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"File Audits"-Working with your TPA and Adjuster

"Audit" is a word we hear a lot this time of year. In WC, File reviews and file audits are both methods of reviewing claim files, but they have different purposes. 


Unlike file reviews, file audits are normally not interactive. The broker performs file audits or hires an independent claim audit company to comment on the TPA's claims handling. The focus is on the quality of claims handling.  The objective is to determine compliance with best practices and account servicing instructions. 


Each file is thoroughly reviewed to determine if:   

1. The TPA is handling the file assertively.

2. Supervision is apparent.

3. Claim contacts are well documented.

4. Effort was made to obtain return-to-work restrictions.

5. Pre-existing medical conditions were recognized and acted upon.

6. Reserves are accurate - not too high nor low.  

reviews and audits 6 months prior to your policy inception dateIf they are scheduled now, it gives the adjuster time to make adjustments in reserves prior to your unistat date. 

Learn more about file reviews and audits in our 2012 Workers Compensation Management Guidebook as a resource to implement and design a workers compensation management program. Bulk prices available for brokers and agents.


Why settle now? A common mistake made by adjusters is to litigate the claim when the claim should be settled. If the adjuster has properly established the settlement value of the claim, the time to resolve the claim is when the settlement value has been established, not months or years later after extended litigation. Learn more. 

A risk manager or workers compensation coordinator understands the importance of bringing employees back to work as quickly as possible following an injury. The challenge is to place the employee in a temporary duty job that will match the restrictions placed on the employee's work by the medical provider while producing a benefit for the employer. This is not just sweeping floors and answering phones. More. 

Data, being released and discussed, shows that assessments for operating expenses made by the NY Workers Comp Board against carriers (and passed on to employers) are five times higher than the national average for all states. Why? Attorney Theodore Ronca explains. 

Make a plan! Considering a less than powerful economy and a rising cost of living, for decades Return to work, in NY comp, has been viewed as a way to deprive a worker of a settlement and a way to deprive a lawyer of a substantial fee. But a mounting sense of uncertainty has changed that. Attorney Theodore Ronca advises.

Congratulations to Danielle Lisenbey who has taken over as CEO of Broadspire, an international TPA well-regarded as one of the best in the industry. Selected as a Lexis Nexis Notable Person of the year in 2010, she moves to the role from COO for Medical Services where she was responsible for the operation of all of Broadspire's medical and case management services. Read on.

WCR Wants to Meet You! The Philadelphia RIMS 2012 Annual Conference & Exhibition will provide unique opportunity to gather information and more. Keystone Case Management Could Give you a PINCH this Spring, LexisNexis Communities Offers This Week Work Comp In Review, Broadspire Combats Physician-Dispensed Drugs, and Texas Department of Insurance - DWC Seeks Public Comment on Amendment Proposals on MDR. Read.

A former MBTA driver (Massachusetts) is looking at a fall trial on charges that she staged an armed robbery, lied about it to police, and then claimed more than $7,000 in workers compensation funds, Suffolk County District Attorney Daniel Conley reported.

The Singapore Manufacturers' Federation (SMA) reports it has adopted enhanced workplace safety standards to minimize accidents and raise productivity. The revised codes of practice will affect about 2,800 of its members.

In the Union's statement to the press, they condemned the terrible conditions faced by thousands of building workers. The Turkish Union of Road, Construction and Building Workers (YOL-IS) recently came out and blamed subcontracting and the anti-union climate in the deaths of at least 11 construction workers, when fire engulfed a giant tent used as a dormitory for workers in Istanbul.

A manufacturing worker lost his little finger and part of the palm on his right hand and also needed two skin grafting operations.as a result of the incident at Crane Building Services and Utilities. The owner of the factory, Crane Ltd, was prosecuted by HSE after an investigation of the manufacturing company. What went wrong?

New summaries for "drug testing and workers compensation state laws" for every jurisdiction are NOW posted on our website. Click on the link above to check it out.

Don't gamble when it comes to Medicare/Medicaid Compliance!  

Gould & Lamb, LLC gather together some of the industry's most respected leaders and experts to provide attendees with 2 full days of compliance education and training, as well as an exciting look into the future of Medicare/Medicaid Compliance.

RIMS Conference and Exhibition is the largest industry conference. If you are new to workers compensation or experienced there are seminars to teach cost containment techniques.

In this widely acclaimed SEAK program, the nation's leading workers' compensation professionals, occupational physicians, occupational nurses, and attorneys will join together to discuss cutting edge issues. Frank discussions and lively question and answer sessions will complement each presentation.This conference is currently the largest and longest-running national workers' compensation and occupational medicine conference of its kind in the United States.

REDUCE WC COST 20% to 50%
Workers Compensation Management Program
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Lowering Workers Comp Costs for Employers

Rebecca Shafer, Attorney & Risk Consultant

Contact Us: Becki@ReduceYourWorkersComp.com

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