What Occurs When Your Claims are Submitted to Your Carrier/TPA August 12, 2015
Determination of Claim Page | 2
Determination of Claim Accept Delay & Investigate Deny Page | 3
Determination of Claim Acceptance – explanation of what goes on when claim is accepted. Facts add up Start with the end of the story Page | 4
Determination of Claim Delay – Investigate No stone unturned Page | 5
Determination of Claim Deny What will the Audit Unit say? End of the story? Page | 6
Benefits Provided Indemnity & Medical Page | 7
Benefits Provided – Indemnity & Medical Indemnity – TTD, PD, SJDV (if applicable) Benefit calculation 104 weeks…then there’s EDD Wage garnishments Page | 8
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? Page | 9
Issues to Address Page | 10
Issues to Address Contribution Cumulative trauma…pointing fingers Page | 11
Issues to Address Apportionment Prior awards Pre-existing Page | 12
Issues to Address Subrogation Pay me back Statue of limitations Unit Stat filing Page | 13
Litigation Page | 14
Litigation Defense Attorney Carrier/TPA panels Find a good partner Page | 15
Litigation Strategy Settle early v. litigate…make smart business decisions Page | 16
Resolution of Claim Page | 17
Role of Your Broker Claims Consultant/Analyst Page | 18
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 Page | 19
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 Page | 20