How to Make Handling a Medical Only Claim Interesting

The handling of medical-only workers’ compensation claims may seem routine or even mundane. Let’s look beyond the surface to see there’s more than meets the eye. Many of the questions considered in evaluating a claim for compensability apply whether the claim is a medical- only or involves indemnity payment. The first step in handling either type of claim involves determining whether there is coverage. So, take a look at the policy dates and be sure the injury date falls within the coverage period.

Also confirm the claimant works for the named insured on the policy and he or she is covered. Owners or officers of a company may have opted out and employees “hired” from a temporary agency may be covered under the agency, not you’re named insured.

Review the first report of injury and be aware of “red flags” including — Monday morning injuries (may really have occurred over the weekend), un-witnessed accidents, injuries reported late or after termination, injuries reported just as seasonal work is ending or injuries occurring in an area where the employee would not normally be expected to work. This is just a partial list of things to consider, even when reviewing medical-only claims.

Scrutinize the medical bill(s) and read the explanations next to the boxes on the Health Care Financing Administration (HCFA) form. The bill tells you whether the charges stem from an auto accident, employment or another accident.

You can also verify the employee’s date of birth and social security number to be certain you have the correct bill. The bill also indicates if this is an initial visit for the current complaints. If it’s not the initial visit, it’s an indicator to pursue other medical records possibly providing an accident history inconsistent with the reported injury, thus warranting additional investigation.

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.

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