We don’t know what will be important as our evaluation continues. Therefore, it is crucial to gather information while reserving judgment for later. Similarly, as the picture comes together, we may need to revisit several sources of information. For this reason, developing a measure of trust and an open line of communication serves you well. Making contact in a way that is convenient for your source keeps communication lines open.
Information sources related to a claim may be plentiful, however the vast majority of pertinent details may be obtained through three sources:
• The Claimant
• The Employer
• The Medical Provider
For the purposes of this article, we will concentrate on effectively obtaining information from these three sources.
The Claimant
The primary source for information related to the claim is the claimant. It is important to have direct contact at the earliest possible opportunity to be sure he or she understands the coverage, his or her role in the claims process, the information that is required, and the anticipated timeframe for a decision (or more importantly, the soonest a claim may be paid). Information requested from the claimant during the call should be sent in writing as a reminder, and to document the request and conversation.
Being upfront and establishing the groundwork goes a long way in building a healthy rapport. This makes future conversations more effective and generates better information because the claimant is more willing to talk to someone who listens and understands their situation.
For far too long, there has been a notion of competition between the claimant and the claim examiner. Statistically, however, the vast majority of claims are approved. The examiner should bear this in mind when speaking with the claimant and exude an attitude of working with the claimant towards reaching a favorable determination. When asked a common question such as, "Do you see any problems with the claim," it is a good approach for the claim examiner to respond that if an issue arises, the claimant will be contacted first. We find that claimants are more at ease if they know they will have an opportunity to get involved if there is a possibility of an unfavorable. This approach puts the claimant and the examiner together working as a team towards a common goal.
In the end, the facts and policy provisions will yield the decision. Therefore, when we find information that appears contrary to the claim, we should dispassionately share that with the claimant, rather than taking a "Gotcha!" approach. Infrequently we do uncover fraud and proceed accordingly, but many times there are explanations you would not have considered that fully explain the outlying information. In this case, a follow up request can be sent to the claimant (or other source identified) to document why the previous information was incorrect or irrelevant. On the other hand, if the claimant does not have any new information to share and a denial is the appropriate next step, they are more likely to accept the denial without appeal at this point.
If proper rapport was established and follow up communications were made throughout the claims process, there should be no surprises for the claimant when a decision is made. In our experience of conducting audits for various claim operations, there has been a direct correlation between the level of communication and the volume of appeals encountered on a given block of claims.
The Employer
Contacting the employer is often a very different experience from contacting the claimant whose only job (aside from trying to get healthy) is working with the insurance company to get his or her claim paid. The employer contact is likely a very busy person with multiple responsibilities. In addition to this, privacy rules, state guidelines and company policies and procedures may inhibit a full response.
Accordingly, in most cases it makes sense to approach the employer in the completely opposite manner than the claimant. First, send a written request for the information you want to cover and then follow up with a call to review the pre-planned questions and gather any additional details available at that time.
Once the validity of the claim is established, the examiner should focus on seeking the earliest safe date for a return to work. The best place to start this process is with the employer. It is important to understand the policies, procedures, and overall mindset of the employer with regard to returning employees to work. Important information to know includes:
• How long will the job be held open?
• Can the position be accommodated for the claimant’s limitations/restrictions?
• Are alternate "light duty" positions available?
• How long will light duty work be provided?
With this information, the examiner can assess where the employee falls within the parameters of the real work environment. Some employers fully understand the value of returning employees to work through accommodations or alternate positions and others only see this as more work in their already overburdened schedule. Knowing which type of employer you are dealing with is important.
It helps to have some statistical information available regarding the ROI of returning disabled employees to work, but realize that changing the culture of an employer is typically a larger job than can be accomplished by one claim person working on one employee’s claim. Typically, culture consultation is best reserved for a more macro evaluation with the carrier’s (or TPA’s) account rep and the employer’s senior management either at the outset of the relationship or during annual reviews. For the claim examiner, it is better to deal with the reality of the situation at hand and attempt to achieve the best possible outcome within that set of circumstances.
The Medical Provider
As with the employer, the medical provider should be contacted in a manner deferring to their convenience. A medical office typically has a set schedule when the provider conducts patient examinations, completes chart documentation, and makes contact with insurance carriers, pharmacies or other outside sources. Accordingly, the initial contact with the physician’s office should be to make an appointment to speak with the provider. Once the appointment is set, it’s best to fax a list of questions or topics in to the provider’s attention at least 24 hours in advance of the contact. If possible, a brief call should be made to the provider’s office to request that a member of the staff verify that the fax was received and ensure the provider is aware that it is in the file for review prior to the call.
Remember that in most cases, the provider is the patient’s advocate and understands the claimant far better than we can through a paper review of the file. Accordingly, while we may have opinions about recovery, care and treatment formed from our knowledge of the file and our own medical staff’s review, it is important to remain objective and be deferential to the opinion of the treating provider. The best approach is to simply hold the provider accountable for his or her opinion and seek an explanation for how that opinion was formed. In the end, the provider will either offer more details to aide in understanding the claimed loss, or it will be clear that the opinion is just that and an objective basis was not evident. In this case, the next steps are typically to arrange an independent medical examination.
The overall process of gathering information via telephone interview involves as much time and effort in the pre-planning stage as it does for the actual interview event. This can be frustrating but the time spent is well worth it if we can achieve a meaningful result and can save a lot of added work that results from making decisions with insufficient information.
Understanding and adapting to the different concerns and perspectives of the claimant, the employer and the physician increases the possibility of an effective and successful audit.
by: Charlie Putnam & Tom Loftus
