Best Practices For Workers Compensation Claims


As a professional in your field, chances are you’ve already recognized -and probably prioritize risk management. Workers compensation costs are escalating rapidly, and while there’s no way to completely prevent incidents, there are certain steps an organization can take to help minimize the frequency and cost of such events. Workers compensation claims are just a part of doing business. Even the safest company in the world will have an employee injury on the job.

Although best practices vary slightly (depending on the insurance company), here is a quick summary of the basic standards of how an insurance adjuster handles worker’s compensation claims. So, let’s take a look at some things you need to think about. When an adjuster, for instance, completes each of the practices, the quality of the compensation claim file reaches a higher standard, and the claim resolution is appropriate.

3-Point Contacts

This process involves the adjuster making contact (whether in person, by phone, or email) with the employer, the employee, and the treating physician within the first 24 hours of the claim being reported to the office. In other words, not just leaving a voicemail or sending a form letter. That being said, three-point contacts are always handled by telephone, except in severe cases where an in-person contact would be justified.

With most adults having access to cellular phones and/or home telephones, there is no reason for not making voice contact. If the principals cannot be reached by telephone, a contact letter should be sent while continuing the effort to reach the principals by telephone.

Please note: The adjuster must ensure that a Work Ability Form provides some sort of medical restrictions on the first doctor visit. If this information, for whatever reason, is not obtained at the first medical visit, the claim will more than likely become a lost time claim. This leaves room for companies to dismiss the claim –not the same as lost time claims– and toss the report right out the window.

What type of injuries are usually covered?

For work-related injuries, in particular, employees might be eligible for compensation for any of the injuries listed below:

  1. Any physical injury that occurred on the job. This can include exposure to dust, toxins, hearing loss, and motion injury.
  2. Injuries caused during lunch breaks, work-sponsored activities (like company picnics, and other social gatherings), and at-work injuries that are caused by company facilities.
  3. Injuries that result in both mental and physical strain brought on by increased work duties from the employer and/or work-related stress.
  4. Preexisting conditions that the workplace accelerates or aggravates. Some examples might include a lower back injury, even though you don’t notice the pain from the injury until later.
What type of incidents aren’t covered by worker’s compensation?

Worker’s comp insurance is designed to cover an employee’s injuries. The range of injuries and situations covered are broad, but there are still limitations. Companies can impose drug testing on the injured employee and can deny the employee workers compensation benefits if the tests show that the employee was under the influence at the time of the injury. Compensation is also denied by insurance companies if the injuries on an employee were self-inflicted; where the employee was violating a state and/or federal law along with company policy; and where the employee wasn’t on the job location during the time of the injury.

Action Plan

An action plan contains a detailed outline of the steps the claims adjuster plans on taking to bring the file to a conclusion. The outline contains a date for each issue, problem, or concern to be resolved. It must be a workable plan with solutions outlined.

Medical Management

If you are facing one of the many stages of a workers comp claim you may be dealing with a lot of confusion. Staying in contact with everyone providing claims, updates, and proof of injury can be really tiresome. Management, however, is vital during this time. That being said, the worker’s compensation adjuster needs to know the nature of the injury, the cause of the injury, the treating physician’s diagnosis, and the return-to-work status. In most cases, the adjuster has the ability to assess the severity of the claim and proactively determine medical management resources needed either based on their experience or predictive modeling tool.

Claims adjusters know medical terms, and they’re also able to suggest physicians early on to assist in determining and evaluating different treatment plans. An adjuster’s access to network providers and use of medical management allows them to provide the treating physician with the necessary information needed for utilizing claim review and pre-certification. If the adjuster utilizes a medical bill company to verify proper billing, the adjuster must be sure the medical bills are provided to the vendor for processing.

Dealing with workers compensations can be very stressful for employees who aren’t experienced in this field, especially after sustaining a work-related injury. The worker’s compensation claim process is often times boring, but it can still sometimes require the delicate touch of an experienced legal professional. In such cases, it’d be wise to seek the assistance of an attorney who specializes in workers’ compensation claims. That way you’re certain that the employer won’t try to find loopholes in your claim to avoid necessary payments.

Thanks for the read! Did I miss anything important? What are some other best practices for workers compensation? Feel free to leave a comment below.


Herman Davis
Herman Davis
Herman Davis loves taking advantage of the sunny weather outside. If you can’t catch him online, you might be able to catch him out playing football with friends or cheering on the Denver Broncos. Follow him on Twitter below.

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