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Underwriting and Claims

Telephone as Case Management Tool

It Isn’t Just for Texting Anymore

Telephone-long


In an era where communications are dominated by instant messages, emoticons and disposable images and videos, telephone conversations might seem passé. The art of having a proper phone conversation appears to have been lost to the convenience and speed of e-mails and text messages.

Over the past decade, technologies such as e-mail, text messaging and social media have ushered in a new era of communication for most workers – particularly those under 40 – redefining standards of etiquette and introducing new tensions between generations. A 2014 Gallup poll confirmed a truth that has become self-evident: Text messages now outrank phone calls as the dominant form of communication among Gen X and millennials. Texting is the dominant form of communication for Americans under 50.

According to communications consultant Mary Jane Copps, aka the Phone Lady, some employees are simply not ready for this ‘new’ reality called “talking”:

“Business still happens on the phone, and when I deal with graduating students, they might want to get into [an industry such as] financial services, and they suddenly realize they have to talk to clients on the phone and they are not prepared. This is terrifying for them, since many of them have never spoken on the phone, and if they have, it’s only to their mom.”

But the lack of phone skills isn’t merely a generational failing, Copps adds. Many professionals have been relying on e-mail as their primary communication tool for years, leaving their phone and interpersonal communication skills rusty. This can be a problem, especially in insurance claims.

Despite the survey results and trends, a real conversation conducted over the telephone remains an important tool, if not the most important, for a disability case manager.

Every disability case manager knows that:

  • Disability management must be proactive rather than reactive.
  • Close communication and cooperation among all stakeholders are essential.
  • A holistic, de-medicalized approach is favorable, and identifying and addressing biopsychosocial factors (BPS) and non-medical barriers early with the insured are essential to increasing the chance of a healthy, successful return to work in the shortest possible time.

By conducting an initial telephone interview with an insured, the case manager can obtain valuable information not always contained in the file and submitted written evidence, such as:

  • The context in which the disability occurred
  • The non-medical, BPS factors
  • The insured’s perception of his/her condition and treatment
  • The insured’s motivation towards an eventual return to work
  • The insured’s expectations and perceptions regarding his/her own disability and abilities

This information becomes even more critical when the insured has a mental health condition or one that is subjective in nature (e.g., chronic pain, fibromyalgia, post-concussion syndrome, or post-traumatic stress disorder).

In theory, this practice seems well established in the industry. In a recent RGA survey, when asked “when a comprehensive interview was conducted on behavioral health claims,” 94% of the companies interviewed indicated performing the interview before claim approval. The breakdown between Canada and U.S. is as follows:

CANADA (n=5) US (n=13)
Before claim approval 100% (5) 92% (12)
After claim approval 40% (2) 61% (8)
Other 0% 23% (3)

Training and/or Measurement issues?

Unfortunately, the practice doesn’t always follow the theory. RGA has observed in claim reviews over the years that the quality of the phone summary content is often lacking. In many instances, the information gathered is not detailed enough or is superficial, while the real issues remain unaddressed.

Although they are done in a timely manner, the initial telephone interview is often a mere formality, either to satisfy the need of the company’s internal QA process, or because of an apparent lack of training in or a case manager’s unease with conducting a thorough telephone interview.

To remedy this, RGA proposes the following ... 

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Training

Companies should emphasize the importance of the telephone as an information-gathering tool and dedicate a significant portion of their staff training module to it. The telephone training module should contain the following:

  • Why telephone interviews and when to do them
  • How to prepare for a telephone interview
    • Knowing what the file tells us
    • What the forms don’t tell us
    • What the case manager should know/find out
  • During the conversation with the insured
    • The importance of building rapport with the insured
    • What active listening is and why it’s important
    • Useful questions and questions to avoid
    • How to use open-ended and closed questions to gain insight into the insured’s motivation, his or her medical, non-medical and BSP factors, and RTW barriers and possibilities
    • How to probe to gather additional information – asking those sensitive questions
    • How to manage a call – the duration and direction
    • How to properly use a template as a guide
    • How to deal with a difficult insured
  • Closing the conversation
    • How to assess it objectively
    • How to take notes and summarize a phone interview

Measurement

If the focus is on completing the telephone interview for the sake of satisfying an internal claims QA (the ‘checklist’ approach), the quality will suffer. We have observed case managers receiving an internal audit score of 100% for the telephone interview category simply because they had used the company template, even though the interviews were conducted without any consideration for the quality of the information gathered, such as whether or not it met the needs of the files, or added substance to the management of the case. Assessing the quality of the interview can be a difficult task when calls are not recorded and the review relies strictly on the telephone summary in the file, hence the importance of a good training program.

A good QA program should focus on the quality of the phone calls, and to do this, they should be recorded.

New training methods

In recent years, RGA has developed a series of guidelines, e-modules and interactive games to adapt to the new claims training reality. Our latest e-module covers telephone interviews, from the importance of file preparation and active listening, to different types of questions case managers can use and what the different BPS factors are. The e-module ends with a telephone interview simulation where the player decides the questions he or she needs to ask the insured.

Communication technologies have given us so many gifts that make both our professional and personal lives more efficient, but they can never replace the power of a real conversation with another human.


RGA Group Insurance Insight is published by the Group Reinsurance Teams of RGA Reinsurance. This publication’s mission is to provide news and information to group insurance professionals and to support the group insurance market. The information contained in the articles represents the opinion of the authors and does not necessarily imply or represent the position of the editors or RGA Reinsurance Company. Articles are not intended to provide legal, consulting or any other form of advice. Any legal or other questions you have regarding your business should be referred to your attorney or other appropriate advisor.

Copyright ©2016 RGA Reinsurance Company. All rights reserved. No portion of this publication may be reproduced without permission from the publisher.

The Author

  • Charles Déragon
    Director, North American Claims
    U.S. Group Re
    Send email > 

Summary

A real conversation conducted over the telephone remains an important tool, if not the most important, for a disability case manager. RGA has observed in claim reviews over the years that the quality of the phone summary content is often lacking. This article offers several remedies. 

  • Attending Physician Statement
  • asymmetric
  • large case group underwriting
  • anti-selection
  • antiselection
  • Group Life
  • group re
  • tele-underwriting