Supervision
- The supervisor plays a pivotal role in
assuring quality claim management. Supervisors focus on managing, coaching and evaluating
the performance of others. They provide technical expertise, recognize improvement
opportunities and ensure the files are properly documented.
Coverage - It is important that policy coverage be
verified before benefits are extended. Proper verification and interpretation of coverage
can avoid estoppel from asserting coverage defenses, inability to recover payments made in
error and unnecessary time and expense expended in attempted recovery of
improper payments.
Notice/Assignment
- The early receipt of an injury
notice with early assignment to appropriate claim handlers is essential to realize savings
through early intervention with establishing contact with all parties to the claim,
conduct thorough and accurate investigations and manage the medical and disability aspects
of the claim to an early resolution.
Contact - Initial and subsequent contact sets the
foundation of claim management. Contact initiates claim communication with all concerned
parties. The information gathered from contact provides direction for further
investigation and case management.
Investigation - A thorough investigation is cost
effective and has tremendous leverage in all phases of claim management.
Investigation is the cornerstone of claim management. It requires timely and
thorough fact gathering, which makes claim management possible. Claims
involving compensability and recovery potential should have an investigation
performed and file documentation addressing the exposure and
outlining the future course of action.
Reserving - Reserves or estimates must reflect the
claim handler’s best judgment of the probable ultimate pay-out of the claim at any
point in time. Estimates are the result of evaluation of all key areas
of development of a claim. Each aspect of a claim; indemnity, medical and expense,
should be
evaluated on its merits and be continually updated and refined.
Disability Management - Efforts to shorten the
length of time between the date of disability and the date the injured worker returns to
gainful employment or the date of claim resolution. When the need for disability
management is not recognized promptly, it can result in prolonged disability payments.
Medical Management - There is substantial economic
opportunity in medical management. The claim handler should be actively involved in
the medical management process. The claim handler coordinates with the
employer, medical provider and any nurse case manager that may be assisting with the
management of the medical aspects of a claim.
Medical Cost Containment
- The concept of managed
care, provider networks and utilization management are critical to reduce claim costs. The
claim handler should take advantage of existing cost containment programs and explore and
utilize new and innovative programs.
Recovery - There are substantial savings to be
realized through recognition and pursuit of recovery opportunities including
subrogation and second injury funds. Recovery is an essential part of proper claim
handling. The recognition and timely handling and pursuit of claims involving
recovery potential is important to maximize recovery.
Litigation Management - The claim handler’s
litigation management strategies should be to 1.) prevent litigation 2.) resolve
litigation timely 3.) manage litigation activities 4.) manage legal/defense costs.
Data Management - The accuracy of the data fields is
extremely important when a claim manager uses artificial intelligence to establish
reserves or perform other predictors for file management or loss prevention.
Claim Resolution - The majority of claims are
concluded by payment of statutory benefits. Frequently medical or disability management is
utilized to return the injured worker to employment. There are some claims that cannot be
resolved through such efforts and require lump sum settlements. A claim handler’s
responsibility is to manage claims. Timely file closure results in cost reduction to
clients.
