Best practices, proper claim reporting

GEORGIA STATE BOARD OF WORKERS' COMPENSATION
www.sbwc.georgia.gov
BEST PRACTICES
PROPER CLAIM REPORTING
July, 2007

Proper Claim Reporting
The success of the claims handling process depends largely on the employer's representative who is reporting information to the claims adjuster handling the workers' compensation claim. Timeliness and efficiency in furnishing required information promotes a high level of service to the injured worker and compliance with governing state statutes.
Reporting the Injury
Best Practices A. The supervisor should take the time to handle the injury properly listen to the employee describe the injury and how it occurred. The injured employee should be the supervisor's only concern! B. If the employee needs emergency care, be sure he is transported to the nearest emergency care center and go with him! C. Otherwise, remind the employee to obtain medical care through the "Panel of Physicians" and assist the employee in obtaining care. D. Report the injury to the insurance adjuster who will handle the claim, either by calling a central telephonic reporting number established by the claim office, or by completing the Form WC1 Employers' First Report of Injury. E. Complete the wage transcript on the back of the WC-1 with the employee's wages for the 13 weeks immediately prior to the accident. If the employee has not worked substantially the whole 13 weeks, use the wages of a similar employee. Never hold the WC-1 while waiting to obtain wage information to complete the form. Forward the First Report of Injury immediately to the claims office and use the State Board Form WC-6 Wage Statement, to report the wages at a later time. F. Attach a list of the Panel of Physicians posted at the work site. G. Advise lost time status, but follow-up with specific information, especially if the employee loses more than seven days from work. H. Have the employee sign a medical authorization form WC-207 and send to the workers' compensation adjuster. The form may be obtained from the claims office or from the State Board of Workers' Compensation, 270 Peachtree Street, NW, Atlanta, GA 30303-1299. All Board forms are available on the State Board's website, www.sbwc.georgia.gov.
Benefits A. Gives personal attention at a time of great need. B. Establishes clear communication with the emergency center. C. Prevents misunderstanding of unauthorized medical care. D. Allows the adjuster to act quickly on the case and authorize medical care or additional action. E. Assures that the correct compensation rate will be paid. F. Notifies the adjuster or the physician rendering care and allows denial of unauthorized care. G. Assures prompt payment of the first indemnity check. H. Assists the adjuster in obtaining necessary medical information quickly.
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Injury Review
Best Practices A. Investigate the accident and make notes of any pertinent information: 1. How did it happen? 2. Who saw it happen? 3. How could it have been avoided?
B. Report any recommendations to the Safety Committee for consideration in improving a Safe Work Site.
C. Advise the workers' compensation adjuster of any prior medical conditions or third party involved in the accident. Be sure to include specifics as reimbursements may be sought through subrogation action.
D. If you suspect fraud or misconduct, do not publicize it; immediately notify the claims office or third party administrator.
E. Immediately notify the claims office or third party administrator whether or not salary will continue in lieu of benefits.
F. Advise the workers' compensation adjuster immediately if an attorney contacts you or you have information that an attorney has become involved. The adjuster will furnish assistance in communication with the attorney.
Benefits A. Early investigation is critical in obtaining accurate information, establishing events, identifying witnesses and conditions which may be valuable information in the future. B. Assures the future safety of employees in the unit. C. Reimbursement from subrogation saves claim expenses. D. Maintain the supervisor/employee relationship while allowing a more impartial source to obtain critical pertinent claim information. E. Furnishes expert advice and assistance in dealing with legal matters.
Follow-Up Reporting
Best Practices A. Keep the adjuster fully advised of lost-time status of the injured employee and whether or not salary will continue in lieu of benefits. B. Advise of any other employer-provided disability benefit for which the employee qualifies. C. Check with the treating physician periodically relating to the specifics of disability and limitation. D. If the physician releases the employee to work, but with limitations, review job with physical requirements consistent with the restrictions. Advise the workers' compensation adjuster if an offer of return to work, in such a job, can be made to the employee. The adjuster will assist with medical documentation and reporting requirements. Refer to Board Rule 240, of the Georgia Workers' Compensation Laws, Rules and Regulations Annotated 2007 E. Assist the employee in filing all medical bills, prescription bills and mileage reimbursement requests with the workers' compensation adjuster. Check with the adjuster as to specific forms which may be required. F. Call the employee frequently during the recovery to check progress, and alert the workers' compensation adjuster of any concerns expressed by the employee so issues can be handled early. G. Advise the adjuster immediately upon the employee's return to work, either to full duty or to transitional duty.
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Benefits A. Assures accurate indemnity payments. B. Certain employers' contributions may qualify employer for offsets against part of the indemnity payments. C. Establishes accurate communication regarding the injury and the requirements of the job. D. Early return to work is good for all parties concerned. An Early Return-To-Work Program manual is available on the Board's website, www.sbwc.georgia.gov. E. Assures proper compliance with all filing requirements and relieves confusion. F. Allows action to be taken by the workers' compensation adjuster quickly giving the employee confidence in the manner in which the claim is handled. G. Eliminates overpayment of indemnity benefits. July, 2007
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