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Workers Comp Medical Only Claims – Your Money Down Toilet


Workers Comp Medical Only Claims And Claims Festering(c)

Certain Workers Comp Medical Only Claims snowball into uncontrolled Lost Time Claims for employers and carriers.  My last post on Medical Only claims pointed out the pitfalls and concerns of medical only claims. I promised that I would get back to how employers should monitor medical only claims.

Picture Of Doctor And Patient Workers Comp Medical Only Claims Shaking Hands

One of the huge mistakes by employers and carriers is the medical only claims are allowed to fester for many weeks and months and not receive the proper attention. I have seen many medical only claims turn out to be an employer’s worst nightmare.

A medical only claim has really had no investigation performed and is usually more of a medical only claim processor’s job. A lost time adjuster may never see a medical only claim until it turns serious, such as a physician’s office calling for authorization for a major back surgery. By that time, it is almost too late to do anything that would resemble a good investigation of the claim.

Medical only claims are not that hard to monitor. Avoiding a delayed investigation by the Workers Comp adjuster is the goal.

Excel Spreadsheet Workers Comp Medical Only Claims Screenshot

An Excel spreadsheet can be used as a diary system. An Outlook or some type of calendar program will work even better. After filing the First Report of Injury for a medical only claim, calendar a follow up with the employee at 30 days, 90 days, 6 months, and one year. If they have an email address, that is the easiest method to contact them.

The others side of the coin, so to speak, is what info is flowing to your insurance carrier or TPA without your knowledge. Medical providers often send the bills and reports directly to the claims office. You should ask that a copy of the medical bills and reports are also sent to your office. If the report points out the employee’s condition is worsening or surgery is anticipated, you will be able to point this out to your Workers Comp claims department.

One of the most heavily posted recommendations by me is having online access to your claims. You can easily see what is occurring in the claim and to see how the carrier is handling the medical only claims. You may also be able to see scans of the medical reports or medical charges paid.

Using these two simple techniques will avoid you surprising your claims adjuster. Do not rely solely on your Workers Comp claims department to catch everything on medical only claims. A surprised claims adjuster may set your Workers Comp reserves very high, which means your E-Mod will be higher, which is money down the toilet.

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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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