Insights from the Field

Evidence-based medicine isn't just a buzzword — it's the foundation of defensible claims decisions. When an adjuster can point to clinical guidelines to justify a treatment denial or approval, everyone benefits: the injured worker gets appropriate care, and the employer avoids unnecessary costs. Are your teams trained to use EBM guidelines effectively?

Self-insured employers often underestimate the value of proactive clinical oversight. Waiting until a claim becomes complex is expensive. Early clinical intervention — even a single nurse case manager touchpoint in the first 30 days — can dramatically change the trajectory of a claim. The data is clear. The question is whether your program is set up to act on it.

A question I get asked often: 'How do we know if our workers' comp clinical program is actually working?' Start with these three metrics: (1) Average days to return to work by injury type. (2) Rate of claims escalating to litigation. (3) Percentage of claims with documented clinical review at 30/60/90 days. If you can't answer these, that's your starting point.

Brokers: your clients are asking harder questions about workers' comp clinical outcomes. 'We have a TPA' is no longer a sufficient answer. The brokers who will win in this market are the ones who can speak intelligently about clinical oversight, return-to-work programs, and evidence-based treatment guidelines. That's a differentiator worth investing in.