TPA/Carrier Claims Culture Impacts Client Outcomes


It is widely understood that the performance of a TPA/carrier’s claims staff impacts the success of a workers’ compensation program. When evaluating if a claims staff is equipped to achieve top-notch performance, consider the culture in which they operate. A supportive, agile, and empathetic culture serves as a compass for claims employees and supports the delivery of outstanding service and results.

Culture can be tricky to assess. Ask a TPA/carrier the following questions to gain insight into their work environment:

  • Do you align claims’ complexity and caseloads with the expertise of your staff? Handling claims that are medical-only versus lost-time or medically complex requires different skill levels. What are their practices around designating team leaders and subject matter experts for technical guidance and direction on complex claims and unique scenarios? What are their pending and new assignment caseloads? Handling a reasonable number of claims helps the staff address the complexity of client special handling instructions, state rules and regulations and drives exceptional outcomes for injured workers.
  • Do claims professionals have clear advancement and development opportunities? Employees seek a culture that encourages growth, recognition, and empowerment. Organizations with this culture excel at talent development and retention that can create outstanding customer service experiences. Do they have robust learning, development, and designation programs? Is there adequate career pathing and promotional opportunities? What is their employee promotion rate?
  • What is your turnover rate for claims staff? Inquire about strategies for retaining staff and attracting new, talented claims professionals. A highly-engaged claims team culture can help optimize your claim outcomes and reduce your total cost of risk. High turnover rates can be a red flag indicating problems with morale, job satisfaction, and culture.
  • How do you leverage technology to operate more effectively? A culture that weighs down a claims staff with manual tasks is not built to last. Ask about how they use electronic data interchange and data analytics to drive efficiencies. Innovative programs and processes allow a claims staff to focus on solutions versus administrative tasks.

A successful culture makes claims professionals feel valued, impactful, and engaged, allowing them to thrive. Great TPAs/carriers foster this culture, and in turn, drive optimal results.

Originally published in Risk & Insurance magazine.

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Michael MacAulay, Senior Vice President, PMA Management Corp.

Mike is the Senior Vice President of Sales for PMA Management Corp., part of PMA Companies' TPA Operations.