Warning Signs for an Out-Of-Control Claim?

warning dangerWhile most of the time, claims that are expected to turn out a certain way will turn out a certain way, there are always outliers. Seemingly routine claims that get out of control and cause major headaches for your adjusters and your bottom line. What can carriers do to prevent those kinds of situations?

A new whitepaper released by Genex, a managed care service provider, sheds light on the topic of case timelines- specifically when and how a claim might go bad. In reading, it is important to remember that no two cases are identical. The indicators provided in the paper only serve to highlight the possibility that a case might start to go south, but just because a claim has one or more of these indicators does not mean that you should immediately raise the red flag or assign a case manager.

The study noted that serious injuries usually get the most intensive case scrutiny right from the start, because carriers have learned from experience that catastrophic injuries can often lead to lawyers or expensive treatments. However, less serious cases can sometimes turn into high-cost claims as well, but by the time carriers identify it as such and assign case managers- it can be too late. To prevent that from happening, what are early indicators of those “tipping-points” that will lead to a high-cost claim that we can look for?

If the worker has a co-morbidity like obesity, depression or another illness, that could affect treatment or quick return to work. Same with lifestyle choices like smoking. A vague or missed diagnosis from the beginning, changing doctors too much or visiting several doctors, or delays in treatment can also foster a risky claim environment. Adjusters who are tuned into the claimant’s medical history or other home-life issues can also go a long way in controlling potentially hazardous claims. The trust and relationship between the injured employee and employer can also affect a claim’s status.

The longer that a hazardous claim goes on without a case manager, the harder it may be to contain it. The company suggests that instead of just setting a monetary threshold for adjusters to intervene in a case, they should look for these warning signs earlier and get on the phone with the worker to try and figure out what is going on. Besides saving carriers money, this practice could mean the difference between a worker who is healthy and happy back at work, or one who is still struggling to close their claim and move on.

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