ESSENTIALS OF ADR FILE REVIEWS

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Effective claims management
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Claims management

• Claims prevention
• Claims management

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Control the Big 3

• Frequency Number of claims filed during a given
  year
• Severity Number of days an injured worker is
  absent during a given year due to a workers
  compensation claim
• Lag time Amount of time between the date of
  injury and filing of claim

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Know your partners
CSS
ESS Safety consultant
Employer
TPA
MCO
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Reporting injuries

• How to file claims
• Report the injury directly to BWC by submitting a
  FROI via ohiobwc.com.
• Report the injury to your assigned MCO.

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Reporting injuries

• Control your lag time and frequency
• Develop internal reporting policy.
• Report near misses.

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Claim flow process

• Injured worker seeks treatment.
• Provider contacts MCO.
• MCO electronically transmits information to BWC.
• BWC issues a claim number.
• BWC notifies all parties by letter.
• BWC notifies MCO electronically.
• BWC investigates and issues an order.

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Develop relationships

• Provider network
• Educated providers

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Claim types

• Medical only 7 or fewer days lost from work
• Lost time 8 days or more lost from work
• Does not have to be 8 consecutive days to be
  considered a lost-time claim

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What happens after an injury is reported?

• Contact with employer, injured worker and his or
  her representatives
• Evidence (factual and medical) requested
• Staff with claims team, nurse, MCO
• Possible physician review

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What happens after an injury is reported?

• The employers role
• Certify or reject FROI
• Accident analysis

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Accident analysis

• Task
• Material
• Environment
• Human factor
• Management / process failure

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Making a decision

• Weigh the evidence (factual and medical).
• Place a BWC order.

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What do I do after receiving the BWC order?

• The 14-day appeal period expires.
• File an IC-12 and appeal the BWC order.
• Submit a waiver.

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Industrial Commission of Ohio (IC)

• District hearing officer
• Staff hearing officer
• IC commissioners hearing
• Hearing administrator

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Partnering for claims issue resolution

• Contact BWC for
• Compensation issues
• Additional allowances.
• Contact your MCO for
• Treatment issues
• Payment of medical bills.

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Outcome management Developing a plan of action

• Independent medical exams
• Return to light duty, modified or transitional
  work
• Drug reviews

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Distinguishing

• Abuse vs. fraud
• Fraud vs. abuse

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Staff your claims
BWC
TPA
Staffing
Employer
MCO
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Computing and paying compensation

• Full weekly wage
• Average weekly wage
• Minimum and maximum award calculations
• When is compensation payable?

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Types of compensation

• Temporary total
• Living maintenance
• Living maintenance wage loss
• Wage loss

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Types of compensation

• permanent partial
• Scheduled loss
• Facial disfigurement
• Permanent total disability

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Types of compensation

• Settlement
• Settlement application filed
• Determination made on potential future cost
• Settlement amount negotiated with all parties
• Settlement agreement published
• 30-day hold period
• Settlement paid / claim closed

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Miscellaneous benefits

• Salary continuation
• Handicap reimbursement
• Subrogation
• Sports letter

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Subrogation

• The right to recover benefits from a third party
  because of negligence
• Senate Bill 227 is effective for claims with a
  date of injury on or after April 9, 2003

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Most common third-party accidents

• Motor vehicle accidents
• Malfunctioning products
• Medical malpractice
• Exposure to toxic fumes
• Machinery accidents
• Animal bites

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Claims management

• Identify trends
• Keep good records

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Sell safety in the workplace

• Top management
• Employees

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How can you impact claims management?

• Conduct an accident analysis.
• Get involved early.
• Partner with your resources.
• Develop early return-to-work options.
• Communicate with injured employees.

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Questions?