Catastrophic Claims Handling Part 2: Team Approach, Preserve the Scene

Handling any workers’ compensation claims can be a challenge, but it is especially the case in catastrophic claims handling for workers’ comp’s most serious injuries. These claims can ruin lives and incur many millions of dollars in costs. Everything done to manage a claim becomes that much more critical when a severe injury is involved

In addition to getting the right treatment to the injured worker as soon as possible and demonstrating care and concern for the employee as well as his family, it is also vital to investigate these claims as thoroughly and as quickly as possible. In addition to the best practices for claims handling, there are additional strategies that can ensure the best outcomes for employees, employers, and payers.

This article is Part #2 in Catastrophic Claims Handling Strategies, view Part #1 here.

Preserve the Scene

The cost and nature of catastrophic injuries is such you need to determine exactly what happened to cause the accident.

• Was it a safety issue?
• Did a machine malfunction?
• Was it a guarding issue?
• Was it a lack of adequate training?
• Was it due to a vendor’s error?

The answer can make a significant difference in how the claim is handled – not from the injured worker’s standpoint but the claim itself. For example, if it is determined that a piece of equipment malfunctioned, the employer may seek money through subrogation. A training problem may signal the need for better and more frequent training. It may even turn out that the injury was not work-related. Such a determination can only be made by a careful, thorough review of the site and speaking with other workers.

While not a crime scene, all evidence surrounding the accident site should be kept intact to further aid in the investigation. That means not washing down the area – even if it is a gruesome scene. Any equipment that may have been involved should be roped off and made inaccessible to other employees. The employer should be instructed to keep all workers away from the area until it has been properly assessed by the claims adjusters and any other professionals who may be called in.

Team Members

Investigating a claim does not require the claims adjuster to be an expert on everything. But she must know where to get any information needed. A subrogation expert may be needed, for example, if it appears financial liability may be shifted to a vendor or equipment manufacturer.

Additional experts likely needed to fully vet the claim include:

1. Nurse case manager. This is typically the very first person the claims adjuster should contact upon receiving word of a severe injury. Some organizations have dedicated catastrophic nurses who specialize in these cases. The nurse can go to the hospital and meet with the various medical personnel to determine the extent of injuries, the prognosis and the care available at that particular facility.
2. Medical advisor. In addition to the NCM, a physician should be tapped to provide additional expert medical advice. If the worker has severe burns, the medical advisor may suggest transporting him to a burn center for more appropriate treatment, or a top-level trauma center rather than a community hospital. The physician should also obtain emergency room medical records on the injured worker.
3. Safety experts. Members of the safety department should be called in to help understand exactly what happened, why and how. These professionals can help decide what is needed to prevent another similar injury.
4. Home health expert. Once the worker is well enough to return home, decisions must be made about the viability of the home environment, whether modifications will be needed and if a care provider may be needed. The home health expert can work with the team to assess these needs.

Paying the Bills

Payers may be shocked when the first bills arrive on a catastrophic injury claim. There are typically up to 50 pages of itemized charges. These need to be carefully scrutinized to ensure only proper payments are made.

There are companies that specialize in this service. They typically charge a flat fee, then handle all the bills.

For companies that undertake the bill review process on their own, the medical provider can help determine if the charges included are accurate. There are a couple of points to consider:

• Were all services included conducted? Because of the extent of items on the bills, you need to make sure you are charged only for those treatments that were done.
• Were any elective treatments included? Services unrelated to the actual injury should not be included on these bills.

Conclusion

Handling a workers’ compensation claim that involves a catastrophic injury should be done with extreme care. You want to make sure the worker is well taken care of, and that the employer/payer is not paying unnecessary costs. The approach taken can be akin to doing a jigsaw puzzle, where the pieces ultimately fit together to form an accurate picture.

Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center.

Contact: [email protected].

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