10 Mistakes to Avoid When Handling a Workers’ Compensation Claim
Medical chart review is at the centre of workers’ comp claims. Here are 10 mistakes to avoid when handling these claims.
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Handling a workers’ compensation claim can be challenging for employers because any wrong step or lack of understanding of the claim can lead to costly litigation. The provision of the right medical care is very important, and typically employers utilize a medical peer review or physician peer review to determine if the injured worker is receiving appropriate care, i.e. medical care that is •
Medically necessary
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Timely
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Delivered in the proper sequence
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Related to the work-related injury/illness
The peer review will provide an objective and qualified medical report regarding the patient’s condition and future treatment, which helps the insurer make an informed decision about the next steps to take. Even though workers’ comp claims are evaluated objectively based on medical chart review and other relevant aspects, many cases go to court leading to loss of time and money. Therefore, employers must take extra caution when handling workers’ compensation claims. There
are
certain common mistakes employers make when handling workers’
compensation claims and determining the validity of the claims. If these mistakes are avoided, it could dramatically minimize the chances of litigation as well as the likelihood of their insurance premiums increasing. 1. Not investigating thoroughly: A thorough and immediate investigation into the event is very important. Early investigation will ensure comprehensive documents gathering and discovery. At a very early stage, the worker is unlikely to be represented by a legal professional and this would enable unrestricted access to the worker. What information should the investigator gather? •
Name/nickname, maiden name, and previous names of the employee
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Address, present and previous
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Contact numbers
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Social Security number and drivers’ license number
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Date of hire and state hired
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Vehicle
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Hobbies
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Time and date of injury
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Body part affected
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Source of injury (hand tools, slippery floors, machines)
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Type of injury sustained
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Witnesses, if any
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Work process involved
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Time and date the injury was reported
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To whom the injury was reported
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Work shift, if applicable
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Oral statement from injured employee
2. Insufficient documentation regarding the accident/injury/illness: Employers should maintain complete and detailed notes throughout every step of the investigation. All statements should be signed. All necessary steps must be taken immediately to preserve evidence and secure the scene of injury. 3. Failure to secure a medical release at the time of injury: This will lead to delay in obtaining the medical records, consequent delay in performing the important medical chart review process, and delay in making the decision regarding compensation. It is best to have the claimant sign a medical release, if possible, at the time of the injury. 4. Failure to obtain all relevant medical records: Medical records, both before and after the injury/illness are important in determining or defending a claim. The current medical records should support the claimant’s physical complaints. Other aspects that need supporting documentation include: •
Whether the claimant has been treated for the affected body part in the past
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Whether the claimant frequently changes his/her medical providers
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Whether the claimant changes physicians when a release for full duty work has been issued
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Whether the medical records provide information not consistent with the appearance or behavior of the injured person
5. Not keeping in touch with the injured employee: Employees lose trust in employers who fail to stay in touch with them through various phases of the injury or provide information regarding how the claim is handled. When employers stay in touch, the workers feel comfortable and wanted. 6. Not having a safety program in place: It is important to invest in safety training and education and to create an official program that addresses all possible dangerous situations including natural disaster emergencies, common injuries, and personal protection against exposure to injury/illness. This will help to reduce the risk of injury and illness in the workplace.
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7. Not having a good return to work program for injured employees: Employers must focus on bringing the injured worker back to work sooner, so that the worker feels he/she is valued by the organization. 8. Failure to keep specific evidence ready for the court hearing: The hearing officer may need specific evidence upon which he/she can rely when denying a claim. 9. Lack of understanding regarding workers’ compensation in general: Employers should be thoroughly knowledgeable about the laws in the state where their business is based. Otherwise, it could lead to legal risks. 10. Failing to submit the claim to the insurer right away: Employers must communicate with their insurance provider regularly, and immediately notify the insurance provider of any worker reported injury. The above checklist will help employers handle the workers’ compensation claims efficiently, and build a good rapport with their employees. Also, it is important to keep in mind that medical records and medical chart review are at the centre of a workers’ compensation claim, which makes compiling all the relevant medical documentation one of the most important responsibilities.
www.mosmedicalrecordreview.com
(800) 670 2809