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|5Star Administrators - Workers' Compensation Claims Specialists -> Capabilities -> Best Practices -> Investigation
Every new claim has the rationale of compensability, which is determined by the adjuster during their initial 24 hour
investigation. Once compensability has been addressed, an entry will be placed in the claim notes as to the adjuster’s findings. If there is question regarding compensability, the Supervisor, Client and/or Defense Attorney will be consulted prior to issuing a denial letter to the injured worker. Compensability factors are determined by state law and statutes/recent case laws within the state.
All claims information will be collected, reviewed and confirmed prior to the issuance of any benefits for workers’ compensation. Verification of first report of injury data is conducted, as well as any supplemental accident investigation forms. Initial on-site investigation by the Client is critical and provides beneficial information for the claim file. 5Star will provide the Client a claims kit with investigation forms and suggestions for claims discovery. This information, if preserved, can prove to be a valuable piece of the analysis process of the claim.
24 Hour Contact – two/three point:
Statements should be secured by all parties to the injury, including supervisor, witness and injured worker. Client onsite investigation is the initial opportunity to preserve the evidence of the stated accident/injury. Uhlemeyer Services will secure statements from parties to the claim upon receipt of the first notice of loss. The adjuster will review any statements from the Client or witness as part of their initial 24 hour investigation.
Within 24 hours of receipt of the first notice of loss, a recorded statement from the injured worker will be secured. A summary of the recorded statement will be documented in the claim notes for future review. If an injured worker contact
is made and no recorded statement is taken, a claim note will be entered to document the conversation and/or why a recorded statement was not secured. From a best practices adjusting standpoint, a recorded statement is mandatory
for the following types of cases: possible subrogation, pre-existing injury/condition, multiple claim files, questionable case, severe injury, employment issue and jurisdictional issue.
Contact with the Client, Physician and Injured worker will be made on all lost time claims within 24 hours of receipt of the claim. This includes any medical only claims that have been converted to lost time claims. Contact with the Client and Physician will be made on medical only claims.
Contact with the Client is made within 24 hour of receipt of the claim. During the initial contact opportunity, items such as, but not limited to, are discussed: authorized medical treatment, work schedule, post accident testing/results, safety
violations, wages, accident facts, return to work, light duty, prior claims, personnel issues, etc. Client contact is typically made by telephone and/or e-mail and will continue as long as the claim remains active. All contact details will be documented in the claim notes.
Claimant contact is made within 24 hours on all lost time/indemnity claims. If verbal contact is not achieved within the first 24 hours, a contact letter will be mailed to the injured worker with request for a returned phone call. An employer
can also be asked to help facilitate this initial contact with the Claimant if the injured worker has returned to work. This contact provides the injured worker an opportunity to present their side of the facts surrounding the accident/incident stated at work. All initial contact details and attempts will be documented in the claim notes.
Physician contact is made within 24 hours of receipt of the claim. During the initial physician contact, items such as, but not limited to, are discussed: patient initial treatment date, patient follow-up treatment date, diagnosis, treatment plan, diagnostics, physical therapy, work status, work restrictions, specialist referral and/or causation/mechanism of injury.
Disability & Wage Verification:
Witness contact is made during the initial investigation process or upon receipt of witness information. A witness statement form is provided to all clients, which can be completed at the time of the stated accident. Witness statements
are primarily used for investigation, determination of compensability and solicitation of additional accident facts. Any witness statement received will be scanned to the claim file and kept confidential.
Surveillance & Activity Checks:
All lost time claims will be verified before benefits are distributed to the injured worker. The verification includes the above contact information, in addition to a documented wage statement provided by the Client. Wage information
will be requested within 24 hours of the receipt of any indemnity/lost time claim. In order to ensure timely payment to the injured worker – according to the state requirements - minimum payments will be issued for indemnity/lost time
benefits until actual wage verification is received. Supplemental/adjustment checks will be issued if applicable. Wage statements are scanned to the claims system and documented in the claim notes.
This activity is utilized in cases that fall within these characteristics: disability is extended, recovery is delayed, activity levels are not within the physician’s limitations and/or in cases of fraud. These services are typically performed by a third-party vendor and the cost for this service is paid from the expense portion of the claim file. Activity checks are typically used for employment, medical, prescription, hobbies, criminal, civil, fatal and permanent total cases. These types of activity checks can be completed at intervals relevant to the progression of the claim. Any/all discovery received is communicated with the appropriate parties to the file, scanned to the claims system and documented in the claim notes.