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Medical Only Claims Adjusting – One Super Critical Task To Consider


Medical Only Claims Adjusting – Where Small Claims Can Turn To Crises

Most Medical Only Claims Adjusting sections in a claims processing manual consist of a very few pages.  Lost time adjusting takes up the majority of a TPA or insurance carrier claims manual.

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The Medical Only claims adjusting section may or may not cover what is just as important as any Lost time adjusting task.   The recognizing, converting, and immediately handling of a medical only claim that has become serious has wrecked more than a few employer’s loss histories.

If a small claim festers lacking any administration/adjusting,  the claim will likely end up being a non-investigated, expensive, out of control mess.   Some claim systems will catch a small % of these claims.  Those systems are few and far between.

How are small claims that are turning into uncontrollable claims discovered?

The usual ways involve:

  • Twilight Zone Phone Call 
  • Employee is denied an unauthorized treatment by medical provider
  • Employee’s newly hired attorney sends in representation notice
  • Employee calls into claims department to complain about no TTD checks
  • Claims reserves peg at higher than normal level for a  medical only claim
  • Claim stays open for months/years
  • Claim is reopened and then re-closed multiple times to pay bills over a long period

Most medical only claims adjusting staffs and lost time adjusters could add on many more items to this list.

Some claim departments required a recorded interview on even medical only claims.  This sickening requirement caused these claim departments to become overloaded in pending recorded statements.    Most claim departments which required recorded statements on all claims changed the task to a recorded statement on all lost time claims and serious medical only claims.

Over the years, I have met and supervised great medical only claims adjusters that had a gut feeling when a claim was souring and going to be more costly than just a small amount of medical bills paid in the first few weeks.

Employer Role In Medical Only Claims Adjusting

I then discovered one of the techniques of these great medical only claims adjusters.  They had established great two-way communications between themselves and the insured.  The adjusters had a great open door policy for the employer to call them if they noticed anything suspicious or extraordinary occurring on even the smallest workers compensation claim.

Even if your company does not have this type of communication and relationship with your medical only adjusters, go ahead and start on it today.  If you see anything strange on a medical bill, or if a large medical bill is received on a medical only, let the medical only claims adjusting staff knows about it immediately.

If the employee has an unexplained absence after reporting a medical only claim, get in touch with the medical only adjuster as soon as possible.

Email your medical only claims adjuster instead of calling in most cases.   The email will allow the adjuster time to pull up the file and then discuss it with the lost time adjuster or medical only claims adjusting supervisor.


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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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