Claim FAQ

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Frequently Asked Questions

Why audit workers’ compensation claim?
Business professionals who are responsible for managing their company’s claims are sometimes too busy to effectively manage their claims. They have also been conditioned to accept claim payments at face value, sometimes underestimating the value of proper claim administration. Inaccurate claim handling and passive enforcement of cost containment procedures contribute to inflated costs, which leads to inflated insurance premiums or retention rates. Here are some other reasons to have workers’ compensation audits:

· To review the efficiency and effectiveness of the claims procedures
· To evaluate the claim management tactics by the claim administrator
· To obtain an independent analysis of the claim reserves
· To review cost containment and cost recovery procedures
· To identify areas for improvement and savings

When is a claim audit needed?
· Prior to unit statistical filing for experience modification calculation
(typically six months prior to policy renewal/expiration)
· Prior to adjustments on retrospective rated policies
· Prior to dividend calculations
· Whenever there are concerns regarding the management of claims
· When confronted with an increase in experience modification factors and/or workers’ compensation premiums/costs
· When there has been an increase in claim frequency or severity
· When there has been an increase in employee complaints about the way that their claims have been handled.
· As part of a periodic review of the claim management process to ensure that performance reaches and
remains at a high level

What are the benefits of a claim audit?
· Maximizes returns of loss sensitive dividends
· Minimizes experience modification factors
· Focuses the current claim administrator’s attention on resolving your claims proactively, efficiently and effectively
· Ensures reserves are appropriate for the exposure of the claim
· Identifies strengths and weaknesses of the workers’ compensation program
· Keeps claim administrators on their toes to perform at a high level
· Long term cost savings for the workers’ compensation program
· Improved administration of benefits to the injured worker
· Improved ability to obtain excess insurance by having an independent review

How can you tell if you need a claim audit?
· Are you paying non-compensable or questionable claims?
· Has your experience modification factor increased?
· Do your claims remain open too long?
· Does it take too long to get employees back to work?
· Do your claim reserves seem to high?
· Are your claims continually moving towards closure?
· Does your claim administrator suffer from high turnover?
· Do you have trouble reaching your claim adjuster?
· Does your claim adjuster seem unsure regarding the details of your claims?
· Does your claim adjuster seem too busy to handle your claims?
· Do you seem to be the one always initiating action plans on your claims?

Why use Insurance Claim Solutions?
· Annually we have saved our clients thousands of dollars and associated expenses
· Our staff assigned to audits averages over 15 years of claim handling and auditing experience
· Nurse, physician, and litigation consultants are contracted to aid in complex claims
· We are competitively priced

How are our services priced?
· Hourly rates
· Per claims reviewed/audited
· A percentage of reserves reduced or premiums collected back
· We can also use a combination of the aforementioned pricing options that meets the needs of our
customers