Workers’ Compensation Quality Claim Review Expectations The NARS Way – Team Leader - Quality Claim Review Expectations • Was the “Average Weekly Wage” calculated accurately and documented, including proper jurisdiction? • Was subrogation recognized, documented, and referred if appropriate? • Are there any SIU issues? • Were ISO matches addressed? • Was the 14-Day status report completed on time? • Was the compensability decision made within 30 days? • Suggested recommendations for improvement with investigation: • The claim specialist should use the information provided on the FROI as a starting point for the investigation and it should not be relied on as the full scope of information. • Once the claim specialist has gained knowledge the injured worker is losing time from work, the claim is questionable, or there is subrogation potential, immediately take the necessary steps to obtain a recorded statement (or as outlined in the Special Handling Instructions). • If an injured worker suffered an injury in the course of employment which may have been caused by a third party, the claim specialist needs to refer to the subrogation unit for the assessment of subrogation potential and feasibility of recovery. • If any injured worker is off work or anticipated to be off work longer than two weeks, what is the return-to- work plan? Has one been outlined? Has a plan been discussed with the employer? Has a job description been obtained? Was it sent to the treating medical provider for review? Is there medical documentation to support the lost time? Evaluation Once the investigation has confirmed the accident did arise out of and during the injured worker’s employment, the claim specialist needs to turn their attention toward evaluating the injury. The cornerstone to the evaluation process is obtaining the medical records and determining if the treatment received was a result of and directly connected to the accident. Each file should be documented with the claim specialist thought process outlining support for the payment of medical expenses, lost time, compromise settlement, or a denial. A medical treatment synopsis should be documented in the file every 30 days. Medical expenses need to be reviewed and confirmed that the treatment received was necessary and as a direct consequence of the accident. Management of external medical strategic partners should also be documented in the claim file. Questions to ask yourself while reviewing for evaluation: • Is there clear documentation of compensability? • Are the compensable accident/injuries clearly identified and documented? • Was all medical treatment casually related to the reported injury? • Was the diagnosis, prognosis and treatment plan documented? • Were ongoing disability guidelines documented? • Did the claim specialist document their analysis to support payment, compromise, or denial? • Were all medical bills verified as being related to the injury? • Was there any duplication of payment on bills? NARS’ Best Practices were created by and for the internal use of NARS and are confidential, proprietary and trade secret documents protected by the Uniform Trade Secrets Act and applicable state/federal law. They may not be copied, distributed, or reproduced, in whole or in part, without NARS’ express prior written authorization. Unauthorized use or distribution may be subject to civil and/or criminal penalties.