Best Practices

Workers' Compensation 

FILE SETUP

  • Files should be set-up 24 hours from receipt in claims office.

RAPPORT/CONTACT

  • Attempted contact with the injured worker, or attorney if represented, employer and treating physician, should occur within 24 hours of receipt of the loss in the claims office and include full disclosure of the process, benefits and prompt payments, where necessary, with reasonable attempts made thereafter.
  • Acceptance or denial of compensability should be communicated at the earliest possible time to the injured worker and employer.

INVESTIGATION

  • Timely and appropriate investigation should be performed to determine compensability, causal relationship, pre-existing medical, second injury fund, and identification or ruling out of subrogation potential.
  • Timely gathering and preservation of facts and evidence, including obtaining recorded statements, when appropriate, should be documented in the electronic file notes.
  • Obtain necessary medical documentation, average weekly wage verification per statutory requirements and IME's based upon facts of the case.

RESERVES

  • Initial reserves should be established within 48 hours of receipt of the loss in the claims office and the rationale documented in the electronic file notes.
  • Reserves should be based upon known facts and evidence at the time the reserve is posted.
  • Reserves should be periodically reevaluated to reflect the probable ultimate cost.

MEDICAL/EXPENSE MANAGEMENT

  • Cost containment, medical management, SIU and recovery programs should be utilized when applicable.
  • All bills should be reviewed for appropriateness and accuracy.
  • Itemized billing, which includes date work performed, description of work, and by whom, should be in increments of one-tenth of an hour.
  • Treatment and medical management should be authorized and overseen.

LITIGATION MANAGEMENT

  • Responsibility for the management and control of the litigation remains with the file handler.
  • Defense cost estimates should be obtained and documented in the electronic file notes.
  • Timely, proactive case resolution strategy (with applicable defenses considered) and use of ADR, arbitration, structured settlements, direct negotiation with plaintiff counsel should be pursued, if appropriate, and documented.

DIARY CONTROL/RESOLUTION

  • The initial diary review should be completed within 28 days from setup.
  • Maximum diary intervals should not exceed 30 days on active cases.
  • The file should contain the current status, updated plan of action, review of the reserves, and a timely proactive disposition strategy.
  • Timely and appropriate negotiations based on the facts of the case are the responsibility of the file handler, not defense counsel.

REPORTING

  • Compliance with regulatory and corporate reporting requirements should be evident. 

Liability

FILE SETUP

  • Files should be set-up 24 hours from receipt in claims office.

COVERAGE

  • Promptly, upon receipt of the claim, the coverage information should be reviewed and documented.
  • If at that time or subsequently it appears that there is a question of whether coverage applies to the claim notify the parties.

RAPPORT/CONTACT

  • Attempted contact with the client and claimant or attorney if represented should occur within 24 hours of receipt of the loss in the claims office with reasonable attempts made thereafter.

INVESTIGATION

  • Timely and appropriate investigation should be performed to determine liability and damage issues.
  • Timely gathering and preservation of facts and evidence should be documented in the electronic file notes.
  • Investigation should include, where appropriate, items such as photos, statements, contracts, police reports, diagrams, medical records and IMEs.

RESERVES

  • Initial reserves should be established on the file within 48 hours of receipt of the loss in the office.
  • Reserving should be based upon what is known about liability and damages at the time the reserve is posted.
  • Reserves should be periodically reevaluated to reflect the probable ultimate cost.

DAMAGES

  • The file should contain documentation of specials i.e. medical bills, wage statements, estimates, etc.
  • Authorizations should be obtained for medical and wage information in a timely manner from the claimant, or if represented, from their attorney.
  • Appraisals should be obtained on property damage claims.


DIARY CONTROL/RESOLUTION

  • Maximum diary intervals should not exceed 30 days on active cases.
  • The file should contain current status, updated plan of action and a timely, proactive disposition strategy.
  • Consideration should be given to the use of resolution techniques such as ADR, arbitration, structured settlements, direct negotiations with attorneys, etc.

EXPENSE MANAGEMENT

  • There should be application of good business judgment in the utilization of counsel, experts and service providers.