Actions We Complete on Your Behalf
Sustaining an Industrial Injury/Illness can be a life altering event. We are here to be an advocate for your recovery. These are just a few actions we complete on your behalf:
- Initial contact with you upon receipt of injury claim information from your Employer, including explanation of general WC process.
- Contact with your treating physician to expedite any pending treatment.
- Continuous monitoring of new and/or changing medical updates/information to facilitate medical care and work status (modified duty and/or full duty).
- Monitoring of treatment requests to ensure we expedite care within our initial Adjuster protocol if at all possible.
- Any treatment requests submitted for formal review to Utilization Review is monitored for a final decision. Utilization Review will determine medical necessity of the request for authorization of treatment consistent with evidence-based guidelines. The Utilization Review process takes up to 5 work days (or no more than 14 days if additional information is requested from your provider) after receipt of a complete request from your treating physician.
- If treatment is authorized 100% as requested, the treating physician will be notified in writing, so please follow up with your physician and discuss your treatment and work status during each appointment. Hold your physician accountable to coordinate the approved care.
- If treatment is modified and/or denied, you will receive a copy of the Utilization Review decision.
- You have a right to accept the decision.
- Or, you may obtain a second opinion through the Independent Medical Review (IMR) process. We will provide you the IMR form and pay for that service but you must fill out the IMR form and submit it to Maximus (The Independent Review Organization) within 30 days of the decision. If you elect to obtain a second opinion, we will be notified by Maximus and will provide them your medical records as required. Maximus will make a decision for all parties and either uphold or overturn the Utilization Review decision. We will monitor the outcome of the decision and complete any necessary action based on their determination.
- Lost time (called Temporary Disability) benefits will be promptly commenced and/or continued as soon as we receive medical documentation from your primary treating physician and verify off work status and/or modified duty that cannot be temporarily accommodated by your employer. If you have a Salary Continuation Program through your Employer, you will not receive direct payments from us during your period of lost time from work until you have exhausted same.
- Modified duty may be available depending upon your work restrictions. Therefore, it is your responsibility to always communicate directly to your Supervisor and Manager regarding your changing work statuses after each doctor’s appointment so an appropriate return-to-work date can be determined based on your treating physician’s assessment. We will also maintain contact with you and your Employer on this issue and assist with coordination of return-to-work.
- We will follow up with your treating physician for a final Permanent and Stationary report (P&S) and/or Maximum Medical Improvement (MMI) report. If your Industrial Injury/Illness resulted in ratable permanent impairment (i.e. loss of use or function, etcetera) and/or need for future medical care, your treating physician will include that information in your final report. We will also notify you in writing and will commence permanent disability benefits, as applicable. On these cases, we will contact you to settle your claim and will obtain final approval from the Workers’ Compensation Appeals Board.
- If you were issued permanent work restrictions in your final report, we will alert your Employer with the information to facilitate the interactive accommodation process.
- You may disagree with your treating physician and may obtain a second opinion through the Qualified Medical Evaluator (QME) process at any time. We will pay for that exam. Just contact us and/or complete the proper forms within 30 days of an exam or notice from us.
- If your claim is delayed as additional information is required to determine whether the injury or illness is work-related, we will explain what is needed from you and/or other parties. Please fully cooperate as it will allow us to make a prompt decision.
- If you sustain ratable permanent disability due to your industrial injury/illness and/or need for future medical care, you have two general settlement options: 1) settlement via Stipulation with Request for Award which may include payments every two weeks until the amount of your permanent disability Award has been paid, or 2) Compromise and Release – lump-sum buyout. Typically, a Compromise and Release agreement is an option only if you are no longer employed with your Employer at the time of settlement. Contact us to ensure that the benefits that you are entitled to receive are formally settled; otherwise, your eligibility for these benefits may not be protected.
We are here for you, every step of the way!