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What quality claims handling should be – working proactively to create the best possible outcomes for people


Claims management is the quintessential people business. It is people working with people during what can be their darkest hour after an unexpected event occurs. It is a time often fraught with uncertainty and fear. Sedgwick employs more claims professionals in the U.S. than any other company to provide assistance in these very real and complex situations.

When a work-related injury occurs, we are guided by state statutes and employers' desire to offer resources that will restore and return much-needed labor to the workplace as quickly and as safely as possible. They partner with third party administrators to ensure this is done in an appropriate time frame, at a reasonable cost, and in accordance with regulations.

In April of this year, Sedgwick launched Performance 360, a new approach to quality that takes the assessment of claims management performance far beyond measuring retrospective behaviors.

With Performance 360, Sedgwick is looking to change the industry. We are redefining quality, taking traditional industry standards to the next level by shifting the focus from a primarily compliance-based process to a more outcomes-focused approach and, at the same time, moving from retrospective review to a real-time lifecycle auditing process, taking place while the claim is active.

The established industry standard for compliance auditing centers on reviewing claims handling retrospectively to ensure the right actions were taken, leading to a pervasive "check the box" mentality. But in the fast-paced claims process, to be able to effectively impact outcomes, and use data to improve current claim files, auditors should evaluate the work as closely as possible to when it is performed. Performance 360 features a continuous review cycle with audits scheduled earlier in the claims lifecycle – a fresh approach that will maximize opportunities to improve results for all parties.

By continuously evaluating what we do and how we do it, we are refocusing our performance metrics and empowering claims professionals to make a meaningful impact on the claims they handle. With modifications in our compliance activities and increased focus on ultimate claim outcomes, we will improve the overall experience for our clients and their employees.

We invite you to join the conversation on this important issue.

David A. North, President and CEO

  • Kim Witmer

    Nice article!

  • Brian Stewart, Dpt

    Mr. North,
    I would really be interested in understanding the metrics you are using to determine "quality" providers and how you are using these metrics to guide the decisions, particularly referrals to providers, by your adjusters and claims team? Our company has been tracking outcomes information for years on measures such as avg. visits, duration in treatment, time between DOI and start in our facilities and maybe most importantly the co-morbidities of our patients and how those factors impact our visits and duration in treatment. We're now working with small local TPA's to determine how ARC is impacting the true outcomes for individuals- What % of the claimants we touched, return to work and what was the avg. cost of the entire claim (Medical + Indeminity) of the claims we're involved in. I would love to discuss this with you at some point.

    Brian Stewart, DPT
    CMAO- ARC PT +

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