Too often adjusters will perform a background check, medical record sweep, or run an ISO sweep* early on in a file and then never do it again. Why not?
- * ISO is a service provider offering a variety of products on statistical, actuarial, underwriting, and claims information. Services include being able to check for potential fraudulent claims in a large database of electronically filed claim information from participating insurance companies and third party administrators
Some of these cases go on forever. Things change. People move. New circumstances arise. Lots of things can happen during the course of a year. If you have a long drawn out litigated case, and you ran one ISO a month in to the file and you did a criminal/medical record background check a few months in, you are not doing your job.
Did you complete a medical sweep, to include hospitals, diagnostic centers, and pharmacies? Did you re-file the ISO every 4-6 months to see if there are any new matches? On those ISO matches you did find, did you talk to anyone at that carrier to see if they will share file details with you?
If not, again you are not doing your job. That’s sad, because this part of the job is supposed to be the most interesting. This is where you really sink in to a claim, by doing the background work and discovering new information to help your defense.
Here are a few tips to think about:
1. Call each carrier on all ISO hits; you never know what you might find. I have seen ISO matches that say “strain” and then I found out the injury was a 2-level spinal fusion. This is because when the claim is setup and the initial ISO is run, a strain may be exactly that. But as we all know, a strain can morph into a monster surgical claim. This is especially true in auto accident cases. There may only be room in the injury description field to write “Arm/shoulder strain”, and not enough room for “Broken leg, shoulder contusion, neck strain, whiplash, and closed head injury.”
2. Try to talk with a manager or supervisor to see if they will give you info about the prior claim. If you just send a generic fax or email over asking about injury or claim details, it is going to get deleted. This is because the adjuster doesn’t have the time to help you defend your claim since they are busy with their own claims. But a supervisor or manager may take the time to help you, and glance through the file notes to see if you have any matching dirt on a pre-existing injury. If you cannot reach a manager, try to find a colleague or vendor marketer to help you get in touch with someone that can help you. If you are referred by a mutual party, your chances for success more than triple.
3. Go back about 10 years in your background search to find out where your claimant has lived. Maybe they have moved a few times, from MA to CT to MI to TX. Once you establish where they have lived, now you can do your medical sweeps around each location where this person lived, and not just where they are living now. If you come up with some positive matches on medical record sweeps, use the signed medical release you have the claimant sign as your way to get prior medical records. I do not recommend to limit medical releases to something very specific. If it were a shoulder injury, I would try to put “Arm, shoulder, neck” on the medical release because this could help you later on. The claimant probably won’t care, especially if you explain to them that current pain in the shoulder could stem from a number of things, and you want to make sure that you can obtain current medical treatment records later on when they start to treat for other “conditions or allegations”. As we all know, extremity pain can come from a number of places, so try not to limit yourself by being too specific.
4. If your file is in litigation, subpoena everything you can. Even if a prior claim or injuries seem like a long shot, you may strike gold in a random primary care doctor medical record. If so, you are going to look like a hero, especially if your claimant talked about “Bilateral knee pain of unknown origin” to their doctor 5 years ago.
5. Keep sweeping every 4-6 months, and try different vendors to get a fresh set of eyes. Each adjuster has their favorite vendor for doing medical sweeps, and maybe you work at a carrier/TPA that has SIU services like these in-house. If this is the case, sweep often. If you are striking out, try a different vendor. They may have a different technique or have different database access than your vendor.
6. Update your ISO often. Each carrier may have different reporting standards, so don’t quit at just one search at the start of your claim. Plus, I highly doubt your claimant will tell you if they were in an auto accident a month prior to their alleged work injury. Or perhaps they were in what seemed like a fender bender while your claim is currently going on. They are not going to report it to you for fear of their claim being denied, so keep sweeping.
Remember your job is to continue to verify that ongoing disability is fully related to this alleged work injury. Just doing a sweep and then giving up is not doing your job. Everyone out there has a history, and the job of an adjuster is to dig up as much of that history as possible. You will not get fantastic results all of the time, but it a great feeling when you discover something that will change the course of the file because of not giving up and continuing to investigate.
Author Michael B. Stack, CPA, Principal, 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: [email protected].
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