Workers Comp Policy Allows Claim File Audits
The Workers Comp policy allows an employer to review files or perform claims audits. I have recently received a large number of questions on the employer’s wish to do a Workers Comp claims file review. The carrier or TPA was less than enthusiastic or not agreeable to having a review of how the claims adjuster handled the files, especially the reserves.
If the TPA or insurance carrier will not agree to a claims file review, the workers comp policy will be the deciding factor. If Workers Comp policy gives the employer the right to inspect the way their files were adjusted, then the TPA or carrier should comply. There may be outstanding reasons such as non-payment of undisputed premium or fees that could possibly void the right to review the Workers Comp files.
The best way to avoid any confusion or strife is to discuss file reviews BEFORE the Workers Comp policy or TPA agreement is finalized. If an RFP was the basis for the agreement, the subject of the right to data and files should be covered very specifically.
We have never experienced the carrier or TPA not allowing access to their files. Some would not allow access to the reserving part of the file notes, for some reason.
As I have posted very often in this blog- having access to the electronic file can save a large amount of funds and time. Reviewing files at the carrier’s or TPA’s office(s) can be much more expensive than reviewing the files off-site.
Please note that when TPA’s are mentioned, the workers comp policy may also be referred to as a Third Party administrator agreement. The TPA agreement may be used for reference on a Workers Comp claim file audit.
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