Poor Documentation Makes Claims Handling 100x More Difficult

File notes and goals are becoming extinct.


Realistically, the only way to move a file along is to set up goals and a timeline on when to reach them. Every adjuster hates this part of file handling about as much as they hate forecasting reserving for the life of a file, but similar to reserves it has to be done. Nobody said it was going to be a fun job!


Turnover is commonplace at Carrier/TPAs. So if you are a new adjuster to a desk, and you inherit 150 files (probably 250 but who is counting) the only way to really sink in to them is to first review the adjuster file notes. What if this prior adjuster was less than stellar at updating file notes?




Poor Documentation Makes Claims Handling 100x More Difficult


If this is the case, your job just got 100x more difficult. Everyone is guilty of poor documentation at some point, but there is a way around it. This would be the claim summary, the 60-day report, or whatever your carrier calls their “Claim review/goals/to-do list.”


This captioned report contains a history, an outlook, a to-do list, and a timeframe of when to get these goals done. This helps the supervisor when reviewing the file and it helps the adjuster to keep moving the file forward. But to be successful, you have to focus on certain areas. I have listed some of these areas below. If you are not implementing them already, you have to start now. It is going to make your life a lot easier.


The injury description and compensability decision—This is where you summarize what happened, why you accepted/denied the file, and the pertinent info on the claimant. This also includes claimant age, height, weight, pre-existing medical conditions, comorbidities, date of injury, hire date, job title, and so on.


Injury/treatment to date and what lies ahead—What treatment has been performed to date, and what will be coming in the future. This could be future surgery exposure, DME needs, physical therapy, RX usage, injections, diagnostics, nurse case management, attendant care, referrals to specialists, etc.


Issues and concerns or barriers to recovery—This is where you list the pre-existing medical conditions or comorbidities and how they relate/affect the injury. Examples include diabetes, smoking, body weight, prior surgeries, permanent restrictions that could affect the injured worker from returning to their regular job, etc. You can also include likelihood to return to work with light duty or regular duty, claimant attitude, and anything else you can think of that could negatively impact the file.


Litigation—Potential for litigation based on claim denial, or status of current ongoing litigation and what your plans are for the defense of the case. You should also include names and contact info of Defense/Plaintiff Counsel, the Judge or Magistrate, and vocational impacts if any.


Subrogation—In this field you should discuss if subrogation was ruled out and why. If you are going to pursue subrogation against a third party you need to outline who their carrier is, the response you have had to date, and the overall chances of success to recovery.


SIU/Surveillance—If you need these services in the future you should outline the plan of implementation. If you have already attempted SIU this is where you discuss the results and if you plan to order further SIU/surveillance later on in the file with target dates. You should also discuss results and the impact it has on the file defense. Also list the vendor name, contact info, and the dollar cost to date.


Long-term RX and medical treatment exposure—For those cases with long term exposure, you need to outline future monthly RX costs, the types of medications being used, if generics are implemented, are you using a Pharmacy vendor, and any other medical treatment needs in the future. This should also include future revision surgeries or more invasive procedures that could come in to play in the future affecting the overall direction of the file and the barriers they could play in file resolution.


Strategy for resolution with target dates—This will be your to-do list, and the dates you plan on having these tasks completed. This could be an IME, vocational evaluation, adding a nurse case manager, getting a MSA forecast, having a mediation performed on the file, etc. Include the month you want to have these completed by and what you predict the outcomes to be.


Reserves—Here you discuss current reserves for indemnity, medical, and expense and if you need to raise the current amounts to cover future exposure and why.


Medicare issues—In those cases with CMS issues, you need to document if you have identified the claimant HICN ID, if CMS has been notified, and the barriers you have to redemption with CMS being involved. Also included would be actual predicted MSA amounts or an MSA estimate from a vendor included in the file. Also if any vendors have been used be sure to list their contact information.


Simple use of an outline such as above will make your handling of the file a lot easier. This is because you are laying out the history, current status, and future plans in one document that you can easily modify in the future when the file comes up for review/discussion again. Doing this will not only help you the adjuster, but also your manager, and also if the file gets transferred to another adjuster they can hit the ground running right where you left off.


Failing to use an outline in the handling of the file can lead to missed opportunities, missed exposure, missed recovery, and overall poor file handling. This will negatively impact all parties involved in the file, the biggest being your insured account that you are trying to protect.



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: mstack@reduceyourworkerscomp.com.


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