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Early Claims Identification

Whether in a managed care system or not one of the most valuable tools any program can establish to minimize and manage workers' compensation costs is an early claims reporting and intervention program. OMCA's Early Claims Identification program is designed to cure traditional workers' compensation reporting short comings, based on the following fundamental truths:

  1. Employees and Line Employers Will Procrastinate
    If there is no sense of urgency regarding reporting of injuries, rest assured this task will fall to the bottom of the stack.

  2. Employees and Line Employers Do Not Know Their Rights and Obligations Under the Workers' Compensation System
    Most employees and line employers will comply if someone merely explains what is expected and why it is in their best interest to cooperate.

  3. An Unreported Claim is Akin to Giving Your Employee a Signed Blank Check
    In situations where there is a bona fide work related injury, the employer will pay all costs whether timely notification is made or not.

  4. Some Employees Exaggerate and Worse
    Only through early identification and intervention does the employer have a fighting chance to minimize and deny suspicious claims.

Time Sensitive Protocols
OMCA will help your company identify protocols that dictate special handling of selected critical first report of injuries. The observant claims handler should be aware of certain triggers that dictate immediate attention by adjusters, case managers, or employer management. Part of OMCA on-going training helps elicit this information from both the employee and the employer.

Examples of these identifiers include:
  1. "Alleged", "suspicious", "un-witnessed", "horseplay", in the narrative section of Injury Description;
  2. Offsite location of injury;
  3. Off hour timing of injury;
  4. Motor vehicle accident;
  5. Weekend delays in reporting;
  6. Unusual time lags in notification;
  7. Third party involvement or independent contractor involvement;
  8. Work description inconsistent with job classification;
  9. Catastrophic in nature or excess reporting required;
  10. Unusually short length of employment;
  11. Safety violation;
  12. Drug, alcohol or other behavior influencers;
  13. Death, major burn or disfigurement;
  14. Involvement of non-employees with injuries.


On-Going Communication
Our nurses and care coordinators institute protocols, approved by carriers, where claimants and employers are subject to periodic and ongoing communication. Our relevant experience tells us that claimants with bona fide injuries want care, understanding and empathy, but they also appreciate and require boundaries. Our follow up is geared to convince the injured worker he will return to work as soon as possible and there is a positive outcome through the labyrinth of the workers' compensation system.

Special Identification Issues

Subrogation

Insurance carriers reserve the "right of subrogation" in the event of a loss. This means the company may choose to take action to recover the amount of a claim paid to a covered insured if the loss was caused by a third party. After expenses, the amount recovered must be divided proportionately with the insured to cover any deductible for which the insured was responsible.

First Report Swat Teams; Fraud, Excess, Third Party
Either through field visits or telephonically, OMCA's professionals are available 24/7 to secure the First Report scene. These individuals are trained in loss control, subrogation and fraud areas, and much like a forensic detective, secure the First Report scene (figuratively or literally), pin down stories and investigate third party negligence, fraud and special handling issues. The thrust of these teams is to ensure third parties pay their fair share of work related injuries, quickly identify claims for special reporting and medical management, and help build the file early for denial of claims that do not meet the statute.

SIC Coding
OMCA performs quality coding of SIC company categories to ensure accurate processing of all appropriate reporting.