Securing Great Outcomes in Workers’ Medical Care
No Surprises! The Importance of Conveying & Gathering Expectations

Welcome to my series, “Securing Great Outcomes in Workers Compensation” which will explore various techniques in effective claims management.

In this first installment, I will explore the importance of conveying expectations to the injured worker relative to medical care.

Expectations and Medical Care
• Notices: It is important to outline any notices the injured individual will receive regarding medical care and any responses needed.
• Medical Control: Explain how medical care is directed by the employer/claim administrator and why.
• Physician’s Role: Make sure to outline the role of the physician in how benefits are administered and their reporting requirements. Itemize potential consequences if the physician does not meet these requirements and how this can be fixed.
• Medical History: Stress the importance of their physician having a complete medical history in achieving recovery, which may include requesting prior medical records, requiring the injured employee’s approval.
• Paying for Care: Outline how physicians and other ancillary service providers are paid.
• Utilization Review: If treatment is subject to utilization review, explain why and how it is used to ensure necessity and appropriateness of care provided. Additionally, what is the remedy available to the injured employee if care is denied.
• Group Health Care: If the claim is being questioned, direct the employee to alternate resources to secure care until a decision is made. Note, some States require medical care be provided by the employer/carrier while investigating the validity of the claim.

Gathering expectations from the injured worker is as equally important. Take a few moments and ask the injured what they expect from the process. The answers are very important in gauging the duration and complexity of the claim.

This by no means is an exhaustive list, but instead topics I found helpful to build a solid foundation in effectively adjusting a workers’ compensation claim and securing a great outcome. I learned that putting the time and care early in the life of a claim paid high dividends and greatly assisted in resolving the matter timely and equitably.

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