The Best Adjusters Know When to Ask for Help: Managing Complex Claims Takes Teamwork

| | Utilization Review

Managing Complex Claims
Historically, claims adjusters managed most claims on their own. Today, however, extensive rules and regulations for medical management make it nearly impossible for adjusters to manage all claims without expert help. Smart adjusters turn to utilization review (UR) providers, peer reviewers and case managers to ensure their complex claims achieve the best possible outcomes.

Recognize a Complex Claim Early

Today, adjusters can still effectively manage less complex claims, such as incident-only and medical-only claims, on their own. In these scenarios, claimants miss no work time, receive minimal medical treatment, and are not eligible for income benefits. Incident-only and medical-only claims require adjusters to monitor minor treatment and billing transactions and approve payments timely and accurately.

Managing complex claims, such as many lost-time claims, are difficult for adjusters to manage effectively without specialized assistance. For example, a worker slips and breaks her hip and is out of work for several weeks. This means the employee will be eligible for income benefits and may need to see multiple specialists and receive many levels of treatment. In this example, the employee would have a complicated recovery process, in both treatment and claims administration. A hospital, an orthopedic surgeon, a physical therapist, a pharmacy, a DME provider and possibly other providers would be involved each with multiple medical charges to audit.

This type of claim requires adjusters to monitor many moving pieces, which makes it difficult for them to ensure the claim is handled according to the state regulations. When adjusters need help to manage claims properly, Utilization Review (UR) providers and sometimes case management services, can help. With these resources, adjusters can more effectively ensure that patients receive the proper and timely treatment in accordance with evidence-based treatment guidelines.

UR Services Help Adjusters Navigate State Regulations

Medical management is partly driven by state regulations. For example, in Tennessee, employers and carriers select the physicians they want in their networks. Regulators believe that if employers and carriers choose their providers effectively, then the network providers will follow the same treatment philosophies and procedures as the employers and carriers who chose them. In theory, this would make medical management much easier.

In reality, employers and carriers cannot possibly know that every network provider follows their philosophies and has a clear understanding of evidence-based medicine without interviewing and monitoring each one. Without comprehensive UR and sophisticated technology, this would be impossible.

If attempts to select like-minded doctors are not sufficient, what should a good medical management program look like? First, it’s important to establish treatment parameters that are appropriate and effective. These parameters help define the treatments that require utilization review. For example, if an employee has a minor injury such as a sprain/strain, the normal treatment process may allow a course of physical therapy during the initial phase of the injury. Continued treatment would need utilization review if it exceeds the parameters identified in the treatment guidelines.

The challenge comes when dealing with injured workers who are outliers to the parameters. For example, if an employee injures his knee, the first step, according to the parameters, is physical therapy. According to the parameters, if the injured worker has not recovered, the next step, is an MRI. What should happen if the MRI does not identify any problems, and the worker still suffers from the injury?

In these cases, employers and carriers can turn to UR providers and other medical management resources. UR providers can assist in managing the treatment of patients who fall outside of the normal parameters. UR processes allow for communication between the treatment provider and the UR physician to discuss outliers and co-morbidities that may be impacting the healing process and additional treatment.

When claims include multiple specialists, various levels of treatment, and complex state guidelines, adjusters need assistance. Given that much of medical management is driven by treatment guidelines, the best way to start implementing a medical management program is to look at the state’s specific treatment guidelines. UR providers and case management services are the best resources for helping adjusters achieve optimum claim outcomes.

Karen Atkins

Karen Atkins, Chief Operating Officer with UniMed Direct, is leading the conversation, and the industry, on how to make the utilization review process more efficient for all stakeholders: physicians, insurance companies and, most importantly, patients.