Four Workers Comp Claim Review Strategies

This is an excerpt from the manual found here that I wrote many years ago. The info is basically timeless. Claims reviews are an integral part of a premium reduction program and even more critical if you are self insured.

There are four possible methods to review your WC claim reserves:

Claims Office Review –

Advantages - reviewing the claims files in your insurer’s claims office is the most accurate way to review the claims reserves; the employers can examine everything that was involved with the file and will call attention to the insurer that your company takes the reserves on the files very seriously; the adjuster or adjusters on the files will usually meet with you face to face.

Disadvantages – the review may not be feasible if the claims office is in a remote location; cost of travel; takes up employer’s time, especially if the claims office is in another state.

Claims Review at the Employer’s Location/Agent’s/Broker's office -

Advantages – saves the employer travel time and the cost of traveling to the claims office; adjusters will sometimes adjust their reserves before the meeting, if the adjuster believes the adjustments are necessary.

Disadvantages – insurers rarely bring files with them, more of a “canned” review as the adjuster has reviewed everything and will present their reasons for the reserve levels; more of a public relations/marketing meeting; the adjuster or claims department usually controls the subject matter of these meetings; this type of meeting takes adjusters away from their files; the employer may pay extra premium to have these meetings.

Online Review - Full access to all adjuster notes, statuses, reserve levels, and reserve history are very important.

Advantages – saves the employer travel time and the cost of traveling to the claims office; immediate and accurate claims review if the employer has full access to the claims files; reviews can be done at any time and can follow the recommended timetable on the preceding page; the employer has control of the review.

Disadvantages – there are little or no disadvantages to online reviews with full access to all reserves, statutes, adjuster notes, etc.; if the employer has limited access to the files, then the employer may not know the justification of the reserve levels.

Employer Self Review –

Advantages – the employer controls the review; saves time and cost of travel, as the employer does not have to incur any travel; all parts of the claims file are available; can be combined with the Online Review or by using loss runs from the insurer.

Disadvantages – employer has to keep copies of all forms, notes, and any other pertinent file material; the employer may spend an inordinate amount of time and expense in retrieving all file material from the insurer, treating physician, and other parties; privacy rules may be an issue.