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Workers Comp Policy Dictates Right To Review Claim Files

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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 employers 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.

Picture of Businessman Workers Comp Policy Review Files Using Computer
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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 TPA contract or workers comp policy, the subject of the right to data and files should be covered very specifically.

Businessman Using Laptop Workers Comp Policy at Desk
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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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James Moore

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Mgmt Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications

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