Effective Claims Management for Workers’ Compensation:
Engage Legal Support Early
One of the most critical steps in claims management is involving legal counsel as soon as possible. Each jurisdiction has different laws, so it is essential to assess potential applicable defenses and contact local counsel.
- Contact an attorney promptly to ensure compliance with deadlines and regulations.
- Engage defense attorneys at the onset of a claim, which can save money in the long run by preventing missteps.
- Schedule initial consultations via Teams or conference calls to discuss the case strategy early.
Documentation & Evidence Collection
Thorough documentation is the foundation of effective claims management. Proper evidence collection helps employers defend against fraudulent or exaggerated claims.
- Send wage statements promptly to attorneys to address potential overpayment issues.
- Preserve and timestamp surveillance videos to provide clear evidence of workplace incidents.
- Obtain a statement from the employee as soon as possible. This can help identify inconsistencies if their recollection changes after seeking legal counsel.
- Utilize video evidence whenever available to support legal defenses.
- Conduct site visits to gain a better contextual understanding of workplace conditions.
- Use videos and photographs to illustrate job-site environments.
- Show medical providers how employees operate equipment to provide accurate assessments.
Employer Responsibilities & Communication
Employers play a vital role in ensuring that claims are handled efficiently. Clear communication and prompt action can prevent costly delays.
- Educate personnel on the importance of promptly reporting claims.
- Ensure all employees understand where and how claims should be reported.
- Establish protocols for urgent claim handling.
- Recognize that laws vary by state; for example, Illinois stair-fall cases differ from those in Tennessee or Connecticut.
- Employers should be aware of state-specific requirements. If uncertain, legal counsel should be consulted immediately.
Pre-Hiring Practices & Surveillance
Proactive measures during the hiring process can help prevent fraudulent claims.
- Take and maintain a photograph of employees during pre-hire to prevent misidentification in surveillance.
- Monitor social media for inconsistencies that may contradict an injury claim.
- Conduct drug screenings, as some claims can be denied based on positive test results.
Legal and Administrative Support
Proper legal guidance ensures claims are handled appropriately and in compliance with regulations.
- Allow attorneys to handle pleadings and correspondence.
- Seek attorney assistance in drafting causation letters for physicians to ensure proper legal verbiage.
- Consult legal professionals when selecting doctors for Independent Medical Evaluations (IME) or medical panels.
- In complex cases, such as catastrophic injuries (e.g., the American Airlines case), attorneys should be involved immediately to structure the case properly.
Personnel File & Prior Claims Investigation
A thorough review of personnel files and past claims can provide valuable insights into potential fraud or pre-existing conditions.
- Employers should share complete personnel files with legal counsel to facilitate informed decision-making.
- If hesitant, employers should assess why withholding the file would be necessary.
- Investigate prior state filings using the ISO database to identify previous claims.
- Cross-reference social media to determine the employee’s activities before, during, and after the accident.
- Identify inconsistencies, such as employees engaging in physically demanding activities despite claiming injuries.
- Example: An employee with an ankle injury seen dancing or a shoulder injury claim from someone who regularly engages in bass fishing.
Conclusion
Effective workers’ compensation claims management requires early legal involvement, thorough documentation, and proactive risk assessment. By implementing these best practices, employers can reduce costs, improve outcomes, and protect their organizations.