Core Competencies. Investigation

Transcription

1 Core Competencies Investigation Claim Investigation Verify coverage for claimant / employer Three point contact (employer, claimant and medical provider) Recorded / written statements (claimant, witnesses, etc.) Field claim adjuster / outside investigator Identify opportunities for recovery / apportionment (SIF, subrogation, etc.) Identify claimant demographics / profile (co-morbidities, pre-existing conditions, ISO index bureau, etc.) Determination of compensable body parts / conditions Clear and concise stated outcome of compensability determination at conclusion of investigation A thorough investigation is the foundation on which proper claim handling is built. It sets the tone for the claim. First and foremost, coverage for the claimant and employer needs to be verified. If no coverage exists it eliminates most of the issues that arise with claim handling. It is important to do as much up front work as possible to ensure all information is documented accurately. A thorough investigation should lead to an informed decision on compensability as well as any issues that present themselves at the onset of the claim. A timely investigation will help ensure that all of the facts are captured accurately. This makes a timely standard three point contact a key element to claim investigation. Recorded or written statements are helpful for permanently capturing facts learned during the investigation. If witnesses are identified, it may be appropriate to obtain a written or recorded statement from them as well. Use of a field claim adjuster or nurse case manager may be a valuable resource to assist in a claim investigation given their expertise and knowledge that can be used to gather important facts while out in the field. The file should be thoroughly evaluated for opportunities for recovery. Identifying the claimant profile will assist in gauging future exposure as well as issues that may arise. ISO index reports are a good source of information to verify claim history that may be a contributing factor to the alleged injury. Once a thorough investigation is complete, it is important to summarize the covered injuries and conditions as well as the rationale leading to that determination as this is the introduction to the claim.

2 Recoveries Pursue opportunities identified during investigation Identify subsequent opportunities that develop Clearly stated outcome of recoveries pursued All opportunities for recovery should be thoroughly evaluated during the investigation of the claim. Opportunities for recovery will differ by jurisdiction. For example, Second Injury Funds exist in only a few states. Third party tortfeasors are another potential source of recovery. Not all jurisdictions allow recovery of workers compensation benefits paid as the result of a third party s negligence. It is important to evaluate the jurisdictional issues that apply. Recovery may be limited by statute. Opportunities for recovery are often overlooked or not adequately investigated. Any opportunity identified should be aggressively pursued. The work involved should be documented in the claim. The outcome of the pursuit should be documented once the issue is resolved. Case Reserving Reserves Timely placement at conclusion of investigation Change in reserve as claim development warrants (surgery, complications, etc.) Evaluate the whole picture at change (include all indemnity, medical and expense exposures) Use a reserve worksheet Estimate of ultimate cost of the most probable outcome Accurate reserving should be exercised and maintained throughout the life of a claim. The reserves should reflect an estimate of ultimate cost of the most probable outcome based on the facts known at the time of reserve posting. The reserves should be consistent with the development of factual information gathered in the investigation and file development. Knowledge of the law and jurisdiction along with claims judgment and experience should be considered when posting a reserve. Reserves should be reviewed and evaluated any time a file activity takes place. A reserve worksheet will assist in considering all factors involved in setting a reserve, and reserve accuracy. A reserve documentation note should be posted indicating the basis for the reserve change. An up to date and accurate reserve is critical, as it provides an understanding of the ultimate probable outcome of the claim. This information is also used outside of the claim department by various entities such as, but not limited to, underwriting, actuaries and state commissions. The administrator has a fiduciary responsibility to accurately reflect anticipated claim costs in the reserving process. Serious ramifications could result from inadequate reserves, which have caused some large companies and insurance carriers to go insolvent.

3 Vendor Management Vendor Management Defense counsel (task assignment, terminate use when appropriate, etc.) Surveillance (only when appropriate, clearly stated objective, etc.) Nurse case managers (complicated cases, assist with investigation, terminate use when assignment is no longer a value added service, etc.) Medical cost containment (bill review for fee schedule / U&C, PPO, etc.) Best Doctors (expert opinions on complicated and catastrophic claims) Vendors are an important resource to claim handling. Each vendor can provide expertise in their respective fields. The key to vendor management is to only use the vendor for as long as the service adds value to the claim. Task assignments should be delegated to each vendor to accomplish a certain task or to meet a certain need. Once the task or need is met the vendor assignment should be terminated. Nurse case managers and defense attorneys, in particular, should be limited to the specific need for the claim. Nurse Case Managers are a valuable resource on difficult medical cases. On more complicated medical claims, Safety National partners with Best Doctors to obtain an unbiased highly qualified opinion to assist in the management of the medical treatment either by confirming the diagnosis and treatment plan is appropriate or by making additional recommendations for consideration. The key to appropriate vendor management is to ensure that control of the claim is never abandoned to a particular vendor. Timely Payment Claim Handling Indemnity (avoid potential fines, penalties and interest) Medical (avoid potential fines, penalties and interest) Late payment of indemnity or medical benefits can result in unnecessary fines, penalties and interest. These expenses are often excluded from coverage by excess policies. Jurisdictional issues apply. Due diligence must be performed before making a determination to delay payment of benefits. There may be times where additional investigation is required before issuing payment. Payment of a claim may result in a concession of liability. In those cases it is important that all necessary groundwork is completed before making any such concession. Documentation Document activity as it occurs (claim should read like a book - introduction, body and conclusion) Complete compilation of claim documents (physical and /or imaged file material)

4 At any point in time, someone other than the primary claim handler may need to review a claim file and readily gain an understanding of the history and current status of the claim. Individuals needing to review the claim file may include internal parties, such as adjusters subsequently assigned the case, claims supervisors or home office auditors, or outside parties, such as state regulators, attorneys, reinsurers or excess carriers. All significant activity, including but not limited to the claim investigation (telephone calls with the claimant / employer / physician / attorney, round table discussions and action plans) should be posted to the claim file. In addition, correspondence such as medical records, legal correspondence, settlement recommendations and discussions should all be posted and summarized within the claim file. Remember, if a particular activity is not documented in the file, it never happened. Action plans Stated proactive activities to move claim to conclusion of investigation Follow up stated revisions to activities as necessary Use a diary or task system in order to track and update activities An action plan is a necessary component of successful claim management. It should be clearly stated and documented at various stages throughout the life of a claim. A welldocumented action plan will provide a brief synopsis of loss details, claim background and desired outcome. The action plan should include proactive activities to drive the claim to conclusion and should be updated periodically as circumstances change. A diary or task system should be used to manage the action plan activities. The desired outcome and goal on all claims should be file closure. Medical Management Document medical status as it occurs Ensure medical remains causally related Use of appropriate medical controls (UR, IMEs, etc) Medical management involves the adjuster identifying the covered injuries or illnesses verified through the claim investigation and ensuring that all treatment remains causally related. It is important that the focus of the claim remains on the compensable injuries and conditions. This is essential to containing the cost of the claim as workers compensation coverage only applies to injuries and conditions that result from a specific occurrence. The use of appropriate medical controls should be used to limit the medical treatment to the compensable injuries and conditions. Jurisdictional issues would apply. If additional injuries and conditions are later claimed they should be thoroughly investigated to determine compensability. All activity should be documented as it occurs, so that a thorough history of medical treatment can be verified through the claim notes. It may be appropriate to arrange for an independent medical examination or other protocol according to statute in determining causal relation. Other medical controls should be considered such as utilization review, second opinions, etc. Settlement Identify issues that can be resolved

5 Negotiation Mitigate claim expense and exposure Protect all interests (Medicare, employer, excess carrier, etc.) The only good claim is a closed claim. The best way to mitigate the exposure is being proactive in resolving any issue when possible through settlement. Jurisdictional issues may apply. Some do not allow settlement of the indemnity or medical where others may only allow settlement of the indemnity. A cost effective settlement via lump sum or structure helps control the cost of the claim by avoiding adverse development. While not every claim can reasonably be resolved through settlement, it is a tactic that should be pursued proactively. It is also important that the interest of each party is protected. A Medicare Set-Aside may be needed to protect Medicare s interest. The interests of the employer retaining risk under an SIR or deductible and the excess carrier must be considered in accordance with terms of the applicable insurance policy. Supervision Supervisor should review claim as the file needs dictate Comments should address compliance and file handling recommendations Follow up as needed At minimum, claim supervision provides the file with a second set of eyes. A management review of the file should be done periodically at intervals throughout the claim life as warranted. This review should be documented and provide insight and recommendations in moving the claim toward disposition. In addition to claim handling recommendations, the review and posted note should ensure appropriate management of the claim file. Additional supervisory input should be considered based upon the ability level of the claims professional. Closure Clearly stated rationale for closure Discuss any potential exposures (SOL, worsening of conditions, reopeners, etc.) The ultimate goal of handling any claim should be complete file closure. When considering a claim for closing, a review should be completed by the claims adjuster to ensure that the file is not being closed prematurely. A short and concise note should be entered stating the rationale behind the claim closing, along with whether there are any potential exposures that could lead to reopening. If the claim has been reported to excess, a brief update indicating that the file is being closed should be provided. A good claim is a closed claim. Excess Reporting Reporting Review / report excess reportable claims upon receipt Identify / report as changes in claim development warrant

6 Provide supplemental reports and / or other information as requested It is important to provide notice on all claims that meet the reporting requirements outlined in the applicable excess policy. A successful partnership between the selfinsured employer, claims administrator and excess carrier is dependent on cooperation and communication on reportable claims. Updates and pertinent file materials should be provided to the excess carrier at regular intervals throughout the life of the claim as required under the terms of the applicable excess policy.