Workers’ Compensation Quality Claim Review Expectations The NARS Way – Team Leader - Quality Claim Review Expectations • Were all strategic partners effectively managed? (Documenting the purpose, the intent, and the anticipated outcome and the duration for use.) • Were medical bills promptly paid per jurisdictional guidelines? Suggested recommendations for improvement with evaluation: • The claim specialist should verify the medical care that has been received and any future planned treatment is causally related to the alleged injury. The claim specialist should verify the medical expenses incurred and submitted for payment are only for the treatment received because of the work-related accident. • In addition to obtaining the medical case records, the claim specialist needs to outline their thought process as to causation between the alleged injury and the medical treatment. • The claim specialist should be aware of the jurisdictional time limitation of payment of medical expenses. • For both management of medical and disability, target dates are needed on the file. Reserving Claim reserving is a significant function of The NARS Workers’ Compensation Team. Having a consistent reserving philosophy is imperative to the organization. Reserves are to be set to the ultimate probable outcome with all known information. Ultimate probable outcome is defined as the total incurred cost of the claim which includes the paid and the reserve remaining. We should reserve for the “middle of the road” probable outcome of the claim, not the worst-case scenario nor over-optimistic. Justification and clearly documented, concrete information to provide sound reasoning for recommended reserves is to be noted in the claim file. Reserve notes should have a short summary with an outline of the outstanding reserves and reasoning for needing different buckets for money (such as medical, indemnity, and expense) left on the claim, even if no changes are being made. We need to be able to understand risk and exposure. If we do not understand how much the claim is going to cost, we do not understand the claim. Questions to ask yourself while reviewing reserves: • Are the reserves adequate for the present exposure of the file? • Do the reserves encompass all the known aspects of the claim file? Negotiations Documenting the reasoning behind any payment of medical expense or loss wages is crucial to the Workers’ Compensation process. Questions to ask yourself while reviewing for negotiations: • Were negotiations properly implemented? Was a strategy executed properly? Evidence to support? • Were negotiations properly documented? • Were negotiations updated during the process? • Were all forms completed, in the file, and used to support position taken during negotiation? • Was there attorney involvement? Was attorney involvement needed? 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.