It is difficult to tell at the start of a claim if it will be easy or difficult. Sometimes what seems like the most mundane claim turns out to be the biggest disaster, and the claim that looks like it has the most baggage turns out to be the easiest.
Plan of Action Report Helps Direct Where Claim Is Heading
Regardless of what initial thoughts are, one of the most important factors early on in a claim is the initial plan of action report. This report gives initial thoughts on the claim, and where the adjuster thinks the claim will be headed based on the information they know at that time, which is usually 14-30 days after receipt and assignment of the actual injury report.
Initial plan of action reports should indicate that the adjuster has conducted a thorough review of all available claim information, has identified current or known issues that need to be resolved, and has determined what steps need to be taken to steer the claim to the next plan of action update. This update could take place another 30, 45, or 60 days down the road.
Initial plan of action report should include:
- Investigation of the claim to determine compensability
- Strategy to manage medical treatment, return to work issues, and potential permanent disability if applicable
- Issues such as subrogation, excess carrier reporting, legal issues, state form filings, etc.
- Key points should be clearly stated in bullet format using stated verifiable facts that are already documented within the claim notes.
- Adjuster’s thought processes for the key points in the plan of action should be evident. These thoughts should be free from expression of opinion or negative comments. Those points can be pointed out in a discussion/summary/opinion paragraph at the end of the report.
- The Official Disability Guidelines (ODG) should be mentioned based on the known severity of the injury. Use of ODG guidelines towards maximum medical improvement (MMI) allows you to outline the appropriate steps and actions that need to be completed to being the claim to eventual closure/resolution.
Subsequent plan of action reports should touch upon a thorough review of all previous and new information while at the same time addressing impact of the overall claim strategies mentioned in the initial report.
Detailed file strategies should include the following steps that outline the plan of action, including:
- Goals that will lead to ultimate outcome of the claim based upon known risk drivers such as age, location, claimant attitude and compliance, injury type and severity, comorbidities, etc.
- The actual steps that the adjuster needs to complete to achieve the stated goals of the claim
- A timeline for completion of the actions needed to complete the claim goals.
Of course this is just a template to follow. At any given day an adjuster may stumble upon new evidence that can change the actions and goals of the plan they have for the file. That doesn’t mean that another in-depth report needs to be completed. If this were the case, an adjuster would spend all day just updating reports. Rather all new information and outcomes can be addressed at the next plan of action report. Older claims usually have reporting updated a few times per year, only being updated before then if something monumental occurs such as positive SIU results, Independent Medical Exam releases to full duty, new litigation, and the like.
Also remember that the use of Official Disability Guidelines is not something that is set in stone. These guidelines are used as a template of sorts, to give an adjuster ballpark estimates and return to work ideas either in a light duty or full duty capacity– especially after a surgical procedure. That is why it is important to keep updating the plan of action on the file at key points during the life of a claim. These are usually updated more regularly early on in a claim, and less often as the claim goes on.
Summary
The use of a detailed initial plan of action report is very important to a claim. This is where the adjuster lays out the key facts, outlines what they are going to do next, and how use of those stated actions brings the claim to eventual probable outcome. These reports are a necessity to keep a claim on track and moving forward.
Failure to complete the initial plan of action report on a claim leads to errors, leakage, and missed opportunities. Many carriers use a reporting template, and claims management maintains strict reporting compliance on their adjusters so that failure is not an option.
Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.
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