As a business who may have a few claims or wants to prioritize safety culture, it is important to perform a quarterly work comp claim review. These meetings help make sure that there is a constant stream of communication between stakeholders and there is transparency and trust in the process. While there is no one size fits all kind of work comp claim review, here are topics you should go over to ensure a smooth and comprehensive process.
1. Timeliness
Address these three questions:
- Was the claim reported timely?
- How soon after the incident was the claim filed? If the claim was not timely, dive into the reasoning. Claims can be filed late for several reasons – such as an employee being worried over losing the job, misjudgment of injury severity, and false claims.
- Were all appropriate stakeholders were notified in a timely manner?
- Identify who the appropriate stakeholders are, when they were notified, and is everyone on the same page on how to notify stakeholders.
- Has the Primary Team assigned to the claim been communicated to all parties?
2. Appropriate documentation
To prevent complications such as claim adjudications, check the following:
- The appropriate paperwork has been completed.
- Typically a first report of injury form, any documentation the carrier needs, and an employee incident/near miss report during the accident.
- Recorded statement taken from injured worker.
- Recorded witness statements when applicable.
- A scene demonstration
- This can be on the employee incident/near miss report– make sure a drawing and any photos of the scene are documented.
3. Could the claim have been prevented?
This is often a complicated and contentious topic. Things to ask around the prevention topic:
- Did the employee receive proper training on equipment usage? If so, did they follow the appropriate safety measures? Is more education needed?
- Is there a remediation plan to prevent this type of claim in the future? Most employee incident/near miss reports have causes, every cause should have an actionable item of prevention. Talk this through and see if those actionable prevention items have been carried through.
4. Nurse Triage (if applicable)
If Nurse Triage is in the work comp program, ask these questions:
- Was it used for this claim?
- Were there any issues?
- Was the Injured Worker referred to the Primary Care Center (if applicable)?
5. Post-claim follow up
- Was there a post-claim follow up with the injured worker, the supervisor, HR, and other relevant parties? If not, have appropriate timelines been set for follow-up or Return to Work?
6. Peer review
A medical peer review determines whether an injured employee is receiving the appropriate care. This is beneficial to make for a fast recovery (closing the claim faster) and lowering claim costs by eliminating medical treatment that is not necessary. Ask these questions:
- Identify if a peer review has been completed on the worker’s comp claim.
- Was an Attending physician’s report filled out? (if applicable)
7. Remediation plan
There should be a remediation plan devised to prevent this kind of claim going forward. Things to consider:
- Make sure OSHA standards are being met
- Keep the plan up to date – review when there are company or industry changes
- Who oversees the remediation plan?
- If there is already a plan in place, All plan actions should have a correction date and person in charge of that action – were those deadlines met?
8. Is the worker able to return to work?
Answer the question of “Is the worker able to return to work?” If the answer is:
- Not at this time: A light duty or off-site job description should have been given. Review the current job description duties and date. Check in with the employee’s wellbeing and progress.
- Yes: Discuss what that process will look like moving forward.
If there is no return-to-work program, consider putting one in place. If that is not on your radar, have a discussion on how to get that specific employee back to work.
9. Claim Status
- Review all open claims and reserve amounts. Have reserved increased or decreased?
- Review recent closed claims and final claim amount.
- Review claims where there are minor indemnity payments for lost wages. Could this have been a medical only claim if a light duty return-to-work program was used?
TIP!! Before you engage with the employee who was hurt, it’s important to remember that most of the time, they were not trying to get hurt. The worker’s comp claim process can be unexpectedly frustrating or confusing to them. Show them compassion, and it is often better to over-communicate to them what to expect during the comp claim process.
Recap
At Mod Advisor, we can help your business preform a successful mod audit to get you on the right track to analyzing claims. Additionally, we can put you in touch with an agent to help you streamline the work comp claim review process and manage your account. Let us help you make work comp simple. Reach out to us today at [email protected].