How to Create an Effective Workers’ Compensation Action Plan

Posted by Veritas Administrators on Apr 20, 2017 3:20:08 PM
Find me on:

Claim Handling

When an adjuster has a lot on their plate - multiple claims, a myriad of activity - their action plan tends to be short-sighted, and "will-dos" tend to multiply.

Here’s the problem with “will-dos” - depending on the reporting period, these items never get done until the next report is due. Claims linger when this happens and the “will-do” list continues to grow.

By including an action plan as part of your claim handling process, adjusters will have a better chance of staying on track and ultimately move the claim forward in a timely and cost-effective manner.

One Action Plan per Claim

The challenge with creating an action plan that can really help an adjuster push a claim to resolution is the adjuster has to anticipate where the claim is going, which is never 100% accurate. This comes down to the adjuster using their experience and knowledge to anticipate where a claim could potentially go based on what they have seen in the past.

An action plan can be divided into three sections:

  1. Brief description of the history of the claim 

    a. History of the claim

    b. Description of injury

  2. Where are we now

    a. Medical status

    b. Legal status

    c. Managed care

    d. Reserving information

    e. Employer/Insured contact

    f. Claimant contact

    g. Work status

  3. Next Steps - Where do we want to be

Claim Example: Injury to Shoulder

Claim HandlingFor example, there was an employee who injured his shoulder while attempting to move an empty pallet at work and was diagnosed with right shoulder strain. His doctor advised him to participate in 12 physical therapy sessions. A follow up visit 3 weeks later showed little to no improvement, so the doctor recommended an MRI, which revealed a rotator cuff tear. Surgery was recommended to repair the tear. 

The doctor stated that the claimant could work light duty with a 5-pound lifting restriction. Since the injury and treatment appeared to be excessive to lifting an empty pallet, it was determined that surgery would be delayed or denied, and an IME would be pursued. In the meantime, the claimant felt that his injury wasn’t improving, so opted not to return to work even though he was cleared to do so with restrictions.

Update the Action Plan

What seemed to be a straight forward claim turned a little complicated once the MD suggested surgery, especially since the treatment for the injury seemed excessive. This is where a solid action plan is necessary.

The action plan should be updated when new information warrants a change in direction. Here are some examples of when the action plan was updated:

  • When the medical status changed and the doctor recommended surgery, it was determined that an IME was necessary. Treatment will be authorized based upon IME outcome

  • Reserves were reviewed and updated, and increased, should surgery be approved

  • The claimant’s work status was updated when he was approved to return to work with light duty work restrictions

  • A follow up conversation with the claimant discovered that he felt he cannot return to work. The fact that he has not returned to work required another update to the action plan.

The claim status can change on a regular basis, and the adjuster needs to be aware of these changes and update the action plan accordingly. If the adjuster is busy with multiple cases, it’s easy to see how “will-dos” can be noted in the file instead of updating the plan. It’s in everyone’s best interest to keep the action plan updated so the claim is handled smoothly and efficiently. 

Conclusion

Focus on where the claim has been and where it is going. This will help you create a action plan that will contribute to driving the claim forward in a timely and cost-effective manner. 

Creating a work plan when the claim is first reviewed is essential. It’s just as important to continue to update it when new information is received. Adding “will-dos” to the case will only multiply and end up making the claim convoluted and even harder to handle. Keep the file clean, and avoid the “will-dos”.


Click below to download detailed information about our Workers' Compensation services.

Learn More

Topics: Workers Compensation

Learn More

Subscribe to Email Updates

Leave a Comment