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 creates a plan of action.  An electronic claim file is promptly created in our system and the following standard procedures are implemented.

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.

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 clearinghouse provides feedback on claims submitted by the claimant to other ISO members.

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.

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. When applicable, professional investigators are assigned to conduct a more extensive investigation.

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.

Fraud Deterrence

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

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.

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.

AOE/COE Determination

The occurrence of an injury that “Arose Out 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.

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.

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 benefit payments are initiated, and cases are closely monitored on a bi-weekly basis.

Payment Processing

All claim-related expenditures are paid through a specific 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.

Provider Oversight

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

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.

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.

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.

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.

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.

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.

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.

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.

Settlement Negotiation

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

Subrogation Recovery

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

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 claims involving lifetime  benefits are permanently archived.

Final Thoughts

The above mentioned 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.

Optimal Synergy

We created MedReview to provide customized utilization review and bill review services exclusively for AdminSure clients.  Due to its seamless integration with the claims administration process, MedReview enables us to be more efficient, to achieve better results, and to offer more flexibility than would otherwise be possible.

Utilization Review

Workers’ Compensation medical treatment in California is regulated by the Medical Treatment Utilization Schedule (MTUS). In fact, this schedule, which includes treatment protocols from the American College of Occupational and Environmental Medicine (ACOEM), is the basis for mandatory utilization review in California.

Recognizing the importance of utilization review, we have assembled an exceptional team of medical professionals, consisting of physicians, registered nurses, and reviewers. These professionals collaborate with our claims personnel on a daily basis. Furthermore, we carefully manage the entire utilization review process in accordance to the Labor Code and California Code of Regulations.

Our utilization review has been awarded Workers’ Compensation Utilization Management Accreditation from Utilization Review Accreditation Commission (URAC). The URAC seal of approval signifies our continuous commitment for quality improvement.

Utilization Review Plan –  Our professional approach to utilization review ensures injured workers receive timely and appropriate care.

Utilization Review Plan

Medical Bill Review

Under California law, Workers’ Compensation medical charges are capped by the Official Medical Fee Schedule (OMFS), Inpatient Hospital fee Schedule (IHFS), as well as other schedules, contracts, agreements, etcetera.

Experienced, State Verified Medical Bill Reviews use specialized bill review software to scrutinize every line of every medical bill for duplicate or unrelated charges and conformance to fee schedules.  The software includes expert system logic to ferret out such anomalies as multiple, initial office exams.  It also ties into several Preferred Provider Organization (PPO) networks that yield further discounts below fee schedules.

Savings from bill review are substantial with an overall average of nearly 70%.

Physician Peer Review

When appropriate, our claims and utilization review personnel submit cases to a panel of board certified specialists for physician peer review.  Also, our physician peer reviewers are available for peer conversations. This process frequently leads to a better outcome for the patient.

Nurse Case Management

For severe or difficult cases, we look to a network of independent, professional nurse case managers who work closely with injured workers to ensure that timely and appropriate medical care is provided.  This not only reassures injured workers, it may reduce the duration, extent and cost of disability.

Pharmacy Benefit Management

Prescription drugs are a significant part of a Workers’ Compensation medical budget.  We work with leading pharmacy benefit management firms to control costs by reducing physician dispensing, creating custom formularies, promoting high quality generics and reducing waste, fraud and abuse, especially in the dispensing of narcotics.

Medical Provider Networks

Medical Provider Networks give an employer partial control over the choice of doctors and medical facilities in Workers’ Compensation cases.  AdminSure has access to established networks which can be customized using carve-outs, or we can build a network from scratch.  Customizing an existing network is generally more cost-effective.