In most states, employers who have over five employees are required to insure workers who may be injured on the job. This article may help you determine the best partner to choose and best administrative practices to employ under your policy.
Depending on the policy, you will be partnering either with an insurance adjuster or a third-party administrator (TPA) to handle your claims.
Claims administration involves the following: payments of benefits and medical bills; processing of claims within state guidelines; file auditing, documentation and reporting; and negotiating claims settlements. Choosing a poor administrator may erase all savings gained from the best safety and return-to-work efforts.
Hopefully the following hints will help you develop a long and rewarding relationship with your claims administrator.
- Claims Office… The administrator should be located in your state or have adjusters familiar with your state’s workers’ compensation laws. Visit the claims office. Nothing compares to “seeing” an efficient operation.
- Claims Adjusters… These individuals must be very well trained and highly experienced. Case Load… The average case load is about 165; more than this historically leads to poor performance.
- Dedicated Adjuster… This is preferable. If this is not possible, obtain a designated adjuster who works only on a designated group of employer claims.
- Three-Point Contact… Ensure this is done with each claimant (a call to the patient, employer and medical provider).
- Medical Management Services… Make sure these are available and pre-arrange pricing.
- Medical Specialists… A good administrator will have access to a range of medical professionals. Ask for the list.
- Investigative Services… Administrators should have established relationships with investigators who use technology and proper reporting for your state.
- Attorney Selection… Your administrator should choose an attorney for litigated claims that allows for the most control over the file.
- Risk Management Services… Up to date IT systems are a must.
- .. Claim detail and customized reports are essential to accurately manage a claim. Every policy holder has different needs.
- Settlement Authority… Ensure that you have input regarding settlement amounts being considered.
- Claim File Review… Arrange a claim review meeting on a quarterly basis.
- Quality Control… The administrator should be continuously training and providing educational opportunities. Be sure internal quality measures are in place within the administrator’s office. This helps ensure quality outcomes.
- Process Documentation… Take the time to write directives that document your account management procedures. They are a guidebook to a fruitful accord.
- Evaluate and Measure… Periodically rate your administrator. You should be quickly receiving claims, accurate reserve adjustments, timely inquiry responses, prompt bill payment history and (hopefully) a low litigation rate.
According to Bonnie Stephens, a case manager for Medcor at the San Diego Zoological Society, “The selection of your Claims Management Partner is vitally important, not only to the efficiency in claims handling and resolution, but also, when performed using best practices, the right selection can save hundreds of thousands of dollars in medical payments, lost time and litigation costs.”
Author: Ben Petersen co-founded Medcor in 1984 and serves as the company’s chief operating officer. Since Medcor’s inception, Ben has led Medcor’s overall operations including hiring and training staff, developing scalable systems, managing logistics, and creating the infrastructure to provide health services for Medcor’s multiple service lines in all 50 states. http://medcor.com.
