TPA Best Practices for Intial, Ongoing Contacts and Investigation of Workers Compensation Claims

Nothing Succeeds Like Success – Or, Let’s Not Reinvent the Wheel

A leading international third-party administrator for large self-insured organizations, provides workers’ compensation, auto and general liability claims management, medical management, integrated disability management and risk and safety consulting.

Part of this multi-national company’s success stems from having a document listing the company’s own best practices regarding workers’ compensation procedures. The claims staff divides their procedures into fourteen discrete areas. Let’s look at these two steps.

Quality Contacts

A three-point contact system results in establishing and maintaining effective communication with all key parties to the claim in order to facilitate investigation, claim control and explanation of benefits.

Initial Contacts – Indemnity Claims

1. The claims examiner will verbally contact the injured worker or attorney, if represented, the employer and the treating physician by the end of the next business day following receipt of the loss to the TPA.
2. When unable to reach a claimant within one business day, a letter will be sent asking the claimant to call.
3. The claims examiner should make at least two attempts to contact the applicable parties within five-business day following receipt of the loss to the TPA. A letter will be sent if unable to reach the parties.
4. If contact cannot be achieved due to circumstances beyond the control of the claims examiner, the claim file should be appropriately documented.

Ongoing Contacts – Indemnity Claims

1. Ongoing contacts with the employer, the injured worker and the medical provider should be performed through the life of the file.
2. All contact efforts should be detailed in the claim notes.
3. The claims examiner should vary calling times to increase the chance of a successful contact.
4. Significant changes in the claimant’s condition should be documented in the claim notes.
5. If claimant is off work or on transitional duty, contact should be maintained, at maximum, every 30 days by the claims examiner and/or medical case manager.

Initial Contact – Medical Only

1. The medical claim analyst verbally contacts the employer by the end of the next business day following receipt of the loss report.
2. The medical claim analyst sends letters to the employee and medical provider by the end of the next business day following receipt of the loss report.
3. On transitional duty claims with lost wages or a reduction in hours worked, three-point contact is verbal for all three contacts areas.

Investigation

Prompt, thorough investigation provides the framework for timely analysis of coverage, compensability decision, effective claim management, pursuit of cost containment opportunities, and the timely issuance of claim benefits.

1. The scope of the investigation considers type of accident, complexity of injury, and compensability issues. Investigation applies to all claims other than those designated as medical-only claims through the assignment process.
2. Initial investigation is completed within 14 calendar days of receipt of the loss report. This TPA utilizes a proprietary claim advantage system, an evidence-based decision tree software tool, to support investigation and prioritize claims. The claim-handling process continues to re-evaluate the exposure as the case progresses and allows for the development of a goal-centered strategic plan of action.
3. Identification and investigation of potential subrogation or second-injury fund maximizes recovery potential and reduces client/carrier loss cost. All claims with potential subrogation are handled by a claims examiner who teams with ‘s licensed subrogation partner to evaluate and pursue recovery opportunities. (workersxzcompxzkit)

The TPA, as a matter of sound business practice, and in recognition of its public policy obligations, has a duty to identify and resist all fraudulent claims. When the evidence supports withholding benefits, such claims are promptly rejected and aggressively defended; when the evidence is inconclusive, the claim is promptly adjusted.

Author Robert Elliott, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, health care, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He can be contacted at: [email protected] or 860-553-6604.

Podcast/Webcast: How To Prevent Fraudulent Workers’ Compensation Claims
http://www.workerscompkit.com/gallagher/podcast/Fraudulent_Workers_Compensation_Claims/index.php

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers’ comp issues.

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