Workers’ Compensation division manages all administrative functions
under one roof. Loss of time and medical claims are handled in the
same office along with medical case management. As is the case with
all of Maxon’s administration systems, our Workers’ Compensation
administration system was developed in-house, and is maintained by
our own programming staff. This gives us the flexibility to provide
any special report desired by our clients. It also provides our staff
the ability to easily coordinate aspects of a particular claim.
Claims Management Philosophy and Best Practices
philosophy regarding the handling of Workers’ Compensation claims
is as follows:
have all personnel involved in a case work hands on as a team. This
means that loss of time examination works hand in hand with medical
examination and medical case management. All personnel are involved
from the opening of a case.
work with the client to ensure quick reporting (24 hours) of claims.
Financial Services Group study reported in 2004, found that claims
filed a month or more after an injury cost an average of 48 percent
more to settle than those reported the first week. The primary explanation
for these results was that “a delay in reporting a claim often
means a delay in starting appropriate treatment. This adds to the
recovery time and the cost of medical care and wage replacement and
can even make the difference in whether the worker will ever return
to the job.”
respond quickly with the Three Point Contact upon first report of
Point Contact process is used in determining the nature and extent
of injury and disability. Through the contact with the injured employee,
the employee’s supervisor and the treating physician, the claim
process of returning the injured employee to work, as soon as practical,
begins. The Three Point Contact is required on all loss of time claims
and will be done within 48 hours after the injury occurs. Timing
is important in order to insure compliance with the section 15 time
limits for processing of initial claims.
use best practices in settling claims.
practice in settling and denying claims includes:
validation of medical diagnoses.
the medical necessity of treatments using the claimant’s
medical history and clinical evidence.
of industry standard treatment guidelines as the starting point
for medical necessity determinations.
of industry standard durational guidelines as the starting point
for loss of time determinations.
of American College of Occupational and Environmental Medicine
Utilization Management Database.
of nurse/case managers that supports the claims administrators’ screening
collection and management of information on a claimant’s
clinical condition, physical limitations, and work status to help
determine the medical necessity of certain types of treatments
common forms can be obtained directly from the
New York State Workers’ Compensation Board