Employers Must Physically Review Workers Compensation Claim Files

Physical review of claim files open and closed, is necessary to reveal the quality of file handling in the past and present. Select new claims as well as old; I prefer review of new claims so there is a greater opportunity to have an impact on the outcome of the claim. When a physician reviewer and experienced claim representative review files they will determine whether medical care is well coordinated and of good quality, whether strategies for claim closure have been developed and followed, and whether time out of work is proportionate to the degree of disability. Overlap of other disability policy payments must be ferreted out as well. In general, the reviewer should assess whether file handling is proactive or reactive, and whether it is properly focused on rapid claim closure. Of less importance, but also important is whether medical bills are reviewed for duplication and fee schedule compliance. Leave a file review with a detailed plan of action for each claim. Assign responsibility and completion date for each follow-up item.

 

Although telephone reviews
 and online review are fine occasionally, in between physical file reviews, because they are less expensive and faster to set up (no logistics of travel), and they allow review of files that are handled overseas, they do have allow the face to face contact to develop a rapport with the adjusters and supervisors who are responsible for your files. Physical review of the files is an educational opportunity for you to learn about the services your claims administrator offers.

 

 

The one party missing most often in a claim review is the MD (medical doctor). When discussing a medical injury and medical treatment, the best person to have to address the validity of the injury, the length of time out of work and therapy, is an MD, yet this is done rarely except by those companies which have medical advisors on staff. The MD will also review whether nurse case management (NCM) has been used timely and has been effective. I find that NCM is often used too late or too early and that protocol for use of NCM has not been integrated with the companies post injury procedures. There are plenty of well-qualified and available MDs who can participate in your claim reviews to read the medical portion of the file.  A doctor that is well-versed in the insurance industry is important also.

 

 

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