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. We can learn something from how they administer the claims. I was lucky enough to tour their facility several months ago, and came away with a much greater understanding of how claims should be handled.
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 three steps.
Having a proper reserving, medical management services and litigation management system in place can help your company keep workers' compensation costs at a minimum.
Reserving Proper case reserving is an essential part of proper claim handling. To meet their clients' expectations of high-quality service, implements timely reserves and accurately projects the probable ultimate cost of the claim and a clear rationale is documented to support the reserve.
Initial reserves are:
1. Established within 72 hours of receipt of the claim.
2. Based on information obtained during the initial investigation.
3. Follow all internal authority guidelines.
Subsequent reserves:
1. Continually reviewed by the claim examiner and team manager for appropriateness.
2. Adjustment to the reserves is completed within 30 days when a significant event occurs.
3. Follow all internal authority guidelines.
Reserve Documentation The two components of case reserving are reserve rationale and reserve calculation and are effectively documented in the electronic claim notes for both initial and subsequent reserves. 1. Reserve rationale is explained on all lost time/claim examiner files. A reserve worksheet, when required, is completed within 30 days of assignment. 2. Reserve worksheet is not required on medical-only claims.
Medical Management Services A team approach is utilized to control loss dollars by expediting a successful return to work, using available resources to mitigate inappropriate and excessive medical expenses. The claims examiner and the medical management team work in tandem to achieve this goal, although each has distinct responsibilities. Utilizing an array of medical management services as a tool benefits the employee and helps reduce claim costs for their — and your — clients.
Services Available 1. Preferred provider network 2. Medical bill review 3. Utilization management 4. Case management 5. Telephonic case management 6. Field case management 7. Medical Department/physician review services
Litigation Management The goal is to employ a multifaceted litigation management program designed to minimize legal costs. The claims examiner is primarily responsible for active case management of litigated files. Litigation management involves initial contact and subsequent interaction with defense counsel. The claims examiner makes referrals to defense counsel outlining the issues, relationship of named parties, and recommendations for handling.
Claims Examiner's Primary Responsibilities for Case Management of Litigated Files
1. Use of law firms selected by the client/carrier to defend appropriate cases.
2. Instructing the defense attorney to acknowledge the receipt of the referral letter within five business days of receipt or sooner depending on the urgency of the filing deadline.
3. Reaching agreement with defense counsel on all assigned tasks.
4. Considering timely, proactive case resolution strategy when appropriate.
5. Developing discovery strategies and budget with defense counsel.
6. Use of alternative dispute resolution, settlement days, special pending case procedures/settlement, committees, mediation, structured settlements, and batching sessions with attorneys. (workersxzcompxzkit)
7. Direct negotiation with injured worker's attorney.
8. Active participation in decisions made regarding motions, discovery, evaluations, etc.
9. Making timely, realistic offers of settlement in coordination with defense counsel.
10. Instructing defense counsel to follow all instructions in the Litigation Management Guidelines.
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 Click here: http://www.workerscompkit.com/gallagher/podcast/Fraudulent_Workers_Compensation_Claims/index.php
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WC Books: http://www.reduceyourworkerscomp.com/workers-comp-books-manuals.php
TD Calculator: www.ReduceYourWorkersComp.com/transitional-duty-cost-calculator.php
WC Calculator: http://www.reduceyourworkerscomp.com/calculator.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. ©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact [email protected]
