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Aggressive Claims Management

Aggressive Claims Management. Preparing for accidents/injuries. Medical Provider Relationships Establish relationships with area physicians Communicate accident/injury protocols Post-accident drug screening Company’s representative at treating facility Modified duty program.

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Aggressive Claims Management

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  1. Aggressive Claims Management

  2. Preparing for accidents/injuries • Medical Provider Relationships • Establish relationships with area physicians • Communicate accident/injury protocols • Post-accident drug screening • Company’s representative at treating facility • Modified duty program

  3. Preparing for accidents/injuries • Orientation • On the job accident/injury procedure should be thoroughly discussed • Have employee sign “Authorization for post accident drug testing” • Conduct orientation that includes your accident/injury procedures

  4. Preparing for accidents/injuries • Transportation • Providing transportation for injured employee to the treating facility • A full-time employee • A contracted representative such as an EMS, worker or nurse • Taxi/Cab Service • Shuttle Service

  5. Accident Packets • Create an in-house claim file that includes: • Accident & Injury Reports • Medical Treatment Refusal • Medical Information Release • Medical Treatment Request • Offer of Modified Duty • Employee statement form • Accident Investigation Forms • Witness Statements

  6. Submitting the Claim • Report the claim ASAP • Usually can be done via phone, fax or email. • Recommend reporting claims within twenty four to forty eight hours. • Lag Time = $$$$

  7. Submitting the Claim • RCS performed a lag time study that included 18,000 claims from insurance programs serviced from 2002 to 2004. Here are the results: • Average cost of claims reported between 1 and 3 days = $3,973 • If reported after 3 days = $4,041 (+ 2%) • If reported after one week = $4,478 (+ 13%) • If reported after two weeks = $5,124 (+ 29%) • If reported after three weeks = $5,546 (+ 40%)

  8. Keeping Control • The key to keeping control is an aggressive return to work program. • Modified duty helps satisfy three critical goals of staffing firms: • Prevents W/C insurance abuse. • Helps employees retain gainful employment, heal faster and return to work quicker. • Reduces the cost of temporary disability benefits and/or indemnity payments. • Modified duty is the number one deterrent to the employee predators who sustain or allege work-related injuries.

  9. Keeping Control • Modified duty offers should include: • Date of release for modified duty by doctor. • Date and time of available modified duty by the staffing service. • Location for employee to report for assignment. • Consequences of failure to report for modified duty. • Acceptance or declination indication by employee. • Signature with date of completion by employee.

  10. Keeping Control • Maintain contact with injured employees. • Employees must report their status, via phone or in person, immediately after each doctor visit. • If allowed by state law, employees must come into the office to pick up their indemnity check. • If not on modified duty, have a staffing rep either phone or visit the injured employee weekly. • Communicate with the physician regarding: • treatment plan. • recovery status of the claimant.

  11. Managing Fraudulent and Malingering Claims • Possible indicators of W/C fraud: • Employee delayed reporting the accident/injury. • Employee is disgruntled (denied time off, layoffs, termination, etc.). • Alleged accident is questionable (no witnesses or possibly staged). • Employee provides vague and/or inconsistent accident/injury details. • Subjective injuries (soft tissue, headaches, etc.). • Attorney letter is first notice of claim. • Alleged injury after time off (Monday morning or after vacation). • Claimant is a new hire. • Claimant refuses accommodating modified duty.

  12. Managing Fraudulent and Malingering Claims • Managing fraudulent claims: • Gather all prior medical records. • Closely monitor ongoing medical treatment. • Maintain contact with the claimant.

  13. Take Away Today • Prepare in advance for accidents/injuries • Set up transportation and medical providers • Accident packets and forms • Submit claims as soon as possible – delays increase costs • Keep control with modified duty programs and constant contact • Weekly Claim to Fame Book • Look out for signs of fraudulent and/or malingering claims

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