Regardless of the employer’s size and operational locations, it is wise to have a technical claim coordinator to oversee the reporting, handling, state compliance, and prompt resolution of workers’ compensation claims. The coordinator is dedicated to the employer, knows the employer’s business, is cognizant of the employer’s relationship with its employees, and is readily available for both the employer and employee needs.
The coordinator reviews the claim handling by the claim technician on behalf of the employer. Proper filing of state forms, claim file documentation, proper calculation and payment of benefits through investigations, medical control, and all other claim requirements will be overseen for successful resolution.
Some agents, insurance brokers, or other Insurance Contact Personnel may be able or want to act as claim coordinators. While they can gather data and work as a go-between the employer and claim technician, it must be noted that coordinating is not their sole basis for operation. Very few have dedicated claim-trained personnel. Some are too small to handle anything more than reporting a claim.
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Protocols:
All protocols for the claim coordinator and employer are done in writing. They establish the following:
1. Full information exchange on primary contacts and alternates. List physical and mail addresses, telephone numbers, cell phone numbers, e-mail addresses, fax numbers, and after-hours emergency contacts.
2. When, where, and how the employer will report the loss. State form numbers for the employer’s need and use are provided.
3. When a loss has questionable overtones, the employer can discuss options and handle thoughts with the coordinator by telephone as soon as the loss is presented. Some jurisdictions take the employer’s first report as prima-fascia evidence that the loss is compensable. Therefore, it is imperative that the wording on the employer’s first report be such as to prevent prima-fascia acceptance.
4. The coordinator will submit reports on investigations, claim status, reserves, payments, light duty requests, medical needs, and authorities. Any changes in the medical diagnosis or uncovering of underlying medical conditions that affect recovery will be brought to the employer’s attention by the coordinator. There may be a need to utilize medical management by registered nurses. Authorities and expected results will be presented.
5. All claims involving subrogation will be kept on a diary until recovery. The coordinator will follow statutes of limitations for subrogation recoveries so that the employer does not miss the opportunity to recover in place of the employee if necessary. When a subrogation issue involves an employer’s client or customer the coordinator will be sure the employer’s desires for pursuit are complied with. This may include a waiver. However, if the employee pursues on their own, it may be necessary to ride silently along unless the client or customer enjoins the employer as a co-defendant. When this occurs, the coordinator will work with the employer’s defense counsel and technician until resolution.
6. The coordinator will keep the employer apprised of all legal actions and other situations where recovery and return to work exceeds usually accepted time frames.
7. The coordinator will ensure that all constraints the employer issues are always in compliance. This includes payment authority levels, settlement authority levels, legal assignments, outside investigations, and vendor appointments.
8. The claim coordinator will help transfer a claim when the employer is not satisfied with the technician’s performance.
9. Some claim departments allow the employer to view their claims online. If this is allowed and accepted, the coordinator will resolve all issues noted by the employer.
10. The coordinator will arrange an annual review of all losses two months before the policy coverage or contract renewal is due. All agreed changes will be on record in time for the new premiums or handling prices for the next term.
11. The coordinator will be responsible for the claim technician to constantly comply with best claim practices. This will ensure the best outcome of the workers’ compensation claims.
Summary:
Claim coordinators are vital in keeping claims on track in the claim departments. They resolve employer concerns between the claim technician and the employer. Their goal is to obtain the best outcome for all workers’ compensation claims. They participate in preparing annual reviews for proper claim costs affecting premiums or contract renewals.
Michael Stack, CEO of Amaxx LLC, is an expert in 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 employers and ties results to a Critical Metrics Dashboard.
Contact: [email protected].
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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.
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