I’ve spent a substantial amount of my insurance career reviewing workers compensation audit files in my capacity as a claim supervisor, a manager and a consultant for a large insurance broker. Those years allowed me to come to the following conclusion: Unless the employer is prepared, it’s wasting its time sitting through a workers’ comp file review.
I know…pretty simple, right? While it looks like sense , you’d be surprised what percentage employers don’t do their prep work. Many times, I’ve seen an employer sitting within the meeting nodding approvingly while the examiner provides a lackluster or imprecise update. The employers — neither being experts nor adequately prepared — don’t know the difference. And because they allowed themselves to be bamboozled, the file reviews are basically for naught.
Don’t get me wrong. I’m not saying file reviews are total rubbish. The mere incontrovertible fact that you requested the file review shows you're somewhat interested and can most certainly motivate the examiners to update files.
But a file review will only scratch the surface. You might as well call the file review, “Tell-me-what- you-want-me-to-know-in-three-minutes-or-less.”
I always advocate for an actual file audit once in a while to supplement your quarterly file reviews on all high value/high exposure cases. When it comes to a file audit, there’s no place to hide. Stone after stone will be unturned so no doubt remains as to whether the file was handled right by the examiner. You see, oftentimes what the examiner tells you — and what the file ultimately reveals — are totally different scenarios. The audit isn’t how to catch the examiner slacking but rather to seek out out if your money is well-spent thereon particular examiner or, more importantly, on that third-party administrator or insurance carrier.
Basically, an audit answers the nagging question: Am I getting the bang for my buck?
Back to file reviews: So what constitutes prep work? This is pretty straightforward. It all boils down to how much you know about the injured worker’s current situation. Do you know his diagnosis and the effectiveness of the treatment regime? The treating physician? The return-to-work situation? Claimant attorney? Employee’s work history? Personnel history? Medical history? Did the examiner establish a plan of action and stick to it? Did he share that plan with you before the claim review? Most importantly, did the examiner continually move forward in reference to file management and expedition to closure?
Some employers would say, “Why would i want to understand all that when the file review will tell me everything i want to know?” If that’s the case, I’d suggest you go back and read the first paragraph. An employer can’t be an active participant if it doesn’t what it’s dealing with.
You must also remember you’re most likely sharing the examiner with several other employers, and the examiner only has so many hours in a day. Her time will be focused on the employers who either squawk the most, or (and this is crucial) closely follow their files. Disinterested employers will always fall to the wayside.
Yes, it will take time to keep up to speed on the claims. But it’ll pay dividends when it’s time for the file review because you’ll be a functioning part of the decision-making.
So be interested. Be involved. And do you prep work. If you’re not prepared, it’s pretty easy for an examiner to gloss over prior missteps, especially if the employer is a workers’ comp neophyte…and missteps cost the employer money.
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