Claims Management Policies and Procedures
CSI employs seasoned, experienced claims managers, adjusters and nurse case managers who administer all aspects of a claim with efficiency and professionalism. These professionals are familiar with the statutory and medical aspects of workers’ compensation claims. Our claims staff, working in concert with network providers and our managed care team, is readily capable of addressing the key drivers in workers’ compensation costs. These drivers consist of managing the cost per unit of care, the number of units of care provided and durations of disability. Key highlights of our claims management policies and procedures are as follows:
Claim File Management
CSI’s Claims System uses an electronic management technology to manage and store claims information. The Diary System is utilized to effectively manage, review and update claims status at regular intervals. Following an initial claim review, the claim adjuster develops a diary based on the investigation, facts of the claim, disability, prognosis and probable outcome. The Diary System allows for files to be diaried at various intervals but no longer than 30 days from the initial review. The Diary System prompts subsequent updates at intervals of 60 days, 90 days, six months and annually. More importantly, the claim system allows all supporting documentation to be stored electronically, readily accessible to all involved parties. There’s no lost paperwork, and instant accessibility to all relevant claim information.
Establishment of Reserves
Reserving is done by experienced, competent and qualified claims professionals. Initial reserves are established for each claim. Reserves are monitored regularly. Documentation for reserving rationale is an integral part of the claim file. When setting a reserve, benefits such as indemnity rates, medical costs, allocated expenses and vocational rehabilitation are all considered. Our professionals also consider other factors such as employment history, restricted work availability, legal jurisdiction and state laws. Initial reserves are established within 21 days of claim receipt. Reserves are updated during the life of the claim as additional information becomes available.
We are committed to providing quality medical care and the timely payment of lost wages in accordance with the applicable Workers’ Compensation Laws. It is also understood that Workers’ Compensation claims must be factually investigated to ensure that benefits are paid to those injured employees who are legitimately entitled to Workers’ Compensation benefits.
Unfortunately, an aspect that must be addressed in adjudicating Workers’ Compensation claims is fraud. In situations where fraud is suspected, we execute thorough investigations and/or surveillance. Surveillance is conducted by approved vendors who have a proven track record of investigative capabilities. CSI also maintains its own internal audit function. Reporting directly to the parent company, this function designs and implements a comprehensive audit plan geared toward ensuring adherence to internal policies and procedures on claims handling as well as standardized anti-fraud testing of the provider and claimant payee records.
Our dedicated claims staff assures that claims receive appropriate, timely referral to outside defense counsel, when warranted. CSI provides counsel with all details of claims handling and medical care provided to allow for efficient use of defense counsel’s time. This leads to reduced legal cost. CSI takes an active role with outside counsel in consultations for legal strategies and assistance with structured settlements. Our claims supervisors maintain an active diary on all litigated claims and prepare documentation for all upcoming hearings. This assists our clients in assessing the progress of legal action.