Welcome to Did You Know from Ask Approach. Throughout 2021 we’ll take a look at lesser-known aspects of services offered by Approach.
Spotting problem claims
At Approach, our claims professionals have more than 300 years of combined experience with Washington workers’ comp. This means we’ve processed thousands of claims, most of which are very straightforward, and we’ve also seen a few things when it comes to people trying to abuse the system. That’s why every claim goes through a Red Flag review as soon as we receive it.
Did you know?
You have 60-days from the claim allowance order to contest incorrect information.
What to check when a claim is filed
Some red flags show up as soon as the claim is filed. Maybe the description of the injury is vague, or the time of the workplace accident does not match your employee’s shift? Another red flag is an incident that was never reported.
Always check the name on the claim
Believe it or not, it’s possible your company can receive a claim for someone who isn’t an active employee! Always check the claim to make sure that the injured worker was actually your employee on the date of injury and that your company is correctly named in the claim file.
One of the best things you can do with any claim is to keep the lines of communication open
Preventing red flags early in the claim
By following a few best practices, you can greatly reduce opportunities for red flags:
- Create an injured employee packet and train your employees to use it
This packet should contain items such as: Report of Accident forms for employees and supervisors, a list of nearby medical providers, a sample of light-duty positions available at your company.
You can find sample materials in the Approach Client Portal
- Require all accidents be reported immediately and in writing
Your policies should specify that workplace accidents be reported immediately and that any injury be reported before the leaving work for the day. Unless it is an emergency, employees should complete the Report of Accident form before leaving the workplace to seek medical care.
- Review the Activity Prescription Form (APF) as soon as your employee has returned from the doctor
The APF is your key to understanding if your employee has been released back to full duty, if they will need light duty work for a time, or if they have been certified off-work.
You should make sure all information on the APF is consistent and accurate. If light duty is needed or they are certified off-work, your Approach Retro Coordinator will help you take the appropriate next steps.
Protesting an invalid claim
If any of the red flags mentioned above are present, we may want to protest the validity of the claim. Claims are presumed to be valid if they meet three basic criteria:
- The worker was acting in the course of employment when injured
- The description meets the legal definition of an injury
- A medical professional determines that the injury was likely a result of a workplace incident or exposure on a more probable than not basis (to include objective medical findings)
If the claim meets these criteria, it will probably be allowed even if we have concerns about the claim.
This means we have to provide evidence that something doesn’t match up. For example, if we can show that the employee wasn’t in the location where the accident was said to take place, this could be a compelling reason for the claim to be denied.
Red flags later in the claims process
Even if the claim is accepted — and even if it started as a legitimate claim — problems can still crop up, especially if the claim remains open for an extended period of time.
As Jenn Truong reminded us in her recent blog post on Hiring a Workers’ Comp Attorney, just because a claim is accepted, doesn’t mean that we must accept every treatment that is assigned to the claim.
That’s why Claim Duration is a red flag all by itself. If the recovery is taking much longer than expected, this could be a sign of unnecessary medical treatments or an effort to continue receiving time-loss payments.
Does our company need a private investigator?
We’ve all seen supposedly injured workers caught on camera going about their daily business. You may be wondering if this type of surveillance could help with your claim.
Approach retro coordinators have experience with fraudulent claims and can advise you not only on when an investigator could help, but also on how to incorporate their findings into the claim file. We can ensure that evidence such as witness statements or video footage are submitted properly to provide the greatest chance of success.
Lack of communication – a big red flag
Finally, one of the best things you can do with any claim is to keep the lines of communication open. This means showing concern for your injured employee, making sure they are seeking appropriate medical care, and offering them the quickest possible return-to-work.
Once the worker stops responding or starts missing medical appointments, that’s a big sign that the claim could be heading in the wrong direction. It can also present the opportunity to move the claim towards closure if the worker refuses to accept a bona fide job offer, so again, this is a place where your Approach retro coordinator can help you to navigate the claim and address any issues with the claim manager at L&I.
Claims 201 – June 2021
Learn more about red flags and other claim management techniques at our online Claims 201™ course, coming up next on June 22, 2021.
And, use our incident report form to report all workplace accidents to Approach, so we can help you identify potential red flags right away, even before the claim is filed!