It is essential that you notify us of any claim or other loss as soon as possible. It gives us the opportunity to investigate while:
Prompt notice is also a practical necessity to minimize any potential disruption to the wages an employee may be losing while away from work. Contrarily, a delayed notice of an accident may also make the investigation, adjustment and defense of the claim extremely difficult and costly. Fast, accurate claim reporting is in the best interest of all parties.
As part of our prompt, thorough investigation, we will secure detailed information from you, the medical provider(s) and in most cases, the employee.
During the fact-finding stage of the investigation, we will be looking to you to provide valuable insight regarding the circumstances surrounding the incident to assist us with our determination on the best course of action to proceed. In some cases, we may not have enough information from one or more sources, whether it is medically or otherwise, to make a final determination. Accordingly, we may categorize the claim as “Denied Pending Investigation” in order to secure the necessary information to arrive at the most accurate conclusions. Once a final determination is made to accept or deny a claim, the parties are notified.
In the event an accident may have been caused by or attributed to a person or thing other than the injured employee, our investigation …
… will include an exploration and determination regarding the feasibility, to pursue civil litigation or other actions of recovery against such third-party. Although a recovery from a third party will not have any impact on the workers’ compensation benefits already owed to the injured employee, it will likely impact your insurance policy favorably. As such, during our investigation and determination process, we will require your assistance in order to achieve the maximum possible recovery.
An ideal way to keep workers’ compensation costs to a minimum is, of course, not to have any injuries. From a practical standpoint, however, this may not always be the case.
Notwithstanding, the steps you take BEFORE and AFTER an injury can be decisive factors in determining the impact of workers’ compensation costs on your business operations and bottom-line profitability.
BEFORE an accident occurs, you have a multitude of powerful, effective and proven tools, techniques and programs which you can implement to significantly limit or even avoid experiencing workplace injuries.
A few of these are:
AFTER an accident occurs, how and how quickly you handle the situation can leave a lasting impression on that particular injury as well as curbing the potential for future injuries.
A few of the more significant actions include:
We make every effort to ensure your employee is receiving the best, most appropriate and cost effective medical care available.
In order to accomplish this, we continuously monitor the employee’s medical progress. At times, we may also include the services of a nurse case manager, who is a Registered Nurse (R.N.), to assist us with achieving this goal. We utilize nurses both in-house, as well as in the field depending on the specific needs of each situation.
The Workers’ Compensation Medical Fee Schedule, which is governed by the statutory rules and regulations, limits the amount of fees and costs which a medical provider may charge for rendering medical care, services and supplies to injured employees.
However, not all medical providers consistently adhere to this billing regimen due to occasional system & data entry errors, accidental miscoding of medical procedures, duplicate & unrelated billing, and a number of other reasons. As such, we have partnered with medical bill review companies to ensure statutory compliance. Throughout the duration of a claim, medical bills are channeled through this process to verify that the medical costs paid on your claims are nothing in excess of what is reasonable and appropriate.
One of the tenets of workers’ compensation is to return the employee to work (RTW). To initiate this RTW process, we will ask that you complete a job description form …
… which details the physical requirements of the employee’s regular work duties, as well as any available transitional work or modified/light duties. Upon receiving this completed form from you, the claims adjuster and/or nurse case manager will coordinate the RTW in tandem with you and the physician to return the employee to work at the most opportune moment when medically indicated. Once the employee has returned to work, medical treatments may continue until his/her condition has fully stabilized.
Having transitional work available is often a win-win situation for you and the employee. Some of the benefits include:
Alternate work options come in a variety of forms. Each has its own unique effectiveness, depending on the type of physical capabilities the employee may have at a given time.
Welcoming the injured employee back to his/her normal position, but with restrictions assigned by a physician.
Example: A physician declares that the injured worker has a 10 pound lifting restriction. It is important to emphasize to everyone including the injured worker, their supervisor and others that compliance with these restrictions is mandatory.
Having an existing position or creating a new position specifically for this employee, on a temporary or permanent basis, that is physically less demanding than their normal position and meets the physical restrictions set by a physician.
Example: A delivery driver accustomed to carrying and moving boxes up to 80 pounds is temporarily assisting the office with filling invoices, due to his 5 pound lifting restriction.
Bringing the employee back to their full working capacity over a set period of time. This process may begin with 1 or 2 hours of work a day and/or 1 or 2 days a week and gradually increases as time passes.
It is not uncommon for Transitional Duty to be combined with Light or Modified Duty.
Example: A new temporary position is created specifically for this employee to sit by the door and greet customers 1 hour/day at minimum wage.
Although some companies may not be able to have or create light, modified or transitional work due to the nature of their business, size of their existing workforce, economic conditions, etc., every effort should be made to explore the feasibility for creating such work for the extensive social, emotional, and financial gains from which both you and the employee will reap.
PPD occurs when an employee has sustained permanent impairment as a result of the work injury.
It is primarily determined by a medical exam from an objective independent physician in accordance with set impairment rating guidelines established by the American Medical Association. Although many cases do not result in any PPD, there are some that do. For these, an employee is entitled to additional benefits. The benefit amount corresponding to the impairment rating is clearly documented in statute and regulated by the Department of Labor.
If an injury results in noticeable permanent disfigurement, the employee may be entitled to a disfigurement award.
Disfigurement includes scars, deformity, and discoloration. Laceration scars and surgical scars are reviewed six months from the date of the occurrence. Burn scars are evaluated after one year.
Upon conclusion of a workers’ compensation claim, we will file a WC-3 Final Carrier’s Case Report with the Department of Labor, a copy of which will be provided to the injured employee and your insurance agent.
This report will outline all the payments made to the employee, medical providers and other parties involved with the case. A similar report is sent to you at the end of each year for all open claims. You may file these reports in your records, as appropriate.
Should you have any questions regarding workers’ compensation, the claims process, or a particular claim, please visit our “FAQs” (Frequently Asked Questions) section which may help answer some of your questions.
Otherwise, do not hesitate to contact your claims adjuster at 537-5221 or see the “Employer Contact Information” section for additional options