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Medical Only Claims – Ignore Them At Your Own Risk

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Medical Only Claims – A Short List of Concerns

Medical only claims turn out to be the worst Lost Time claims if not monitored properly.  How can a few $250 claims cause such havoc?

Sign Medical Only Claims At Your Own Risk
Wikimedia – MOTOI Kenkichi

The old saying concerning “Big things come in small packages” applies very well to this situation.   The least monitored claims can blow up very quickly. Why?  

I coined the the term claims festering approximately 10 years ago.  Yes, the term came from what happens to an ignored sore.  The ignored claims sometimes:

  • Stays reserved with the automatic amount ($250  or $500) too long
  • Increased just to pay a bill
  • Not reviewed due to small dollar amount – one cannot expect an adjuster to examine a $450 claim.
  • Keeps being handled and reserved for a low dollar amount for months
  • No supervision = no control of the medical
  • Festered medical only claims usually turn into large claims headed down the wrong path – think snowball from hell

How does a claims department and/or employer avoid this mess?  The question begs to be answered in this manner.  Technology – not claims analytics may be the best answer. 

Nurse Medical Only Claims With Patient In Corridor
StockUnlimited

A very talented medical only adjuster knocks the claims monitoring out of the park.  I have experienced this often with medical only claims adjusters who worked with or for me in my claims career. 

Getting the file transferred to a lost time status is a critical step.  A good experienced medical only claims adjuster generates this transfer most of the time.  Asking an overloaded claims supervisor spells trouble for a festering claim. 

The main concern coming from a festered claim is the lack of supervision over a very acute claim.   A laughable situation occurs when a lost time investigation commences six months too late.  Technology sounds great as the solution.  It does not suffice in this instance. 

Picking out a festering claim from a list of what can be thousands of medical only claims will be a monumental if not impossible task. 

Why did I write this article?  I just reviewed a loss run with 125 medical only claims.  Five of those were deemed festering claims.  Five of `125 claims may not seem that large of a percentage.   These claims were tracked by a spiffy claims analytics software package.   

Some types of software track the festering better than others.   An IT person would input the level where a warning would be given if a claim festers too long, not an adjuster

Oh, my, human intervention wins again even with the small medical only claims.

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2 Responses

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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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