Post on 19-Jan-2016
What Occurs When Your Claims are Submitted to Your Carrier/TPA
August 12, 2015
Determination of Claim
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Determination of Claim
Accept
Delay & Investigate
Deny
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Determination of Claim
Acceptance – explanation of what goes on when claim is accepted.
Facts add up
Start with the end of the story
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Determination of Claim
Delay – Investigate
No stone unturned
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Determination of Claim
Deny
What will the Audit Unit say?
End of the story?
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Benefits ProvidedIndemnity & Medical
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Benefits Provided – Indemnity & Medical
Indemnity – TTD, PD, SJDV (if applicable)
Benefit calculation
104 weeks…then there’s EDD
Wage garnishments
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Benefits Provided – Indemnity & Medical
Medical – MPN, UR, AME/PQME
Asserting treatment within the MPN
Utilization Review…what’s your plan?
IMR…usually favors the employer
Should you AME or QME?
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Issues to Address
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Issues to Address
Contribution
Cumulative trauma…pointing fingers
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Issues to Address
Apportionment
Prior awards
Pre-existing
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Issues to Address
Subrogation
Pay me back
Statue of limitations
Unit Stat filing
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Litigation
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Litigation
Defense Attorney
Carrier/TPA panels
Find a good partner
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Litigation
Strategy
Settle early v. litigate…make smart business decisions
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Resolution of Claim
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Role of Your BrokerClaims Consultant/Analyst
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Role of your Broker – Claims Consultant/Analyst
Client advocate on your work comp claims
Understand your company’s dynamics, how it wants claims administered/resolved
Provide alternatives to effectively posture claims toward a quicker resolution
Review reserve setting
Analyze settlement requests for authority
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Role of your Broker – Claims Consultant/Analyst
Collaborate with your carrier/TPA to provide for a better outcome on the claim(s)
Claims Adjuster should be your best friend
Transparency, access to claim information
Assess effectiveness of claims handling
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