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The Warning Signs: When Complex Claims Need a New Direction

WorkCompWire
Full article on: workcompwire.com

By Elizabeth Ulloa Lowry, Senior Vice President of Risk Solutions at Paradigm

Every claims professional knows those claims. The ones that seem to grow more complex each week. The ones where care and cost keep expanding, the treatment plan lacks clear direction, or the injured worker’s recovery simply isn’t progressing as expected.

Eventually, these claims reach a point where the path forward becomes less clear. And the longer that uncertainty lasts, the riskier these cases become—financially and for the long-term well-being of the injured worker.

A claims team’s first thought might be, “What else can we do?” But sometimes the answer isn’t more care, but rather a clearer understanding of what’s preventing recovery and what specifically needs to change.

When to reevaluate the recovery strategy
Highly complex claims often come with warning signs that deserve attention before rising costs become the focus of the next claim review. Common indicators include:

Delayed or prolonged recoveries

Unexpected complications

Chronic wounds and infection concerns

Comorbid medical/psychosocial barriers

Long-term care planning or coordination needs

Escalating medical costs

Uncertain recovery trajectories

Poorly integrated or suboptimal treatment plans

Any one of these issues can complicate recovery, but they’re often interconnected, creating a web of cause-and-effect barriers that can be difficult to untangle. This is the time to step back and reevaluate whether the right care, expertise, and goals are in place to address the core underlying issues and get recovery back on track.

What changes the trajectory
Some claims need a reset. Not to revisit every decision, but to take a comprehensive look at the whole person, not just the latest problem. A meaningful reassessment should:

  • Be led by a multidisciplinary care team with expertise in the diagnoses, alongside experience addressing complex recovery challenges.
  • Identify the real barriers to recovery, whether medical or psychosocial or both, and develop a treatment plan centered on resolving them.
  • Align the care team around measurable goals, ensuring everyone understands the desired outcomes and how progress will be evaluated.
  • Map out clear next steps, identifying which interventions should continue, which should change, and where additional support is needed.
  • Anticipate and plan for long-term care needs and coordinate the resources, services, and support required to keep recovery on track.
  • Continuously monitor progress and adjust the recovery strategy when outcomes aren’t aligning with expectations.

Case study: What a new perspective can uncover
Recently, a client came to us with a claim involving a traumatic brain injury (TBI). Seven months after the injury, the injured worker had made limited progress toward independence and remained reliant on others for daily care. She had experienced repeated hospitalizations and transitions between care settings, while complications (including infection risk, skin breakdown, and aspiration concerns) continued to threaten her recovery. There was no coordinated long-term strategy for where she could safely receive care, and there was uncertainty around both her recovery and future costs.

The Paradigm team stepped back to look at the whole picture. A specialized medical director and behavioral health specialist reassessed her needs across care settings, focusing on two priorities: stabilizing the medical issues most likely to send her back to the hospital and determining the least restrictive setting that could safely support her long-term needs.

The result was a shift from fragmented care to a coordinated long-term strategy, giving the injured worker greater stability while reducing the risk of repeated hospitalizations, unnecessary medical utilization, and escalating costs.

Don’t wait for complexity to compound
Not every difficult claim needs more treatment, and not every unstable recovery needs a brand-new approach. But when progress stops matching expectations, bringing together the right expertise can change the entire trajectory for the patient and the case.

About Elizabeth Ulloa Lowry
Elizabeth Ulloa Lowry is Senior Vice President of Risk Solutions at Paradigm, leading operations and strategy as the product owner of catastrophic care management. Before joining Paradigm, she spent 11 years in leadership for a workers’ compensation TPA, overseeing a regional claims and managed care operation. Earlier in her career, Elizabeth served as Chief of Staff at the University of New Orleans and has maintained her connection to higher education as an adjunct faculty member at Tulane University’s Freeman School of Business, where she teaches Brand Management. She brings over 20 years of leadership and client management experience and is completing her PhD in Business at Florida Atlantic University. She has held a board position at LASIE for self-insurance and served as an Ambassador for the Alliance of Women in Workers’ Compensation.