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Quality Control Claims Review

Submit an individual claim (or several claims) to us for review by a medical doctor or claim expert. We provide an impartial review, but do not serve as expert witnesses.

The review will include evaluation on file handling. Suggestions for improvement will be noted. Below are the two types of Quality Control Reviews we offer.

Quality Control Medical Review: A Medical Doctor (MD) will review, evaluate and comment on a sampling of your claims to determine use of Industry Best Practices by insurers, claims administrators, clinics and medical providers, including:
Over and under-utilization of services such as medical treatment, physical therapy, chiropractic, diagnostic procedures and surgery
Effectiveness of medical cost containment services, including Nurse Case Management
Completeness of cover letters to Independent Medical Examination Doctors
Effectiveness of Independent Medical Exams
Doctor cooperation with Return to Work Program and Transitional Duty
Accuracy of diagnosis and causal relationship to workplace
Recognition of subtle medical language indicating symptom magnification
Whether the injury was caused or aggravated by work or whether other possible causes should be explored
With older files, additional opportunities for Second Injury Fund reimbursement are found
Percentage of claims where length of disability is proportionate to time out of work
 
Quality Control Claim Review: Our Claim Experts review, evaluate and comment on your claims to determine whether sound, aggressive claim management is focused on timely and positive resolution of the claim including:
Investigation
Compensability Determination
Policy Coverage
Benefit Administration
Supervision
Case Management
Medical Management
Return to Work Management
Claim Resolution Efforts
Negotiation & Settlement
Subrogation/Recovery
Financial & Reserving
Outcome
Litigation Management
File Documentation



VIEW QUALITY CONTROL
CLAIM REPORT
SAMPLE PAGE (.pdf)



"Workers Compensation Management Program: Reduce Costs 20% to 50%"

To learn more about how to lower your workers compensation expense, read the guidebook from Advisen and the Workers Comp Resource Center, Workers Compensation Management Program: Reduce Costs 20% to 50%, which covers the following:

•   BONUS CHAPTER! Process Overview for Workers Compensation Managers
• Workers Compensation Basics
•   Fundamentals of Cost Containment
• Best Practices Roles and Responsibilities
• Management Commitment
• Employee Communications
• Controlling Fraud and Abuse
•   Return to Work and Transitional Duty
• Claim Reporting
•   Other Indemnity Cost Containment Services
•   Directing Medical Care
• Medical Cost Containment
• Physical Therapy & Physical Rehabilitation
• Pharmacy Benefits Management
• Training Supervisors
• Working with the Insurance Company and TPA
•   Claim Resolution and Settlement
•   Safety and Loss Control

Workers Compensation Management Program 2012: Reduce Costs 20-50%
Learn more about the comprehensive guidebook from Advisen and the Workers Comp Resource Center: Workers Compensation Management Program: Reduce Costs 20% to 50%.

Learn more: Workers Compensation Management Program: Reduce Costs 20% to 50%
Learn more about included documents, bulk pricing, and custom imprinted covers for brokers, carriers, and associations.

 


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