Medical Management for Claims Examiners - Part 1

Saturday, February 2, 2002 | 0

One of the jobs of a claims examiner is ensuring that the injured worker gets appropriate medical treatment. As with most other aspects of claims management, the best approach is an active approach. In other words, don't monitor the medical, manage it! In this article we will review the basics. Following articles will get into more detail with some medical management strategies.

There are certain guiding principles applicable to this entire discussion. Let's review some of the basics:

The definition of treatment under a workers' compensation policy is similar in most states.

The employer/carrier has a basic duty to provide adequate treatment.

The employer/carrier is responsible for the prompt authorization of all medical treatment that is reasonably required to cure or relieve the employee from the effects of the industrial injury.

In order for a worker to be eligible for workers' compensation medical treatment. There must first be a compensable injury as defined by your state jurisdiction, and there must be a direct relationship between the industrial injury and the medical expenses incurred. State laws will differ in the technical details so check your state for specifics .

Workers' compensation medical is different from private medical insurance plans in several respects. Workers' compensation medical benefits have some features which are not ordinarily part of private medical plans. For example, there is no deductible to be paid by the injured employee in a workers' compensation plan. In most cases, there is no limit to the dollar amount of medical benefits that the employer/carrier will provide, and there is no stated time limit when benefits cease (i.e. even if a policy expires, medical benefits may be due on that policy for many years thereafter). Each state has specific guidelines governing the right to medical benefits so be sure you are familiar with those rules.

There are three general categories of injuries necessitating treatment under a workers' compensation scheme, sorted by complexity: first aid, medical only, and indemnity. Though similar in concept, some states may call these types by different "brand" names and critieria.

First Aid Claims involve one time treatment for minor scratches, cuts, burns, splinters and other minor industrial injuries. Work comp covers treatment usually rendered by the employer, and typically such claims do not require a formal report of injury to the carrier .

Medical Only Claims are simple claims where medical treatment requiring more than one visit is needed, but there is no claim being made for time off work (TTD) or permanent loss of function (PD). Medical only claims usually close in six months or less, have no lost time, no subrogation, no litigation, and result in no permanent disability.

Indemnity claims are more complex and serious. They result in more extensive treatment and larger medical costs, lost time, litigation, and permanent disability. 60% of all claims fall into this category.

The vast majority of indemnity claims fall within three categories of severity: Minimal - there is no lost time and no significant treatment; Slight - no lost time but needs more than minor treatment; and Moderate - ongoing treatment and lost work time, but no overnight hospitalization.

Now that we've established some definitions, here are some basic helpful hints applicable across the board:

When you authorize treatment, make sure that you establish up-front exactly what is being authorized. Document the file with the medical plan, expectations and time frame. Follow this up in writing. Pre-negotiate your bills when you authorize treatment, or you may pay the price in full! Note that some states do not allow the regulation of bills for reasonableness. Cover letters for treatment authorization must be tailored specifically to the claim. Boiler plate- letters are simply not acceptable because they are too vague - if you have to contest a certain course of treatment the burden will be on you to prove you did NOT authorize it. Utilize your resources to develop a cost effective treatment plan (bill review, utilization review, medical management nurses).

The next article will review management of specific orthopedic issues, as orthopedic injuries are by far claimed the most.

Author Cyndi Koppany is Vice President in charge of Training for Cambridge International. She can be reached at ckcyndi_koppany@cisgi.com.