Regardless if the workers’ compensation claim is compensable or contested, it is mandatory that all claims be properly documented.
When the claim is accepted as compensable, proper documentation will prove the basis for acceptance and reduce the chance for second guessing or challenging aspects of the case.
Proper documentation of contested claims will develop the facts and testimonies for defense of the case.
Documenting a File:
Files are documented by the following items:
- Statements, either Written, Oral, or Recorded, with full comprehensive containment of fact.
- Witness statements, either Written, Oral, or Recorded.
- When obtaining oral statements make careful notes as to what is said discussed and explained. Prepare a full report of the conversation and post it to the file at once. Document date, time, place and reason statement was only done orally. Record all telephonic discussions. This is a common practice for many businesses It is acceptable with proper legal advice before the conversation starts.
- Medical Records, confirming or contesting facts for causal relationship.
- All past medical records that have a bearing on the claim.
- Independent Medical examinations or Consultations.
- Medical Case Managers as necessary with Utilization Reviews as needed.
- Personal & Physical backgrounds as well as lifestyles of the claimant.
- Independent Investigative Reports from Other Sources such as Police, Fire, EMT units, OSHA,
- i.Safety Inspectors, Union Representative, and Newspaper Articles.
- Personnel records (especially if any negatives are present.)
- Past claim records from Employer, Insurance Company, Claim Units, as well as Central Index Bureaus and Insurance Services Offices.
- Become a member in each and participate with reciprocal information. Follow through on gathering all data on possible matches. It is suggested all losses be filed with the bureaus as soon as the loss is filed or claimed. Review all A&H cases to determine if any correlations might exist.
- Investigations of Social Media, and Activities developed by Private Investigators.
- Record or document all telephone discussions with anyone connected with the claim.
- Be extremely detailed when reporting to the file on conversations.
- Keeping the file on proper diary for facts, reserves, payments, plans of action, litigation time tables subrogation and gathering information from attorneys, investigators, medical providers and other sources.
- Proper Identification of the employee.
- Photographs and Videos of accident locati, and claimant activities.
- Copies of all applicable contracts with vendors or others.
- Copies of all training programs and employees participation therein.
- Employee’s personnel record including references, disciplinary actions, evaluations, promotions, demotions, salary records, and union membership.
- Utilization of professional experts, engineers, and technical advisors.
- Subrogation or shared exposure opportunities that can lower claim exposure.
It is prudent to review investigative needs with defense counsel for documentation on each specific case.
It is crucial to begin documenting claims as soon as they are received. Every claim may not develop into the need for heavy documentation handling. However, it is the claim technicians responsibility based on, experience, employer tips, usual and customary outcomes, proper compliance by claimants, and supervisory review, to undertake as much action to document as necessary.
A few other problems that may occur due to late documentation handling:
- Claimants and Witnesses may alter their versions of how things happened.
- Attorneys can enter the scene causing all sorts of changes that may affect a proper outcome.
- Physical evidence may alter, disappear, or have improper chain of control.
- Experts may lose the edge for getting good outcomes.
- Public records that are incorrect may not be able to be changed.
- True exposure values may be late to develop.
- Research opportunities may be lost.
- Medical management opportunities may be lost.
- Independent medical opinions may be jeopardized or become ineffectual.
- Background information may not be found or be inadequate.
- Lost subrogation, second injury fund relief, or apportionment sharing.
- Poofs for fraud, malingering, or compliance may be missed.
All workers’ compensation claim files need proper documentation on the record. It must be based on facts gathered through proper investigation, claim handling, supervision, legal input, employer consultation, adjuster alertness, and customary medical outcome.
Proper Documentation needs to begin as soon as the claim is reported. The degree and intensity for documenting must conform to best claim practices.
Documentation proves the technical handling is being done to the best interest of all concerned.
Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional