The quality of your claims management will directly impact the ultimate cost and the future cost of your workers’ compensation insurance. If an employee is misguided by the wrong “professionals,” that person’s return to work can be needlessly delayed to serve the financial interest of medical providers and attorneys.
Traditional risk management has often dictated that workers’ compensation programs are coordinated by you and your insurance carrier. According to Barbara Leonard of GMGS Insurance Services, a higher level of workers’ compensation risk management exists. The best protection occurs when your program is facilitated by three parties: the employer’s management team, the insurance carrier’s claims adjusters and your broker’s in-house claims specialist. This collaboration ensures the best care for injured employees and equitable insurance costs for the future.
Many brokers today have reduced or completely eliminated claims assistance. Others will assess additional fees for such services.
Smart Business spoke to Leonard about why companies should not settle for either, but continue searching to find the right full-service risk management insurance broker.
What are some key characteristics of an effective workers’ compensation program?
Upper management involvement is crucial. Active participation in your program enables the company’s CEO to validate that the employees are the company’s greatest assets. Your management’s role involves working hand-in-hand with the insurance carrier and the broker’s claim specialist to ensure that the injured employee is receiving proper and timely medical care. This message will quickly permeate the entire company and pay dividends in the future. Successful risk management programs can be measured by employees’ recognition that they are truly valued.
Experience modification ratings are valuable benchmarks used to compare workers’ compensation claim loss experience against your competitors. A cohesive culture can enhance your program making you a frontrunner within your industry.
What should employers know about their workers’ compensation policies?
Most workers’ compensation insurance polices require participation in Medical Provider Networks (MPN). Carrier-specific MPN notices must be issued to all employees whenever a policy is written with a new carrier. Improper notification may result in non-defendable medical bills.
It is paramount that your MPN industrial clinics understand your operations. Periodically schedule staff physicians to tour your facilities so they are familiar with your operations. A representative of your management team should visit the MPN clinics to verify the level of service offered, including how the facility is operated, cleanliness and overall care.
What can an employer do to help the claim process run more smoothly?
Ongoing education is key:
- Reinforce that all claims or incidents must be reported immediately to supervisors, management and the insurance carrier.
- Provide proper documentation to employees, including claim forms and MPN notices at the time an injury occurs.
- Reinforce the need for early identification of suspicious claims/injuries, including those caused by a third party.
- Communicate in a timely manner with the carrier and your broker’s claim specialist on serious or problem claims so your claim can be expedited. Carriers only have 90 days to investigate suspicious claims.
Many times a problem claim is identified too late when large reserves are posted months later. Proper communication is the greatest tool in limiting claim exposures.
How involved should employers become in the claims management process?
Employers should identify a designated individual responsible for ongoing communication with the claim adjuster, including tracking of lost time, medical treatment, return-to-work restrictions, etc. Your broker’s claim specialist can assist by setting standards regarding the information your insurance carrier should provide, which includes missed doctors’ appointments, medical care issues, surgery dates, investigations, reserve changes, depositions, hearings and potential settlements. However, the employer must take ownership to ensure the best possible outcome for both the injured employee and the company.
How do employers work with their insurance broker when a claim is filed?
A broker’s claim specialist has been compared to the third leg of a tripod — essential to completing a risk management team. Specialists provide guidance and education to your staff. They not only will decipher the workers’ compensation jargon but also can assist you with processes on timely contact with claim adjusters. The specialist keeps a claim moving in an aggressive manner to achieve a win-win result for everybody.
What is the role of timing in successful claims management?
Your broker’s claim specialist will participate in quarterly or semiannual claim reviews focusing on claim action plans and appropriate reserving. Reserve negotiations should only be done at times of financial impact. With traditional insurance programs, financial impact occurs twice per year, usually at the annual calculation of experience modification rating and prior to policy renewal. Badgering a claims adjuster about reserves when it has no financial impact is a common mistake, which distracts adjusters from properly handling your claims.
The specialist should possess the knowledge to lead a round table discussion with the insurance carrier’s defense attorney, claims manager and adjuster when necessary to facilitate a realistic solution.
Barbara Leonard, WCCP, is the workers’ compensation claim specialist with GMGS Insurance Services. Reach her at (949) 559-3379 or [email protected].
