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Claim File Reviews – End of Year Time Waster (Usually)

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Claim File Reviews –  Use This Simple Diary System

Every year we receive requests to perform claim file reviews to close out an employer’s calendar year.  Basing a claims review on the calendar year can be a waste of time.

As part of their customer service, carriers or TPAs (self-insureds) sometimes contact employers to close out the year with a claim file audit or review. Large deductible workers comp policies should have the same review timeline.

When I worked for carriers or TPAs, we often did this type of calendar year review.   At the time, I did not realize I was wasting the insured’s, agent’s, and employer’s time. I have written and spoken very often on this subject.  Claim file reviews can be a powerful tool to have the worker’s comp file reserves set properly and for the life of the file.

Setting up a recommended diary system will help greatly in keeping the reserves in line and moving files to closure while providing the proper benefits to the injured employees.

A Quick Example

The first question I usually receive is –  “Why Start So Early?”.  Let us look at a quick example – (not state-specific)

  1. A lower back strain claim resulted in a surgery recommendation
  2. The reserves were properly set (usually at 60 days after the injury) for $265,000
  3.  The surgery did not occur due to conservative medical treatment
  4. The injured employee returned to work part-time and eventually to full-time work
  5. The $265,000 reserves would now be considered excessive or over-reserved

 

A $265,000 file up for a file reserve reduction would require many approvals.  File reserve reductions would first have to be

  • Reviewed and recommended by the adjuster  – check here to see where that ranks in their daily job duties 
  • Reviewed and approved by their supervisor;
  • Forwarded to the Claims Manager for approval
  • Final approval by the Claims VP

The whole claims file review process would take at least 90 days if not longer.

Claims File Review Timeline

The all-important Unit Statistical Date occurs 180 days after a policy ends.   The UNISTAT date is when the carriers report the claims data for the prior policy to the rating bureaus such as the WCIRB, NCCI, NCRB, PCRB, and other independent bureaus.

One complicating factor comes from carriers and agents using predictive analytics.  The old way of thinking that your Experience Mods generated by the rating bureaus are the only measure of an employer’s safety programs has been slowly changing over the last decade.

Ninety days after a policy ends is the deadline for when an employer should let their adjusters know that a file looks over-reserved for reduction purposes.  Do not wait until two weeks before your UNISTAT date to contact your adjuster on any file that you feel may need a reserve reduction.  You will be disappointed with the result.

 

Using the 90-day claim review date gives the carrier time to proceed across the screens of the insurance carrier’s claims file review process. I will cover the self-insured timeline next week.

 

aztec calendar claims file review timing
Wikimedia License – Keepscases

 

 

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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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