Responsibilities of a Workers’ Comp Claims Investigation Leader

Central to successful leadership is attention to detail, solid work ethic and commitment.

Members of the claim management team and fully-engaged employers must exhibit these same traits when it comes to workers’ compensation claims. All claims must be investigated promptly – by the book with no corners cut. This process also includes the development of best practices to manage risk and control workers’ compensation program costs.

Responsibilities of a Claims Leader

There are several goals a good leader must undertake when developing a program. This is something that can be done inside an insurance carrier or company. Items to consider should include:

Develop a program to sniff out fraud. This program includes being proactive to prevent it from taking place and detecting it early on to mitigate program costs;

Update upper management within the organization on issues concerning the overall workers’ compensation program. This position should be able to effectuate and promote change;

Understand how to conduct an effective investigation. This is especially important in more complex claims or those which involved special or unique circumstances; and

Coordinate all efforts between defense counsel and the clients. This should include all interested stakeholders to promote an effective program.

Special Investigation Unit: Dealing with the Tough Claims

Not all workers’ compensation claims are the same. Some claims are more difficult than others. This can include instances where the employee sustains a severe injury, the circumstances surrounding the claim are suspect, but difficult to prove it did not occur or fraud. Proactive claim management teams and employers can address these barriers by developing a “special investigation unit.”

Teamwork is key when working on special claims. It all starts with a dedicated leader who knows how to peel back the layers and get to the bottom of things. Important characteristics of this leader should include:

Someone with law enforcement or military background. These are people who faced difficult challenges in the past and are resourceful;

A person who has a reputation for being fair and honest. Remember, all injured employees need to be treated with dignity and respect. Integrity is paramount;

Knowledge of the law and other applicable tools to complete the goal. An attorney can be considered for this role, but not necessarily required; and

A leader who can effectuate change within an organization.

Leading from the Front – Taking the Lead

The leader of a special investigations unit needs a strong supporting crew. This can include assistance from the following departments:

Human Resources: This area brings an understanding of other applicable rules and regulations together to assist in claim investigation and help an organization avoid countless pitfalls;

Legal Department: An attorney can advise the unit on legal issues and provide advisory opinions, guidance and assist in the development of a legal strategy;

Medical: Having an on-call nurse or doctor who can assist in complex issues such as utilization review of medication or other procedures will drive down costs. They can also assist in injury response; and

Management: It is important to include a representative from senior management. This person can help clarify the mission of an organization and desired results.

Conclusions

Workers’ compensation claims present challenges that call for special measures. To be successful, proactive employers and insurance carriers can develop special units to tackle these matters head-on. This includes engagement from a variety of areas within an organization to resolve claims and reduce workers’ compensation program costs.

Michael Stack - Amaxx 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: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.