This was the slogan of an old associate I had way back in the day. I have mentioned it here in this blog many times, in many capacities. “To trust but verify the truth” is what claims adjusting is all about. We take the word of the injured worker, but at the same time verify on our own the “extent” of disability. At times we are shocked. Other times not.
Verification of a work comp claim has many tentacles of which to explore: Verification of witness statements, of medical records, of causal relation, of wage records, of injury details, and so on. Even further is verification of activities outside of work using surveillance, or verification of the injured worker’s status as a Resident of the USA.
Even a simple work comp claim has a lot of details of which to verify. So in general terms, let us think about a few of the many tasks the adjuster has to verify during a claim:
Verify injury details
This is obvious. The worker will claim what happened, and how they were injured. The adjuster then makes that first phone call to the employer, in order to verify the injury details. This is where it all begins. Did the worker accurately recall what happened? Was the worker performing normal job duties at time of injury?
Verify injured worker information
This will include DOB, SS#, tax status, height, weight, tobacco/alcohol use, prior medical history, prior surgical history, prior medication use, prior drug use, current job tasks, other work duties, other employers, other injuries, other car accidents or prior work comp claims, and so on. This is where the claim is put together and these risk drivers are used to allocate the exposure of the claim.
Verify the causal relation of the mechanism of injury to the injury allegations
Claims people ask the doctor to correlate objective medical information and assemble the puzzle of work-relatedness. This is where we verify the details of the claim, the mechanism of injury, and injury allegations, and the objective evidence. A claim is accepted or denied based on this outcome.
Verify activity level against what the worker reports to their doctor
Completed by using onsite surveillance, we see if the worker is as disabled as they claim to their doctor. Some are, others are not. This is where you verify how honest they are and identify any secondary gain issues.
Verify future exposure
During litigation, you want to make sure you look at the whole picture. Future medical, MSA exposure, RX use, vocational issues, loss of earning capacity, whatever your jurisdiction has to offer to injured workers you have to take in to consideration as exposure. This then has to be tied in to a monetary value of what the claim is worth, and what settlement value.
Verify ability to work in the USA
This one is a newer one, although not so new. Many immigrant workers come to the USA in hopes of creating a better life for themselves and their families. Sadly some are never able to complete a Resident process, or have a proper work visa. We all know some story of an employer that has an army of illegal immigrants working for them. When they become injured the employer dumps them aside. In some jurisdictions, these workers do qualify for work comp medical benefits but no wages. Some obtain a partial wage and medical, etc. The key to remember though is to check everyone. A lot of the SIU/PI firms use a service to verify immigrant status, and many will show the SS# matching to your claimant. However when you present the same information to the Social Security Administration (SSA), your injured party is nowhere to be found. This means thousands upon thousands of dollars in work comp pay may have been in error. Redemptions worth thousands may have all been leakage due to the fact that the adjuster did not verify that a SS# matched up to the worker, confirmed by the SSA. So verify your indemnity claimants, not only through ISO, and through your SIU firm, but also through the SSA.
Verification of claim details is an integral part of the claims process. One that every adjuster tackles every day. But how much verification they really complete is not known. How much do you think your adjuster verifies?
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. http://reduceyourworkerscomp.com/about/. Contact: email@example.com.
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.