Define an Escalation Process For Workers’ Comp Causation Determinations

 

Determining whether or not a claim is work related can be sometimes difficult and can be sometimes very simple. Hello my name is Michael Stack I am the CEO of Amaxx and today I want to talk about those difficult causation claims. Those difficult causation related decisions and setting up a process and a system to consistently get the right answer.

The Adjuster

Now there’s difficult workers’ comp causation related claims can often be complex in terms of medical terminology, medical research, medical studies, medical testimony, medical expert opinion. And if we think about the individual who is often times charged with making this decision, its the adjuster. The adjuster is charged with making the decision of whether or not a claim is work related. When i talk about some of the complexity of these very challenging workers’ comp claims, this individual does not have training on medical terminology, interpretation of medical studies. They do not have an expert medical opinion to lend to the case .

The Escalation Process

So what i want to talk about in this little video today is an escalation process or system in order to bring in this medical terminology to help the adjuster on these complex claims. You should have a system and you should have this set up internally if you’re a claims organization, if you’re an employer with your claims organization. What instances is that adjuster bringing in additional help, bringing in additional medical expertise to help us make the right determination particularly on these complicated or somewhat complicated workers’ comp medical causation determinations.

Tips For What The Escalation Process / System Should Look Like

I want to give you a couple of tips for what this escalation process or system should look like and very simply i want to give you this first tip. It just doesn’t smell right, it just doesn’t smell right. It just seems like there is something a little off with it and i need a little bit extra help with this.

If there is any kind of ambiguity in the claim itself anything that’s kind of a little bit off or doesn’t seem right, little bit of ambiguity, something seems off, something doesn’t smell right. That’s your first inclination that i need to bring in some help for this and I’m not even going to go any further than that because that’s a great little marker because we all know the difference between that. We all know that yeah, that seems right but you know what I’m not really sure about this one and i want to bring in some extra expertise and generally speaking the expertise that you’re going to bring in there is a physician. So you’re going to bring in a physician. Now if you’re at the TPA you ask your TPA. They can do this internally, you could also bring in external resources, external third party organizations that have these physicians, medical advisors, peer reviewers advisors, medical experts that can now lend this opinion and review the case and help make that correct determination.

There are some cases in Workers’ comp that are very simple to define whether its work related or not. There are many cases that are not as simple. We need to have this escalation process and system in place in order to help make the right determination. Again, my name is Michael Stack and I’m the CEO of Amaxx and remember your work today in workers’ compensation can have a dramatic impact on your company’s bottom line but it will have a dramatic impact on someone’s life. So be great.

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.

Contact: [email protected].

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