Best Practices Call for a Strategic Plan of Action
To alleviate the burden of keeping track of everything that needs to be done, the insurer’s/ self-insured’s Best Practices provide the adjuster with a roadmap to what needs to be completed. Even then, it is still a challenge to accomplish everything that needs to be done on each claim file. To prioritize the adjuster’s work on each file and to obtain the proper resolution of the claim, Best Practices call for a strategic plan of action.
When an adjuster receives a new claim, Best Practices will require the adjuster to verify coverage; contact the employer, employee and medical provider; and set the initial file reserve all within the first 24 hours of the claim. Once these must-do items are completed on the new claim, the adjuster will review the facts developed and create the initial strategic action plan for the future actions to be completed on the file.
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Initial Strategic Action Plan
The initial strategic action plan should contain both the activity to be accomplished and the date it will be accomplished. The action plan can be included in the adjuster’s file notes, or it can be a stand-alone document. The activities to be included in the initial strategic action plan can include:
- The next contact with the employee to learn the employee’s medical status, work restrictions and return to work status and a date for completion of this activity
- Verification of the receipt of the initial medical report and work restrictions, if any, and a date to complete this activity
- The next contact with the employer to establish the availability of modified light duty within the employee’s work restrictions and date to complete this activity
- Verification of the receipt of the documentation of the average weekly wage and the date it is to be completed
- Completion of any remaining investigation (Best Practices normally dictate the completion of the investigation within 14 days of the claim being reported) and the date the investigation is to be completed
- A determination to accept compensability or to deny the claim, and the date the decision must be made
- Issuance of the first temporary total disability benefits check and the date it must be completed
- Placing a third party on notice of subrogation and the expected completion date
- The ISO filing and the date it is to be completed.
- The filing of all state forms and the date(s) each form is due
- If the claim is reportable to an insurer, excess insurer or any other party, the completion of the report and the date the report is due
- The date for the next strategic plan of action (normally 30 days after the first strategic action plan, but the time frame can be longer or shorter depending on the facts and circumstances of the claim)
The strategic plan of action is not static, but constantly evolving. As activities are completed, and additional information is obtained, a new strategic action plan is developed. Over the course of the claim, the one claim file can include numerous strategic action plans. Normally, by the time the second strategic action plan is created, the activities in the initial strategic action plan have been concluded. If there are activities in the first strategic action plan that the adjuster could not accomplish, for any reason, the activities are carried over to the second strategic action plan. This is true for all future strategic action plans with any incomplete activity being carried over to the next strategic action plan. This prevents needed activities from being missed.
Subsequent Strategic Action Plans
Subsequent strategic plans of action after the first action plan will include new steps/activities that need to be taken to move the file forward. These activities and their due dates can include:
- Reevaluation of the file reserves
- Evaluation of the need for a nurse case manager on the claim, if one is not already assigned
- Coordination of return to work full duty or restricted duty
- Obtaining and evaluating medical reports of the on-going medical treatment
- Regular and on-going follow-ups with the employee, employer and medical provider
- Obtaining and evaluating the disability rating
- Subsequent reports to insurers, self-insurers or other parties
- Subsequent ISO filings
- Completion of any additional state forms
- Scheduling and obtaining a peer review or independent medical examination
- A litigation plan and litigation budget if defense counsel have to be involved
- Settlement evaluation, including both the strengths and weaknesses of the proposed settlement
- Notification to Centers for Medicare and Medicaid Services if a Medicare Set-Aside Arrangement is needed
- Settlement of the claim
- Obtaining all required waivers and/or releases
The strategic plans of action keep the adjuster focused on moving the claim to a conclusion. By using the strategic action plan to accomplish all needed activities on the file in a timely manner, the adjuster obtains the best possible outcome for both the injured employee and the employer.
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