from Claims Pros' 2025 Survey Responses
Industry Perspectives from the Front Line
To stay informed about the industry’s top concerns and priorities, Healthesystems conducts the Annual Workers’ Compensation Industry Insights Survey. In 2025, 515 industry stakeholders responded to the survey. Eight percent of those responses came from claims adjusters employed by insurance carriers, employers, and TPAs.
Looking through the lens of claims professionals, some survey results differ in interesting ways from the aggregated data and provide front-line perspective on everyday challenges and current trends.
Over 68% of claims professionals said that complex/high-dollar claims are a major challenge, as compared to slightly less than 51% of participants overall – a difference of more than 17 points. Factors that can turn a routine claim into a complex one, such as comorbidities, mental health conditions, high-cost therapies, and communication gaps have become more common in workers’ comp and can make it harder for claims professionals to identify risks and manage medical care appropriately and cost effectively.
Which challenges facing the workers’ comp industry most concern you today?
Claims Adjusters More Concerned About Complex Claims
Complex/high-dollar claims
68%
Poor worker health/comorbidities/social determinants of health
Workers' comp litigation
Mental health conditions and coverage
Healthcare provider/ service shortages
Employment of predictive models to identify claims where overutilization of therapies or services is likely, guiding intervention earlier in the claim
Engagement programs that help influence injured workers’ behaviors and attitudes toward their care and the workers’ comp process
Low-touch or no-touch automated solutions to reduce burden on overtaxed claims adjusters for faster identification, escalation of, and attention to complex problems
Comorbidities Biggest Barrier to Recovery
Claims professionals cited comorbidities as the biggest barrier to recovery at a rate of 72%, as compared to 62% of general survey participants. Comorbidities can complicate injured worker recovery and send a claim off track, making it important to consider these conditions in medical management, even when they are not directly related to the compensable injury.
Data collection and aggregation capabilities that combine transactional data with unstructured data to create a more holistic view of injured worker health and well-being
Leveraging AI in the clinical review process to help clinicians quickly uncover insights in the medical record that inform therapeutic recommendations, such as a comorbid diagnosis
72%
say comorbidities are biggest recovery barrier
2
3
Opioid Control Still Important Pharmacy Goal
Opioid and substance abuse prevention was the top pharmacy program goal overall, but with only 47% of survey participants selecting it, as opposed to over 61% of claims professionals. This higher level of concern is understandable from the claims professionals who were on the front lines of the opioid crisis in workers’ comp, and it serves as an important reminder that opioids are still prescribed to injured workers and vigilance in managing them is still warranted.
66%
66%
66%
53%
47%
Medical/pharmacy price inflation
What are the goals for your workers’ compensation pharmacy management program in the next 2-3 years?
Opioid and substance abuse control/prevention
Decrease usage of high-priced private label topicals
Reduce physician and third party dispensing of drugs
61%
42%
39%
What are the top priorities for your workers’ comp medical management program?
Manage individual patient chronic conditions/comorbidities
Solutions to support front-line claims decisions and efficiency
Increase use of in-network providers
60%
57%
43%
Solutions to Support Front-Line Claims Decisions Near Top for Medical Program Priorities
Although claims professionals ranked comorbidities as the top medical program priority, solutions to support front-line claims decisions was a close second at 57%. Solutions to support front-line claims decisions was ranked #1 by survey participants overall, but with a slightly lower 55%. This indicates broad alignment across the stakeholders implementing such solutions, and those using them.
4
Healthesystems Works with and for Claims Professionals
Claims professionals are great assets to workers' compensation organizations, and their perspectives - both from experienced professionals and those new to the industry - can provide valuable insights to inform effective payer strategies. Healthesystems works directly with claims professionals to design solutions that work for them and support their objective of facilitating effective and affordable care for injured workers.
1
Example Strategies to Help:
Example Strategies to Help:
Employment of predictive models to identify claims where overutilization of therapies or services is likely, guiding intervention earlier in the claim
Engagement programs that help influence injured workers’ behaviors and attitudes toward their care and the workers’ comp process
Low-touch or no-touch automated solutions to reduce burden on overtaxed claims adjusters for faster identification, escalation of, and attention to complex problems
Example Strategies to Help:
Employment of predictive models to identify claims where overutilization of therapies or services is likely, guiding intervention earlier in the claim
Engagement programs that help influence injured workers’ behaviors and attitudes toward their care and the workers’ comp process
Low-touch or no-touch automated solutions to reduce burden on overtaxed claims adjusters for faster identification, escalation of, and attention to complex problems
Example Strategies to Help:
Consultative, data-driven prescription trends reporting to guide program strategies
Clinical expertise and knowledge operationalized within automated rules, edits, and workflow decision support to guide therapeutic decisions and avoid unnecessary issues and escalation
Targeted provider intervention, including outreach and education, based on prescribing behavior
Example Strategies to Help:
Direct injured worker outreach & engagement based on predetermined risk criteria, including but not limited to, controlled substance use
5 Key Highlights
Mental Health Conditions Might Be Most Concerning Comorbidity of All
The 77% of claims professionals who were most concerned about mental health conditions is considerably higher than the 59% of general survey participants who shared this concern. Claims professionals at insurance carriers (84%) and TPAs (80%) indicated even higher levels of concern about mental health conditions. Historically there has been reluctance to add psychosocial services to a claim, but when mental health concerns go undetected or untreated, health outcomes can be worse and downstream costs are often higher.
5
Employment of predictive models to identify claims where overutilization of therapies or services is likely, guiding intervention earlier in the claim
Engagement programs that help influence injured workers’ behaviors and attitudes toward their care and the workers’ comp process
Low-touch or no-touch automated solutions to reduce burden on overtaxed claims adjusters for faster identification, escalation of, and attention to complex problems
Example Strategies to Help:
Embed clinical guidance, where and when it's needed through the claims process workflow
Automate routing and escalation to save valuable time
Connect to multiple medical services from a single platform for easy referrals
Example Strategies to Help:
Allow monitoring of claims activity in real time for current and accurate information
Facilitate communication through digital patient engagement solutions
Connectivity and workflows that make it easier for claims professionals to make referrals to specialty service providers that may benefit the injured worker or claim.
Example Strategies to Help:
77%
say mental health conditions are the most concerning claim complexity
For more information about How Healthesystems technology helps claims professionals, please visit:
Technology Built for a Better Claims Experience - Healthesystems
Regular touchpoints with injured workers, including digital communications like texting and mobile apps, can provide opportunities to identify warning signs of mental health concerns.
Access to reliable data and relevant information from the injured worker’s medical record, along with expert clinical decision support, can provide guidance on appropriate action.
Early screening: Mental health conditions that develop after an injury usually arise during the first six months. Administering confidential screening questionnaires to at-risk patients can help identify injured workers who might benefit from a referral to a mental health service provider.
