Workers’ Comp Claims Audit: Initial Action Plan Checklist

Claims audits and reviews are one of the most commonly used tactics by companies to control workers’ compensation costs. In fact, according to the RIMS 2009 Annual Benchmark Survey, 90% of companies had conducted a claim audit or review of at least some of their claims within the previous six months. These audits ensure that each claim is handled efficiently and in compliance with state regulations while also identifying areas for cost containment.

One critical tool aspect to review during a claims audit is the Initial Action Plan Checklist, which helps ensure that all necessary steps were followed in the early stages of a claim. This checklist plays a pivotal role in maintaining organization, meeting deadlines, and keeping costs in check.

Initial Action Plan Checklist

The Initial Action Plan for the workers’ comp claim should contain the following key steps:

1. 1. A follow-up date for further contact with the employee (ability to return to work).
   2. A follow-up date for further contact with the employer (availability of a modified duty position if the employee is unable to return to full duty).
   3. A follow-up date to verify the receipt of the initial medical report.
   4. A follow-up date to verify the receipt of the documentation of the average weekly wage (should be within 14 days or less depending on the jurisdiction—in order for the adjuster to issue the first TTD payment or issue a denial of claim).
   5. A follow-up date to complete any further investigation of the claim (should be within 14 days of the date the claim was received).
   6. If subrogation is appropriate based on the investigation, a date to put the responsible party on notice of the subrogation claim.

1. A date to verify the claim is accepted for compensability or the date the claim will be denied.
2. A date for the TTD benefit payments to be calculated and the first TTD check issued, if applicable.
3. A date for the completion of the ISO filing (within 14 days of the receipt of the claim).
4. A follow-up date to verify all state-required forms have been filed with the state work comp board.
5. If the file is reportable to an insurer, excess carrier, or any other party, the date the reporting will be completed.
6. A date for the next Action Plan to be completed (usually 30 days after the first Action Plan, but the time frame can be shorter or longer depending on the severity of the claim).

Conclusion:

The Initial Action Plan Checklist is a crucial part of the claims audit process, offering a structured approach to reviewing how your workers’ compensation claims are managed.

By following these steps in a review to ensure that all required documentation and follow-ups are completed in a timely manner, companies can significantly reduce errors and unnecessary costs.

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].

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Injury Management Results (IMR) Software: https://imrsoftware.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.