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Best Practices and Handling Protocols

New Claims

All new claims will be reviewed and investigated by the ProComp Claim Manager within 48 hours following the receipt of the claim notification and an electronic claim file will be established. All new claims as well as existing open claims will be electronically recorded so that the claims manager proactively reviews each claim.

Claims Investigation

Investigations will be initiated by the claims manager within 48 hours post receipt of the First Report of Injury document using a three (3) point contact plan. The (3) point contact plan includes:

  • Injured worker
  • Doctor or medical provider
  • SI employer

Medical Cost Containment

Upon notification of an injury, the Claim Manager will contact the injured worker, medical provider and employer for information about the injury. This information is then provided to our Nurse Case Manager who will conduct an assessment of the injured worker’s medical needs, review treatment that has been provided and evaluate available options. This information is communicated to the employer, Claim Manager and any other interested party to the claim. Below is a list of criteria we utilize for determining when the Nurse Case Manager should be further utilized in the ongoing management of the claim:

  • Temporary Total greater than 60 days
  • Herniated disc
  • Catastrophic claim
  • Light duty greater than 90 days
  • Serious burns
  • Serious head trauma
  • Amputations
  • Fractured limbs
  • Multiple periods of disability
  • Chiropractic care requested beyond 90 days

Our Goals include the following:

  • To facilitate recommended treatment plans so that appropriate medical care is provided to the injured worker
  • To assess alternate medical services for appropriateness and cost-effectiveness based on established medical standards
  • To encourage the injured worker to follow the prescribed medical care
  • To focus a medical plan towards return to work in a safe and timely manner, taking into consideration any restrictions or residual functional limitation

In addition, we implement several other cost containment strategies including:

  • Medical Bill Review: We partner with ReviewWorks to provide professional bill review and utilize their PPO Network. In addition, ReviewWorks has a Utilization Management and Peer Review process which has assisted our Claim Managers in controlling medical costs by evaluating medical necessity, frequency, compensability and duration of treatment. Cost of service is 20% of savings above Ohio BWC Fee Schedule.
  • Return to Work Programs: Our Claim Managers proactively work with clients to develop a Transitional Work Program before an injury occurs. Policies are created with step-by-step instructions and all roles are addressed in the program. Once guidelines are established, Claim Managers contact Physician of Record within 24 hours to obtain restrictions and send over job analysis. We have found it extremely beneficial to create a relationship with the physician’s office to help facilitate a quicker return to work timetable.

Independent Medical Examinations & Physician’s Reviews:

Medical providers’ reports and/or reviews will be requested immediately in those claims where medical information is needed in order to better assist the claims manager deciding claim compensability and/or extent of disability.

Payment Options of Medical, Indemnity and Allowed Expenses

Checks with signature authority will be processed through ProComp. Upon completion of the checks, the checks are signed and distributed with copies retained in the claim file and forwarded to the SI employer for inclusion in the onsite claim file. Detailed check registers are provided with each check run to the SI employer. Medical and Compensation payments will be made on a bi-weekly basis.

Light Duty

ProComp reviews all claims for light duty and/or restricted duty work when indicated by a physician and/or medical provider. A light duty employment assignment will return the claimant to employment post the employer forwarding a written letter of employment to the claimant (pursuant to the SI claims manager’s request). If the claims manager isolates the claim or claimant for potential of light duty placement that has not already been discussed with the physician of record, a consultation will be initiated with the SI employer onsite workers’ compensation designee. After consulting with the SI employer, the physician of record will be contacted by the TPA’s claims manager to communicate the arrangement of a transitional duty job position.

Post contact with the physician of record, the TPA claims manager will advise the employer to forward written notice of light duty position availability to the claimant with the physician of record’s agreement of same included as an attachment.

Pre-Audit Consultation

Upon notification of a pending audit of self-insurance claims, the TPA claims manager will conduct an onsite pre-audit to prepare the SI employer for the upcoming audit. BWC now performs online audits and our software has the ability to allow the BWC auditor to access all pertinent information online. The claims manager will assist the SI employer with the completion of all audit questionnaires and will spot-check the claim files, as well as review the BWC’s SI procedures with the employer’s onsite SI claims designee.

Post completion of the BWC’s onsite audit, the claims manager will review the results and advise the employer regarding the preparation of any further requested documentation by the Ohio BWC.

Review of Assessments

The SI Claims Manager will prepare all documentation for the purposes of independent auditing, and/or employer’s filing of Ohio BWC assessments. This includes assistance with completing annual SI-40 report and calculation of all annual assessment amounts.

Claim Recoveries

The SI Claims Manager will pursue all appropriate financial recovery on behalf of the SI employer from all state agencies, responsible third parties and any other contracted excess carriers that may be associated with a particular claim.

Independent Medical Evaluations (IME’s), Physician’s Review, Or Functional Capacities Evaluation:

The SI Claims Manager will advise the SI employer’s onsite designee that claim’s facts dictate a scheduling of an independent medical evaluation, physician’s review or functional capacity evaluation. In instances that warrant this type of additional evaluation, the claims manager will refer the claim for appropriate scheduling and further review for the purposes of the evaluation to be conducted on behalf of the SI employer.

Private Surveillance

Surveillance may be suggested by the SI Claims Manager as part of the workers’ compensation initiative in certain cases. Possible rationale may include, but are not limited to, whether or not the claimant and or the claimant’s dependents in P.T.D. cases are still alive or are still entitled to claim benefits, cases where there exists a suspicion of malingering and cases where a discrepancy between the reported cause of injury/illness and the received reports of the claimant’s activities. Activity checks are recommended for all ongoing disability cases which are deemed to be excessive by the SI employer or the SI Claims Manager. The SI Claims Manager will not schedule Private Surveillance without the authorization from the SI Employer.

Hearings

All contested claims are reviewed by the SI Claims Manager whenever any such claims are assigned to the SI Employer’s policy by the Ohio BWC. The initial contact is made with the SI Employer’s appropriate personnel to obtain any necessary information and to discuss witnesses where they are indicated. The SI employer’s defense strategy is additionally discussed. Once the contested claim is scheduled for hearing, the SI Employer is contacted again to verify that all claim documents have been received by the TPA. At this point, the claim is prepared for the Ohio Industrial Commission Administrative Hearing.

Workers' Compensation Diary

All lost time claims will have a diary entered into the computer system within 7 working days of receipt of the initial report of injury. The diary, which is included within the employer’s electronic claim file, is updated as the claim progresses. The diary, or “Claims Strategy”, will indicate the additional work anticipated (IME, litigation, rehabilitation, surveillance, etc.) and expected time frames to complete said items.

Payment of Benefits

All medical payments will be made in accordance with the Ohio BWC guidelines and fee schedules. Bills will be confirmed through medical reports and other proper documentation (a copy of which will be maintained in the claim file) before they are paid. The SI Billing Manager insures that all fee bills (prior to remittance) are reviewed for clear relationship to the allowed conditions in the claim, appropriateness of treatment and that they are from the recognized attending physician(s). If the fee bills are deemed unrelated by the SI Billing Manager, they will remain unpaid and a written explanation is returned to the provider with reason (s) for the lack of payment.

All indemnity payments will be made, at minimum, in accordance with the appropriate state agency statutes. Prior to the payment of compensation, contacts will be made with the appropriate SI Employer’s onsite designee to discuss the matter. The contact will be made on a bi-weekly basis, as determined during the employer’s initial implementation meeting. All compensation payments will always be withheld until appropriate receipt of the injury and/or occupational disease report from the SI Employer regarding a workplace incident. Copies of the documentation are maintained in the claim files.

Reserving

Reserving of workers’ compensation claims is a very important function for our Claim Managers and we monitor reserves closely to ensure they represent the ultimate cost of the claim. The establishment of reserves is more of an art than a science, but they are not the result of a guess. Accurate reserves are a function of the experience of the Claim Manager, the quality of the investigation, a good claims control program, and most of all the impact of the injury on the employee. An initial workers’ compensation reserve will be established within 7 working days of receipt of the First Report of Injury/Incident Report and entered into our computer system. The reserves will reflect exposures commensurate with the injury and degree of disability. The claims manager will discuss with the employer when setting/adjusting reserves. In addition, each claim file will contain reserve comments in the computerized narrative log relative to initial and ongoing reserves. The reserves will then be reviewed every 30 days and adjusted accordingly.

File Documentation

The TPA will maintain an electronic claim file in accordance with BWC rules and guidelines. The file will contain all reserve estimates, revisions, etc., will be clearly explained in the file via a reserve estimate worksheet or a narrative electronic document.

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