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Medical Only Claims Festering – Fuse May Be Lit For Huge Loss


Medical Only Claims Festering (c)

The term medical only claims festering was coined by me in the late 1980s.

picture Of Hand Typing On Laptop Medical Only Claims With Stethoscope
Wikimedia Commons – Daniel Sone

Most medical only claims are just that – claims with low dollar values that close within 90 days. They usually do not affect your E-Mod (Ex-Mod) in most situations. There is one area where a simple medical only claim can become your company’s worst nightmare. It is a term that I coined known as claims festering.

This is not necessarily a set of claims that can be caught by doing an E-Mod reduction review. Medical Only claims must be constantly monitored for adverse development. I have a claim that was sent by a self- insured on the desk in front of me right now. The Total Incurred (Paid + Outstanding Reserves) is over $400,000.

The claim festered in a medical only status for months. From most of our file reviews, med-only claims are not monitored that well. It is the nature of the business. The Risk Management technique for these claims is easy to monitor.

Picture Doctors Medical Only Claims Personnel Posing to Camera

If a medical only claim is open for six months, then the claim needs to be monitored heavily. Insert the clams on a diary and inquire about their status on a monthly basis.  One cannot let the claim turn into a large claim due to a lack of follow-up or control.  Communication with the medical only claims adjuster is critical for this type of claim.    Long-standing medical claims often turn into complex claims with litigation as the eventual outcome.

This task will be much more difficult if you do not have online access to your claims. If your insurance carrier or TPA offers this, sign up for it today. Monitoring medical only claims off paper loss runs will usually not result in any savings.

There is actually a much worse type of medical only claim. I will cover that next time.

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One Response

  1. I agree with the comments regarding the monitoring of medical only claims. As a defense attorney we see cases where the unmonitored medical treatment continues and “expands” beyond the original scope, in a aeffort to “find out what is wrong”. At times, the recommendation may be a removal from work, “to see if rest has a pallative effect”. Yes, for the most part, medical only claims are minor cases and remain minor. Where the “red flag” appears, they merit more atttention.


James J Moore - Workers Comp Expert

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Management 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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