Common Mistakes: Medical Care and Accepting Every Claim – Article 3 of 3

The experienced claim handler has the innate ability to identify the problem with employer-related issues and make recommendations on how their partner can improve processes for better outcomes. When this is implemented, the claim process and the health of the overall workers’ compensation program will improve. This article reviews common areas of concern and what changes can be made to reduce workers’ compensation program costs.

Delayed Medical Care

Employees need and deserve an immediate medical response following a work injury. When they receive prompt medical care, it will help improve outcomes.

• • Proper First Aid: Employers should have properly located and adequately supplied first aid kits. In addition to having kits, they must be checked and resupplied on at least a monthly basis. Providing training on basic first aid should be compulsory.

• • • Telephonic Nurse Triage: Employers who subscribe to these services have seen an immediate reduction in workers’ compensation program costs. These services allow anyone within the workplace to contact a licensed nurse to evaluate a non-life-threatening work injury. The nurse can better evaluate the injury, assist in applying first aid, and better direct medical care.
  • • Culture of Safety: Safety always needs to be emphasized in the workplace. This needs to be driven from the top so others will pay attention.

Members of the claim management team can also assist with these issues by making timely decisions regarding primary liability to avoid situations where the employee is without medical care.

Care from the Wrong Treating Doctor

Employees sometimes receive medical care from the wrong doctor. This is mainly because employees can generally select their healthcare provider. When a direction is not given, the employee is left to their own devices in selecting a treating doctor.

Employers can be proactive in this by creating their own Preferred Provider Organization (PPO). When this occurs, employers can inform all employees of a healthcare facility where they can receive initial medical care and continue with care at that facility during their recovery.

There are other critical benefits to establishing a PPO where injured employees can receive medical care:

• • • Variety of medical doctors to provide primary medical care;
  • • No referral requirements when a specialist is necessary; and
  • • Greater control over choices of health care specialists to provide better medical care to the injured employee.

Now is the time to consider existing a PPO to avoid costly mistakes.

Accepting (or Denying) Every Claim

A best-in-class workers’ compensation program pays 100% of the claims and 0% of the claims it should not. Incorrect decisions on claims are often made by incomplete communication between the employer and the claiming team. Ways to solve these issues include:

• • • Establish a point of contact within an employer organization regarding all workers’ compensation issues. This person needs to have access to decision-makers within the company and have excellent communication skills;
  • • Claim handler follow-up with the employer representative is essential. This will improve the lines of communication and ensure all relevant information on a claim is received; and
  • • Include the employer representative on file reviews. This will ensure everyone knows what is going on.

Breakdowns in communication are the common denominator in claims being incorrectly accepted or denied. Better decision-making on issues concerning primary liability sets the tone for the claim and results in scarce resources being better allocated. This includes the retention of defense counsel and avoiding unnecessary litigation.

Conclusions

Many common errors occur within the workers’ compensation claim process that causes delay and drives high costs. Some of these issues rest with employers. Proactive and innovative members of the claim management team need to engage with their insureds proactively to highlight these opportunities to improve the system and implement change for the better.

These changes include recommending how employers can provide proactive and immediate medical care following a work injury. Once medical care is needed beyond basic first aid, the employee must be directed to the correct doctor, and mechanisms are in place to ensure the proper care is received. When this occurs, better decisions regarding primary liability that promote program efficiency can be made. Now is the time to examine improving the process by working with insureds.

Michael Stack, CEO of Amaxx LLC, is an expert workers’ compensation cost containment systems and provides education, training, and consulting to help employers reduce their workers’ compensation costs by 20% to 50%. He is co-author of the #1 selling comprehensive training guide “Your Ultimate Guide to Mastering Workers’ Comp Costs: Reduce Costs 20% to 50%.” Stack is the creator of Injury Management Results (IMR) software and founder of Amaxx Workers’ Comp Training Center. WC Mastery Training teaching injury management best practices such as return to work, communication, claims best practices, medical management, and working with vendors. IMR software simplifies the implementation of these best practices for employer and ties results to a Critical Metrics Dashboard.

Contact: [email protected].

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