confirms.

Mr Rabbitts is in favour of this move: "It's important that we move towards a consistent approach amongst claims handlers."

In addition, Mr Maddock believes the appetite for such a course will grow as rehab becomes an integral part of insurers' propositions. "Whether that should be a stand-alone qualification or wrapped into modules, such as the ACII, is another question."

However, he offers a word of warning that reflects the concerns expressed by Dr Bonikowski and others: "We need to build awareness but in a responsible way - I am in no way advocating putting medical decisions into the hands of the unqualified."

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