Anatomy of a Simple Workers' Compensation Claim

October 8, 2020

What is the definition of a simple Workers’ Compensation (WC) claim? Typically, claim professionals define a simple WC claim as one that only involves medical treatment with a return to work so that no indemnity dollars are involved in the claim.

Examples of these types of claims include: cuts, bruises and minor strains. With these medical-only claims, the employee is treated and then returns to work with no long-term impairment. In other words, after a conservative course of treatment, they are back to normal. Seems like that should be pretty “simple”, but the process involves the injured worker, the employer, the insurance agent, the medical provider and the insurance carrier. So, it can get complicated without a clearly defined process.

The Ins and Outs of a Medical-Only Claim
The good news is that Amerisure has a proven process that begins as soon as the claim is reported. While the exact process varies by state, let’s explore how the process usually plays out:

  • The employee is injured at work and notifies the employer.
  • The employer can direct the initial point of treatment in most states. Employers often have a neighborhood industrial clinic that provides a point of entry for most injuries. If an injury is more severe or occurs outside of regular hours, it may be necessary to go to the emergency room.
  • The employer reports the injury to the carrier within a specified timeframe (the sooner, the better). This report is called a First Report of Injury (FROI) and is state specific.
  • WC claims can be reported to Amerisure over the phone, the internet, by fax or e-mail.  The employer usually provides the FROI but it can also be provided by the agent who has gathered the necessary information from the employer.
  • The FROI typically includes the following information in addition to the employee’s personal data.
    • The time, date and location of the injury.
    • The nature and/or cause of the injury, such as: a fall, laceration, machine or human error, etc.
    • The parts of the body that were affected by the injury (and may have room to note any previous injuries to these areas).
    • How the injury occurred, such as lifting, bending, etc.
    • The names and contact information of witnesses and the direct supervisor
    • Depending on the state, the FROI may include return-to-work dates, wage information and provider details.
  • Once the claim is received, Amerisure provides same day contact with the employer, usually by phone, giving the policyholder a chance to provide additional details and identify any concerns.
  • The claim representative then confirms the details of the claim to determine compensability. This includes confirmation that:
    • The injured person is an employee and not an independent contractor.
    • The employer has Workers’ Compensation coverage.
    • The injury occurred within the course and scope of employment.
  • The claim representative will also address any coding necessary to file state reports via electronic data interchange (EDI) or by form.
  • The claim representative will coordinate medical appointments and maintain contact with the employer representative to ensure that the employee is able to return to work, following their medical evaluation. The authorized treating physician will address work status and note any restrictions, if applicable.

Wrapping Up the Claim
All of these steps are required for a work-related injury, so it’s not surprising that the average timeframe for a medical-only claim to close runs from 45 to 90 days. Amerisure’s claims team works closely with the risk management team throughout the claims process to help the employer develop a plan to avoid recurrence of similar claims.

“We have a service team approach to all Workers’ Compensation claims, which includes partnering with our Risk Management Consultants and Marketing Underwriters within Amerisure,” commented Kerri Friederich, ACA, CCP, Workers’ Compensation Unit Manager at Amerisure. “That’s what sets us apart from other carriers; Our holistic approach for better claim outcomes. Then we work with network providers who understand work-related trauma, manage our pharmacy utilization with a prescription benefit manager and all while assuring accuracy of our claim spend through bill review.  And, since we provide same-day contact with employers, we can identify anything that needs special attention from the get-go.”

In other words, a simple medical-only Workers’ Compensation claim at Amerisure is managed through a tight but empathetic process that helps the employer manage the medical component of these losses. That adds up to lower costs for the employer and better outcomes for employees.

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