An uncooperative claimant or unresponsive legal counsel can stop a claim in its tracks. Here’s how to get it moving again.
We all know that workers' compensation claims can become drawn out and cumbersome. However, it is our duty as claims professionals to resolve claims timely and cost effectively. Recognizing red flags, pre-existing conditions, health concerns, and degenerative issues at the onset is critical to helping determine what tools are necessary to move a claim forward to conclusion.
Establishing Contact and Maintaining Communication
In beginning the claims process, establishing contact with the insured and claimant is key. Contacting the insured at the creation of a new claim provides you with a more complete understanding of the claim and also helps you establish a line of communication. Building a rapport with the contact encourages a steady flow of information, moving the claim along and ensuring a quicker and more complete process. In contacting the insured, determining if he can provide alternate work assignments under modified or light duty assists in returning the claimant to work quickly, even if the injury has not been completely resolved.
While contact with the insured is an important part in the life of a claim, claimant contact often can determine the level of accuracy and effectiveness you will have in managing the claim. Establishing claimant contact is important in determining the best source of contact and the likelihood of cooperation. In contacting the claimant, you are assuring him that you are helping him return to work and to obtain all necessary medical treatment.
In addition to the conversation via phone, recorded statements are recommended, depending on the severity of the injury. If you are unsuccessful in reaching the claimant, you should follow up with a certified letter. Always keep a paper trail and maintain a well-documented file. Losing track of your claimant will result in complications throughout the life of the claim. This applies not only in return-to-work situations but also in instances of lost claimant contact due to lack of cooperation or termination of phone service for personal and/or financial reasons. Constant, clear communication also is vital in instances where the claimant faces personal constraints, such as a lack of transportation due to personal or medical reasons. In such cases, the claims professional may be able to assist in finding a means of transportation.
Along with claimant contact, maintaining contact with the claimant’s medical providers is crucial to ensuring the speed and efficiency of the process. Obtaining medical treatment notes and billings throughout the treatment ensures the timely processing of claims information as well as payment to the medical provider.
Monitor Compliance with Treatment
It is the claimant’s responsibility to be compliant with treatment. The claimant must follow the outlined medical treatment in order to ensure both the effectiveness and timely completion of the treatment. Failure of the claimant to comply with the determined appropriate course of medical treatment can extend the claims process. If you are working with a non-compliant claimant—and/or physician’s office when it comes to obtaining medical records—it may be beneficial to assign a nurse case manager. The nurse case manager can assist with obtaining a history from the claimant and may be able to obtain the medical records in a more timely fashion. In some cases, the nurse also may attend the appointments and provide an immediate update to your office. This also is a benefit to the claims professional in times of ongoing or unnecessary treatment. The actions of a nurse case manager can help ensure that the medical treatment provided is required and received in a timely fashion.
In addition to the above-mentioned instances of claims stagnation, some of the following instances and their solutions may apply. In a case where the medical treatment has exceeded the guidelines for a specific injury, a utilization review or an independent medical exam is useful in terminating further benefits or providing the necessary treatment plan going forward. In certain instances of experienced mental trauma, such as witnessing a death or the loss of digits or limbs, the attention of a trained psychiatric medical practitioner can benefit the claimant and aid in return to work. In the case of a serious injury where the claimant continues to receive lost time benefits, it is to our benefit to refer the case to vocational rehabilitation to retrain the individual and return him to some type of employment.
Similarly, in instances of maximum medical improvement, an open line of communication with the claimant is crucial in ensuring his understanding of this determination and the process moving forward. Vocational rehabilitation in this instance will be of great importance to the individual to ensure his ability to function productively. This also mitigates exposure on litigated claims when the worker is classified as a permanent total.
Remain Diligent with Litigated Claims
Litigation can be a cause of stagnation, as well. Restricted direct access to the claimant can limit the flow of information and progress. Not only are we prevented from continuing an open rapport with the claimant directly, but also we may be met with an unwilling or unresponsive legal counsel. In a situation of a litigated claim in which there is no response from the plaintiff’s attorney, it is beneficial to have your defense attorney motion this case up for a hearing and/or request a motion to dismiss.
Conclusion
While the above instances of claims stagnation are, for the most part, universally applicable, recognizing your state’s guidelines and utilizing the applicable tools to maintain an active claim are the key to resolution. The guidelines set in place in specific jurisdictions often can determine your ability to act in a situation of stagnation, and will guide your course of action. In any situation, however, an open and constant line of communication is vital in ensuring that a claims professional can resolve a claim quickly and accurately. After all, the only good claim is a resolved claim.
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