Create System to Gather All Needed Workers’ Comp Claim Information

7 Ways Your TPA May Be Underpaying Your Company Workers Comp PaymentsGarbage in; Garbage out!  If you are putting garbage into your workers’ compensation program, it goes without saying the results will not be pleasant.  Now is the time to focus on gathering all the necessary information to obtain high-quality results in order to pay claims appropriately, and improve efficiency.



Create a System That Creates Repeatable, High-Quality Results


A significant improvement in the world of claims management over the years is the implementation of an electronic system for entering and managing claims.  Used by employees of the Carrier/TPA, this is an automated system that assigns risk if certain conditions are present.  These systems allow for the following:


  • Claims professional to gather more information in less time;


  • Provides for appropriate follow-up on responses to high-gain issues; and


  • Assists in the evaluation of information systematically.




System Guides the Questions So Nothing is Missed


The person receiving the claim for the Carrier/TPA will have questions that need to be answered.  If the answers are positive for certain criteria, the system will assign the claim a risk number within certain values from the software. The higher the score, the more risk is assigned to the claim. The system will be used initially for 3-point contacts to the injured worker, the employer, and the medical provider.  Positive responses to certain criteria will pop up other questions to ask which ensures the adjuster does not forget anything that can be crucial to the claim.


Processing claims through a system like this allows the claim handler to understand the “pain points” of a claim when it arrives at their desk.  This will better direct their investigation and reduce unnecessary or excessive time spent on a claim.




Encourage Claim Handlers to Follow Best Practices


The implementation of a bonus system is another tool to use.  Carriers/TPAs often use a bonus system to reward adjusters, and these bonuses revolve around timeliness of their contacts, resolution of their claims, and overall reserve savings by proactive claims handling.  This encourages the claim handler to follow best practices.


Claims practices can also be classified based on their system score.  Medical only claims or minor lost-time claims can be routed to the appropriate adjuster, instead of going initially to a senior level claim handler.  Other inefficient claim handling processes include assigning a claim based on what information is listed in the injury report.  This process can be inefficient if the injury report was completed in error.  Time and money can be saved when each claim handler is making the highest and best use of their day.



Using Outside Service Providers When Necessary


Outside service providers can be used immediately in certain circumstances.  These assignments can include:


  • Field Nurse Case Manager: These service providers should be used in instances where the employee will require significant or extended medical care and treatment.  This can equate to large cost savings as this month can include crucial moves within the claim, preventing missed work when a return to work could have been possible.


  • Medical Specialist: Claims involving complex injuries can be referred to a specialist at the onset of a claim where the identified injury will likely require surgery or extensive physical therapy.  Instead of waiting for the paperwork the case manager can get it at the appointment and send it to the claim handler the same day, instead of when the actual medical reports come in with the bill weeks later.





Several technological advancements are going on within the claim industry.  As an employer, you should be open to new technology, and trying new things in order to be more proactive in the claim process.  Oftentimes the claim handler is very set in their ways, and there can be some resistance to the introduction to new techniques and new technology.  These advancements are made to help all parties involved to make the process more streamlined and more effective for the claims profession.




Michael Stack - AmaxxAuthor 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.



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