Going Undercover: Why Leave Management Professionals Should Consider Secret Plan Shopping

Absence management experts spend countless hours designing best-in-class programs, plans, and processes. Although most absence claims are handled without issue, we often hear about the errors, misinformation, delayed turnaround times, and suspected fraud that slip beneath the radar. As such, it’s often difficult to verify if those errors are the exception or the rule. We need to be confident that our programs, plans, and processes are running as designed and meeting our standards of quality and service, especially when working with external administrators.

One of the best ways to assess whether partners are administering an absence program appropriately is through a full program and claim audit that reviews a statistically significant sample size or targets specific claims to pinpoint areas of concern. Audits randomly select claims and dissect each decision point to see if your partners pass or fail at each stage of this capability assessment. For example:

• Intake: Was intake successful? Was the claim set up accurately? Were case notes documented clearly?
• Claim decisions: Were decisions made in a timely, accurate manner and accompanied by phone calls when appropriate?
• Communications: Were appropriate communications sent to claimants and managers?
• Return to work: Were instructions for return to work clear? Did outreach for timely return to work occur on schedule with appropriate follow-up?

While audits help diagnose issues, they are detailed and therefore require additional time, budget, and external support. In some instances, the best place to begin — even before an audit is considered — is to go undercover and evaluate each component of your absence program and its administration through a secret shopper operation.

One important consideration is ensuring that designated secret shoppers understand and have sufficient knowledge about the plans to know if the information they are reviewing is compliant and accurate.

Another consideration is the appropriate cadence for your review. If you are performing the review internally, it may be optimal to evaluate a specific number of calls or claims each month to eliminate the burden of a more significant review. For example, analyzing five claims throughout the month is more manageable than reviewing 60 claims at one time. If you are outsourcing, then a one-time, larger scope is more reasonable.

There are limitless options related to secret shopping, but the focus should be on pain points for your organization. Consider actions that address five common areas of concern:

• Review customer service performance.
• Investigate task completion, turnaround times, and caseloads.
• Facilitate surveys.
• File absence requests.
• Dissect specific claims.

Setting specific goals and targets is also essential as you plan the review. Although claim review and audits are critical to success, they may not yield a direct return on investment. Remember, the goal is to ensure the program is on track and provides a positive experience for employees and stakeholders. It is unlikely you will discover financial “wins” that can decrease future issues, errors, and duplicative work, which would add indirect savings to the program.

Review Customer Service Performance

In most programs, intake teams and customer service staff are an employee’s first impression of an employer’s absence program, so customer service representatives (who are sometimes not very seasoned members of the team) must be well trained. Although training on your program is important, it is critical that staff knows where to find the right answers since some programs change daily. Unless you have a dedicated team, it is less about memorizing answers and more about verifying information quickly and accurately for customer service and intake resources.

The best way to ensure that employees receive accurate information is to call the service center and ask representatives the questions you expect your employees will ask. Not sure what those might be? Consider these frequently asked questions:

• Which programs will I be eligible for?
• Which programs run concurrently?
• How much will I get paid?
• What paperwork do I need to complete and when?
• What do I do when I’m ready to return to work?

As a secret shopper, call your leave administrator and ask questions about the program. Keep track of the individuals you speak with and their responses. Any errors should be escalated immediately so that professionals can get the education and training they need. Use your tracking document to assess and identify trends.

Investigate Task Completion, Turnaround Times, and Caseloads

In addition to phone reviews, investigate task completion, turnaround times, and caseloads. Obtaining this data may be difficult, depending on how your absence team is structured and how your internal or external system is programmed. But these details are important to plan performance. If service issues exist, they become critical data points to help you understand if errors are due to understaffing or if there’s a larger issue.

Caseloads vary considerably so they should not be reviewed in a vacuum. But tracking caseloads along with tasks and due dates can provide a complete picture of partner performance. Ideally, tasks should be completed on the day they are due. If vendor partners cannot provide reports, ask them how they monitor tasks internally — a critical component of staffing management that should be on their roadmap if it isn’t already available.

A checklist for those items should be set based on your plan and process. The following timelines should be considered:

• Intake to notifications
• Intake to eligibility decision
• Intake to case assignment
• Intake for outreach to employee, employer, and provider
• Certification information to decision
• Accurate letters/emails to employees
• Timeline for recertification follow-up
• Timeline for return-to-work follow-up

Facilitate Surveys

Another way to gain insight into how programs are working is to ask employees who have been out on leave about their experiences with the process. If you conduct a formal survey, start with basic questions about satisfaction and, when appropriate, dig deeper to understand what was challenging so you can enhance the process over time. If employees have negative feedback, ask to talk with them directly to understand the gaps in more detail.

If you prefer something less formal, ask them about their overall experience, understanding of the process, if communications are easy to understand, and if they felt supported throughout the absence. The more specific the employee is willing to be (ideally sharing specific letters that were confusing), the easier it will be to identify process improvements that may have been missed with a traditional review.

File Absence Requests

Perspective is everything when it comes to assessing programs and identifying areas for improvement. Since human resources (HR) professionals have a thorough understanding of the leave plans they might have helped create, their perspectives will be different from employees experiencing the process for the first time. Through a survey or claim inquiry, you can understand how employees feel about the process and their experiences.

Consider filing fake or “ghost” absence requests. Experts on your team can experience the leave process and apply critical review for how a case is handled. In many ways, this can be the best way to audit a program, even if it’s just a few claims!

If you don’t have any individuals within the HR department who have experienced claims, talk with your account management team about filing a fake or ghost absence request. The request should be treated just like regular claims. However, ensure it doesn’t trigger changes to your payroll file or checks to be initiated.

Dissect Specific Claims

Negative feedback can be the best trigger to investigate a claim from beginning to end. Performing a claim-specific audit can help the team understand what went wrong and pinpoint areas for training, process improvement, and better oversight. Cases with negative employee or supervisor feedback are usually complex, so expect them to be challenging and complicated. Set up a meeting to review the claim with your account team, which should be able to walk through the details related to claim processing, except medical information unless the organization is self-insured and privy to that information.

For example, if an employee contacts HR or the vendor expressing dissatisfaction, that should trigger a claim review that would look at procedural, plan, and process details. It would verify whether turnaround times were accurate, decisions were sound, tasks were set, and timelines were followed. All communications, including emails and letters, should also be reviewed for accuracy and clarity.

Going Undercover

Your undercover operations have an ongoing goal of creating a stronger, better program for HR, employees, and supervisors. As a result, it is rarely a one-and-done initiative. Consider secret shopping a small monthly task that includes making a few calls, asking a few questions, dissecting a few claims, and then tracking the data and monitoring it month after month instead of a major project tackled annually or every other year. This will show your internal and external partners that the initiative is part of your continuous quality improvement efforts. It should also solidify their desire to stand with you in that pursuit. Keeping continuous quality improvement within your leave programs will ensure greater accuracy. As mentioned earlier, setting smaller samples (five inquiries a month) may be easier to monitor than a full, detailed audit every other year.

As cases are reviewed, provide feedback to your vendor partners at the senior level and to the personnel who answer phones, respond to questions, and document decisions. Providing this feedback to everyone involved makes them feel like they are part of the solution.

If an undercover operation does not produce the intended change, it’s likely time to dig deeper into a full claims audit with an organization that specializes in absence management. A Harvard Business Review article provides a powerful example from a retailer that highlights the value of executives experiencing stores as customers do, and how that firsthand experience changed the operations of a big-box store in positive ways.¹ What will your secret or mystery shopping experience tell you?