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THE EMPLOYER'S ROLE IN WORKERS' COMPENSATION CLAIMS MANAGEMENT By Pinnacol Assurance Understanding the workers' compensa- tion claims process and your role in it can help you manage your claims better, avoid litigation and reduce the cost of claims. At Pinnacol Assurance, we believe the claims process begins before an injury oc- curs and there are important steps you should take to ensure your company's claims run smooth. Before a work - related injury occurs 1. Designate a medical provider for your in- jured workers from Pinnacol's SelectNet provider network and inform your em- ployees in writing of the name, address and phone number of your designated provider. 2. Discuss your workers' compensation and safety programs with employees prior to any accident. Employees who understand the process prior to an accident or illness are less likely to be dissatisfied with the claims process. 3. Designate an employee to report all claims to Pinnacol within 24 hours of the injury or accident. Ensure all employees know to whom they should immediately report injuries. When an injury or illness does occur File a first report of injury via telephone or the Internetwithin 24 hours of the accident.You are immediately given a claim number and as- signed a claims representative. The claims representative, nurse, and medical claims assistant team begins pro- cessing the claim immediately. If the injured employee will lose more than three days from work because of the injury: • A claims representative is assigned and calls the employer within 24 hours to review the claim. The claims representa- tive also calls the injured worker to review the claim. Benefits are explained to the injured worker and an admission is filed. • For serious injuries, the team nurse con- tacts the physician within 24 hours to obtain a treatment plan and to ascertain any physical restrictions. The nurse also contacts the injured worker to review the treatment plan and answer medical questions. For minor injuries, the team's medical claims assistant (MCA) contacts the phy- sician to obtain a treatment plan and to ascertain any physical restrictions. If the injured employee will lose less than three days from work because of the injury: • The medical claims assistant (MCA) will provide medical oversight on medical - only claims. The MCA will contact the employer when there appears to be a question of compensability; if concerns about compensability remain the claim could be turned over for investigation, if necessary, or denied, if indicated. • The MCA contacts the provider to obtain a treatment plan. If the injured worker is not fully recovered from the injury within six weeks duration of temporary total dis- ability, $7,500 incurred, or upon a request forsurgery,the claim is immediately trans- ferred to the nurse for medical oversight. If you believe there is a concern with a safety violation, compensability or fraud,tell the claims representative or MCA immedi- ately. Pinnacol can assign a safety consultant, in -house doctor or investigator to review the claim and a recommendation can be made to deny the claim or to investigate it further. Once Pinnacol has knowledge of a claim, the law requires we admit or deny liability within 20 days and, if the claim is compen- sable, to pay benefits in a timely manner. After the claim has been filed Once Pinnacol has admitted liability, your claims management team works with the medical provider to ensure that all rea- sonable and necessary treatment is provided to bring the employee to maximum medical improvement, and the employee receives all lost wage benefits afforded by law. Your claims management team will frequently contact you and the injured workerthrough- out the duration of the claim. The employer, however, continues to play an important role in the claims process. • Communicate. Regularly contact your injured worker, especially if he or she is un- able to work. There is a direct correlation between regular employer- injured worker communication and lower claims costs. Offer Modified Duty. At Pinnacol we strongly believe that safely returning in- jured employees to work as soon as pos- sible is an effective way to manage costs. Our return -to -work specialists can help. Communicate, Part 2. Contact your des- ignated medical provider regarding your employee's restrictions. Additionally, if you have any questions about your employee's claim, contact the claims representative. Once the injured employee reaches maxi- mum medical improvement, the employee may be entitled to compensation in addition to lost -wage reimbursement. Early identifica- tion and expert cost analysis is the key to the settlement process. Claim representatives are trained to evaluate compensation and medical exposure. We partner with you in the settlement process early on so issues such as ADA and other employment issues can be addressed at the time of the settlement. After the claim is closed Don't file the claim and forget it. Ensure that any safety concerns that may have contributed to the accident have been corrected. Call your safety consultant to discuss any concerns. If any internal safety or claims management procedures were not adhered to, talk with your employees about the importance of maintaining a safe work environment and effectively managing the company's claims. Finally, request a loss his- tory report from Pinnacol and lookfortrends; your safety consultant can help you identify accident trends and implement solutions. If you have any questions, call Pinnacol Assurance at 303 - 361 -4000, or contact your association representative. 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