The successful video game Pitfall! was released in 1982 and featured Pitfall Harry, tasked with finding fortune in a mystical jungle infested with quicksand, tarpits, rolling logs, crocodiles, snakes, scorpions, campfires, and swinging vines. Part of the maze included pitfalls that would lead our hero to sudden death.
Handling workers’ compensation claims is similar to the challenge our believed hero, Harry, faced. Claim handlers and interested stakeholders are tasked with the daily challenges of moving claims toward settlement while avoiding the hazards presented by attorneys, medical doctors, and experts and catastrophic work injuries. Now is the time to learn tips to succeed and complete the maze.
It All Starts with Early Claim Analysis and Case Evaluation
The claim management team members often receive a new file with little background information or substance. They are tasked with reviewing limited information and making important decisions related to primary liability, the reasonableness of medical care, and getting the employee back to work. Constants barriers are in their path – employer representatives who do not return phone calls, attorneys who never respond, and injured employees whose only contact is to leave constant voicemail messages.
Meeting the expectations of a claim start with early analysis and proper evaluation:
- Review all files and materials entirely and immediately after they are received. Never let that new file collect dust;
- Determine the completeness of the claim materials as submitted and what additional information is required; and
- Never guess when it comes to denying primary liability on a claim. Denying too many claims is a bad practice as a default. Always make sure you have a valid legal reason supported by the facts.
Members of the claim management team should be proactive on all new claims. The claim that collects dust is the claim that will cause problems in the future.
Engage Employer Representatives
Claim handlers who succeed in their practice develop relationships with the insureds. When making the initial contact, ensure the employer representative has complete contact information. Please make yourself available to meet with them at the onset of the claim.
- Use videoconferencing tools when available. This is an effective way to develop a relationship;
- Review the medical care provided to the employee; and
- Inquire about a return to work efforts and what can be done to get the injured employee back to work; and
Never delay in making contact with the employer. This can also help develop fact witnesses to the injury and obtain background information on the claim and mechanism of injury.
There are many opportunities for a claim handler to open the lines of communication with interested stakeholders in a claim. This can also foster cooperation as the claim develops in vital areas:
- Avoid discovery issues: An injured employee may take the immediate steps of retaining an attorney. Get that attorney’s name and provide them with your contact information. Request a copy of their Retainer Agreement as a reference point for counsel representing the employer and insurer’s interests;
- Determine if Medicare will be an issue: Medicare Secondary Payer compliance is here to stay. Issues of inquiry can include medical insurance coverage for the employee and their Social Security Disability Insurance. This information is needed; and
- Working with a defense attorney: The claim management team should know when it is the right time to select a defense attorney. Never forget there is nothing wrong with reaching out to counsel before referring a file to obtain their thoughts on how to position a claim and other strategies.
All of these matters require effective communication by the claim handler.
Other Issues to Consider
There are many other issues to consider to avoid danger when handling a claim. Some of these issues can include:
- Anticipating issues and defenses – and understanding how they change as the claim progresses;
- Witness preparation – employer representatives, other lay witnesses, and medical and vocational experts.
- Preparing for settlement. Never forget to consider mediating the closure of files – even the most troublesome.
The list is endless. Never forget to treat all people involved in the process, especially the injured employee, with respect and dignity.
While many spent countless hours trying to reach the ultimate prize in Pitfall!, the ability to reach timely settlement in workers’ compensation claims is not as difficult. Like attempting to master a video game, it does take time and patience to avoid the many hazards. Taking the above items into consider will help any claim handler find success.
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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