Proper denials of primary liability start with claim handlers successfully investigating matters of causation. Issues of concern include understanding the mechanism of injury and activities the employee was performing. It also includes obtaining the necessary medical records and providing a consistent response. These challenges can be overcome with careful claim practices and patience. Now is the time for claim handlers to consider these issues to improve work outcomes and effectively resolve cases.
Initial Claim Investigation
This is a crucial part of the claim handling process and helps set the tone for making the right decisions. In this part of the process, the claim handler needs to do the following:
- Ensure that the employer reports the work injury promptly. Studies demonstrate that claims reported within 24 hours result in less money being spent on the claim;
- Obtain detailed information regarding the work injury that includes information about the mechanism of injury, witnesses, and the employee received medical care. This information will assist in defense of the claim – especially when it comes to medical causation; and
- Making contact with the employee to fill in any gaps in terms of claim information. Securing authorizations to obtain medical and other records is a must.
Failure to conduct a top-notch investigation of any injury can result in bad decisions regarding primary liability.
Get to Know the Employee’s Job
Determinations regarding causation are often dependent on known work activities of the employee and what they do daily. One piece of important information is a detailed job description for the employee. This information is often found in the employer’s human resources office. If a job description is not exhaustive and in writing, any experienced claim handler will know how to reach out to the employer to obtain it.
Job descriptions are essential as they will tell someone what the employee does and where they should be on a regular workday. Having this information is critical in terms of knowing:
- Known when and where the employee works and what they do when they are not at work;
- What types of job activities should they be doing? This is especially important in instances where the employee is claiming a repetitive use injury; and
- Understanding activities the employee should and should not be performing. Examples can include prohibited activities the employee may be engaging in when the work injury occurs.
Understanding the exact movements, weights, and measures of what the employee was doing at the time of injury is of the utmost importance when making decisions regarding primary liability. It will also be added to the credibility of an independent medical examination report. It can also play a crucial role in return to work efforts if liability is accepted or established.
Get to Know the Treating Doctor
During any claim, there will be extensive contact with the employee’s treating physician. It is essential to understand that person’s personality and other characteristics in how they handle work injuries. It is also valuable to know if the treating doctor has a history of recommending conservative medical care or rushing someone down the route on prolonged care followed by surgery.
The importance of establishing the relationship with the treating doctor has other reasons:
- Establish credibility with the care provider as a claim handler who seeks to ensure reasonable and necessary medical care is approved promptly;
- Maintain an open line of communication. If a service is going to be denied, it should be done promptly with a rationale provided. Cart Blanche denials often prompt extensive ongoing medical care; and
- Understand limitations on the care available and when second opinions or referrals may be necessary. It may also help with the timing of the independent medical examination.
Skilled claim handlers are great communicators when it comes to interacting with health care providers. Investing in the relationship can have positive implementations.
Many things the claim management team members can do to ensure a claim involving medical issues is appropriately accepted. To do this, the claim handler must ensure the claim is timely reported, understand the employee and employer, and have a firm grasp of the mechanism of injury. This also includes establishing a relationship with key stakeholders and responding promptly. When done effectively, the correct decisions will be made.
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 the founder & lead trainer of Amaxx Workers’ Comp Training Center, which offers the Certified Master of Workers’ Compensation national designation.
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