Claims Administration

     Claims administration plays a vital role in Workers' Compensation and Liability programs.  Knowing this, AdminSure uses proven methods that are designed to achieve the best possible outcomes.

A.  Case Setup

     The process begins when a claim is first reported.  Each new claim is assigned to a claims administrator, who reviews the matter and devises a plan of action.  An electronic claim file is promptly created in our system and the following, standard procedures are implemented.

B.  Immediate Contact

     Within one or two workdays of receiving the claim, we initiate contact with the claimant or an attorney, if the claimant has one.  Also, treating physicians and employers are contacted in Workers’ Compensation cases involving lost time.  This is known as three point contact.

C.  ISO ClaimSearch

     All indemnity claims in Workers’ Compensation and injury claims in Liability are reported to ISO ClaimSearch.  Formerly known as the Index System, this information clearing house provides feedback on claims submitted by the claimant to other ISO members.

D.  Reserve Analysis

     Accurate reserves are an important and necessary part of the claims
administration process.  Upon the setup of a new case, initial reserves are established in several categories.  Every 90 days, these reserves are reviewed and updated, if necessary, as the case develops. 

E.  Initial Investigation

     In many cases, the only investigation necessary is a department or supervisor’s report and an ISO ClaimSearch.  Sometimes, other items of investigation are sought.  In selected cases, professional investigators are assigned to conduct a more extensive investigation.

F.  Special Investigation

     There are occasions when in-depth investigations are appropriate.  With client approval, professional investigators are engaged to look into questionable or unusual circumstances – or possible fraud.  Assignments are limited to specific tasks.

G.  Fraud Deterrence

     If there are indications of fraud, the matter is referred to the Special Investigation Unit.  With client approval, the Special Investigation Unit prepares and then submits the case to the appropriate law enforcement authorities for criminal prosecution.

H.  Risk Transfer

     Cases are tendered to responsible third parties when apportionment, contribution or indemnity are available.  This can occur when a claim is misdirected against the client, there is shared exposure or the client has an indemnification agreement with a third party.

I.  Liability Evaluation

     Upon gathering the facts in a Liability case, the liability exposure is evaluated, factoring in all pertinent issues, including statutory, case law and jurisdictional considerations.  This evaluation is used to determine whether a claim should be denied, settled or compromised.

J.  AOE/COE Determination

     The occurrence of an injury in the "Act of Employment/Course of Employment" is the primary determinant of compensability in Workers' Compensation cases.  Our claims administrators are specifically trained, and certified by the State, to make this determination.

K.  Damage Verification

     In Liability cases, damages are verified by obtaining and scrutinizing repair estimates, damage appraisals, itemized bills, medical reports and other documents.  With client approval, experts are retained in certain cases to evaluate the merit of claimed losses.

L.  Benefit Delivery

     In Workers’ Compensation cases, a determination is made as to what, if any, benefits are due.  In accordance with legal requirements, proper benefit notices and payment streams are initiated.  While benefits are due, cases are closely monitored on a bi-weekly basis.

M.  Payment Processing

     All claim related expenditures are paid through a special checking account that is set up for each client.  Benefits, losses, legal and other expenses are carefully audited to ensure they are necessary, reasonable and directly related to the claim.

N.  Provider Oversight

     Many service providers are called upon to assist in the handling of claims, including attorneys, doctors, investigators, translators, etcetera. These providers are monitored for quality, timeliness, effectiveness and reasonableness of charges.

O.  Ongoing Contact

     During the life of a case, we maintain contact with all interested parties, promptly returning calls and responding to inquiries.  Ongoing communication keeps programs running smoothly and reduces the kind of misunderstanding that often leads to costly litigation.

P.  Status Reports

     Clients are provided with status reports on cases when there are important developments, or significant events are about to occur.  In addition, periodic status reports may be provided at regular intervals, according to client preference.

Q.  Case Management

     AdminSure takes a proactive approach to managing claims.  Utilizing an online diary system, cases are periodically reviewed on a scheduled basis.  In each case, a plan of action is followed, and updated as needed, with all activities recorded in online file notes.

R.  Medical Management

     In Workers' Compensation cases, we monitor medical treatment and coordinate medical management activities, including utilization review, bill review, nurse case management and referrals to specialists.  State rules and regulations are followed when arranging for medical evaluations.

S.  Disability Management

     Various techniques are utilized to manage temporary and permanent disability in Workers' Compensation cases.  These include arranging for occupational therapy, work hardening, return to work programs and reasonable accommodation, when appropriate.

T.  Litigation Management

     When litigation occurs, cases are referred to an approved defense attorney.  Litigation guidelines are followed, correspondence monitored, bills audited, settlement conferences covered and assistance provided to the defense attorney – all in order to achieve an optimal outcome.

U.  Record Keeping

     All activities are carefully documented in a paperless system.  Digital records are stored on secure database and file servers.  Correspondence, mail and other case documents are scanned and preserved in our system for review and audit purposes.  All records are the property of the client.

V.  Excess Reporting

     Should a case meet excess insurance reporting criteria, the initial and subsequent reports, including all pertinent file documents, are submitted to the appropriate carrier.  In the event excess coverage is penetrated, reimbursement is obtained from the carrier.

W.  Settlement Negotiation

     Many cases are best resolved through settlement.  In those cases,
an evaluation is prepared, defense attorney consulted (if litigated) and settlement authority obtained.  Talks are then initiated, with the goal of concluding the matter for a reasonable amount.

X.  Subrogation Recovery

     When appropriate, loss recoveries are pursued in cases involving potential subrogation.  If the case warrants it, a law firm specializing in these types of recoveries is engaged on behalf of the client to pursue litigation against responsible third parties.

Y.  Case Closure

     After all claim issues have been resolved, all losses and expenses
have been paid, and all final documents have been filed, cases are promptly closed.  Workers’ Compensation cases involving lifetime  benefits are permanently archived.

Z.  Final Thoughts

     The foregoing procedures are meant to give a glimpse of the claims administration process and are, by no means, all inclusive.  The process involves a detailed knowledge of rules, regulations, laws and technical issues that goes far beyond the scope of this discussion.