Claims management means checking and rechecking
Retail Services not only processes claims, but our staff also investigates to establish that injury claims are valid. The savings from illegitimate claims help RS keep workers’ comp insurance rates down for members even before they qualify for partial refunds.
Two recent examples illustrate this value for members.
Claims Administration Manager Nancy Barnes’ additional research resulted in a rejected injury claim earlier this year.
An employee filed a workers’ compensation claim for injuries to the neck and shoulder. In the course of the research, the worker mentioned similar problems dating back two years. In the injury claim, the worker was unclear which of the injuries occurred at work.
Nancy obtained an independent medical examination to determine whether the worker’s current medical situation was a natural progression of a pre-existing condition, including a neck fracture that persuaded the worker to forgo shoulder surgery.
During the investigation, the worker declined multiple requests for additional information. Labor & Industries wound up rejecting the claim. Had it been allowed, the worker could have had surgery performed under the claim, received time loss payments and associated permanent partial disability costs.
Claims analyst Brigitte Le Vie pursued documentation in the case of an injured worker earlier this year to avoid wasted time loss payments.
The worker filed an injury claim about breaking a rib leaning over a piece of equipment at work. Brigitte checked with the witnesses offered by the worker in hopes of supporting his claim.
In researching the case, Brigitte learned that medical records related to the treatments diagnosed the rib injury as being caused by persistent coughing, not an injury caused by equipment on the job. Labor & Industries rejected the claim as a result. Had it been honored, it would have resulted in improper time loss payments that could have stretched out for weeks of healing from the injury.