Safety & Loss Prevention
Claim Handling File Documentation Instructions and Guide
This document is intended to assist the Office of Safety and Loss Prevention Claim Examiner by defining the information needed to effectively handle the Worker’s Compensation claims of the University of Wisconsin System campuses. The roles and responsibilities of the UW-System Claim Examiner and Campus Coordinators vary to some degree, by campus. This Guide is intended to outline the information needed for proper claim handling and to illustrate file documentation procedures. It is not intended to define the roles and responsibilities of the claim examiner or campus coordinator.
This Guide will address claim handling procedures and file documentation suggestions and requirements. Several of the procedures, e.g., medical bill audit, utilization review and case reserves, are already in place, this Guide is not intended to replace those documents. Any questions concerning previously established policy or procedures should be referred to the UW-System Claim Examiners or Worker’s Compensation Manager.
It should be recognized that this Guide is not intended to be all inclusive and that situations will arise that are not addressed in this Guide. It is hoped that this Guide will be a useful tool, which will be utilized to more effectively handle and document worker’s compensation files. It should not limit the creative process, so often needed to effectively manage worker’s compensation claims.
The Employer’s First Report of Injury, WC-12, is sent to UW-System by the Campus Coordinators. This form is usually accompanied by the Employee’s first report, Occupational Accident and Injury Report, DOA-6058. It is at this time that a determination on future handling is made. Claims are generally distinguished in 2 categories, Medical Only and Lost Time claims. This Guide is intended to specifically address Lost Time claims. The information found on these reports includes, but is not limited to; the Injured Employee’s name and address, the employing Campus and department, the date of injury, nature and extent of injury and description of how the injury occurred. If any of this information is missing, the UW-System Claim Examiner must contact the Campus Coordinator for the missing information. The DOA-6058 also includes information completed by the Campus Coordinator or other campus personnel, specifically that information includes funding information, OSHA information and loss coding, i.e., ‘Cause, Occurrence, Object, Result and Location’.
Upon receipt of the First Report of Injury, the Claim Examiner enters the required information into the WCCS, Worker’s Compensation Claim System. Information from the WC12 and DOA-6058 is entered into the system. Claim information entry into the system should be thorough and complete. The Loss Descriptions codes are also entered into WCCS. It is important that the coding is accurate and consistent, as this information is used for safety and accident analysis and trending. It is suggested that all claims be entered upon receipt, including Medical Only claims, prior to receipt of medical bills, as this will more accurately reflect monthly claim counts and loss cause statistics. If the Claim examiner notices a trend of claims from a specific campus or type of injury occurring at more than one campus, the UW-System Worker’s Compensation Manager and Safety Director should be notified, as loss control efforts may be appropriate.
Lost time claims are those claims where an injured employee is absent from work for a period of 4 or more days as a result of the injury or disease. Lost time claims can be distinguished from Medical Only claims, in that an "indemnity" payment is made or exposure exists. Indemnity is defined as "compensation for damage, loss or injury suffered" and is paid directly to the injured employee. Benefits included are TTD, TPD and PPD, and do not include payments for medical treatment, prescription drugs or mileage. Claims where the injured employee is away from work or where there is TTD, TPD, or PPD are coded "LT". Two examples of Lost Time claims where the injured employee is not away from work for 4 or more days are, 1) an amputation to a member, i.e., a finger, where the injured employee is allowed to return to work, within 4 days of the injury, but where PPD benefits will be due and 2) an injured employee returns to work, on modified duty, where if not for the modified duty assignment, the employee would be unable to perform the assigned duties of the position held.
It is also our policy to code all "Carpal Tunnel Syndrome" claims and "Occupational Disease" claims as Lost Time. CTS claims and other "Occupational Disease" claims are distinguished from accidental injury claims in that the nature of the claim implies that the Injured Employee’s injury or disease is a result of the job or task performed and not an accidental injury. Therefore, these injuries should be considered "preventable" and special steps should be taken. Handling procedures for these claims will be addressed later in this Guide.
Only those claims where lost time does not exceed 3 days and limited medical treatment is required to relieve and cure the effects of the injury, should be coded "MED". In general, if medical expenses in excess of $500 are paid, the claim should be coded "LT" and lost time claim handling procedures should be followed. To top
3 Point Contact
3 Point Contact is the recognized process used in determining the nature and extent of injury and disability. Through the contact of 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. 3 point contact is required on all lost time claims and should be done as soon as possible after the injury occurs, usually within 72 hours, as the first report of injury must be filed with the Worker’s Compensation Division on the 4th day after an accident. Although the Claim Examiner is responsible for the handling and processing of the claim, the 3 point contact process can be completed by the Campus Coordinator and other campus personnel.
The Employee contact should be done as soon as possible after the accident. Information concerning how the accident occurred, the exact nature and extent of the injury and the physical limitations, should be the focus of the contact. The injured employee’s treating physician, treatment plan and return to work date, should also be determined. This contact is intended to establish a genuine concern for the injured worker. This contact can also determine if the injured employee has any other issues, pre-existing medical conditions, financial issues, which may hinder return to work. Employee contact should be done at least once every 2 weeks and after every doctors appointment until the injured worker is returned to work. The employees direct supervisor should be included in the contact process, as they best understand the employee and the employees job responsibilities.
The Employer Contact is done to verify the facts of the accident, as reported by the injured worker. Job analysis and physical requirements should be determined. Modified duty issues should also be discussed. The employer may also identify other issues concerning pre-existing medical conditions, prior worker’s compensation claims or other non-work related issue, which may hinder the return to work effort. If there is no modified duty available, the supervisor or department manager should be asked what portions of the job the injured worker might be able to perform, with the focus on part time return to work. If modified duty is not immediately available, the employing department should be contacted after every doctor’s visit and every time the injured worker’s restrictions change, until the worker is returned to his original position.
Treating Physician Contact
Contact with the treating physician is essential. Rarely is there direct contact with the "doctor". However, most offices have an individual responsible for Worker’s Compensation claims or contact can be made with the doctor’s nurse or the office medical records department. This contact should establish the exact injury, diagnosis, treatment plan and next scheduled appointment date, the physical restrictions, as a result of the injury and verify if lost time is authorized. It should also be used to advise the doctor of modified duty, if it is available. The claim coordinator should not accept a prescription form indicating lost time, without discussing the job requirements with the treating doctor’s office. Contact with the medical provider should be made after every visit and the physical restrictions should be confirmed in every contact. To top
Before a claim can be paid, the decision that the claim is compensable, i.e., that there is an employee/employer relationship, that the employee sustained an injury, that the employee was in the course of employment and that the injury arose out of the employment, must be made. Much of the needed information will be gathered in the 3 Point Contact process. However, often additional information is needed. If it is not clear that the claim is compensable, the employee should be immediately advised, usually by phone, followed by a letter, that more information is needed. The 2 most common issues in dispute are, 1) the employee did not sustain an injury and 2) the injury did not arise out of the employment, i.e., preexisting back injuries. In these cases, more information must be gathered. The employees medical history must be established, through prior medical records, to confirm or deny the relationship of the injury to an accident. Further investigation of co-workers and witnesses may also be necessary, if compensability can not be easily determined. In theses cases, a referral to an independent adjuster may be required for in person contact with the employee and other involved parties. In these cases the WCCS claim file should be documented regarding the need for further investigation. The UW-System Worker’s Compensation Manager and the Department of Administration, must be notified of all claim referrals. The Claim Examiner is responsible for directing the independent adjusters investigation.
Injuries and accidents are sometimes caused by another parties negligence. In these cases, an investigation regarding the cause of the accident is required. Automobile accidents, slip and fall accidents, off premise and defective products and machinery claims are examples of claims where third party negligence may be involved. Wis. Stats. Section 102.29 , protects the rights of the injured employee to make a claim against a responsible third party, while providing the same rights to the employer. In all cases where there is the possibility of third party negligence, the responsible party and the insurance carrier should be notified of our rights under Section 102.29. If the injured employee retains an attorney for representation in an action against the responsible third party, the attorney, too, should be notified, in writing, of the subrogation rights. Files should contain documentation of the investigation, subrogation possibilities, and when recovery can be expected. Note that the employer’s rights are only as good as the injured employees. Therefore, a 3 year statute of limitations applies to 3rd Party claims and an action must be started within 3 years, even if the WC claim is not concluded. Either the injured worker or employer may maintain an action in tort and reasonable notice must be given at the time to either party. If, as the claim is developed, subrogation possibilities seem remote, the file should contain documentation that the claim will no longer be pursued. UW-System is entitled to 100% recovery of all payments made to the injured employee. At time of settlement, no percentage less than 100% should be accepted without discussion with the Worker’s Compensation Manager. To top
Rehabilitation Nurse/Medical Case Management
The Claim Examiner is responsible for all aspects of case management. Upon receipt of a "compensable" lost time claim, the Claim Examiner must determine if the injured worker is receiving appropriate medical attention and care, to cure and relieve the injured employee and to return the injured employee to work as soon as practical. Whenever lost time exceeds 3 weeks, when return to work or end of healing is delayed or whenever medical treatment is complex and treatment plans are incomplete, the Claim Examiner should consider assigning a Medical Rehabilitation Nurse to the case, to work with the injured employee, campus personnel and the physician, to assure appropriate medical care is given. The Rehab Nurse is the employee’s advocate. It is the role of the Rehab Nurse to determine the employees duties and responsibilities and physical requirements of the job. The Rehab Nurse will also contact the employees supervisor to determine whether modified duty is available in the employee’s department or any where on campus. The Rehab Nurse may also attend doctor’s appointments with the employee to assure appropriate treatment is given and to answer any questions the employee may have regarding the treatment plan. It is role of the Rehab Nurse to assure appropriate reasonable and necessary medical treatment is given and to return the injured employee to work as soon as practical. Rehab Nurses should be hired on all compensable stress claims.
Medical Treatment Utilization Review
Worker’s Compensation law requires the employer/insurer to provide, "all care that is reasonably required to cure and relieve the effects of an injury." The State of Wisconsin, Bureau of State Risk Management, has contracted with Intracorp to conduct utilization case review of treatment plans of injured worker’s. Intracorp employees registered nurses, and physicians to review treatment plans and procedures. Intracorp reviews the following, Inpatient/Outpatient Hospitalizations and Surgical procedures, MRI and CT scan imaging, physical therapy and chiropractic treatment. Referrals for acupuncture, work hardening, occupational therapy and massage therapy and other exotic treatments, are done on a case by case basis. Referrals to Intracorp should be made as soon as the Claim Examiner is aware that hospitalization, surgery, or imaging is planned or when physical therapy or chiropractic treatment exceeds the recommended window. Claim Examiners are encouraged to contact chiropractors and physical therapists, when they recognize the treatment is about to exceed the recommended "window", as this contact puts the provider on notice that UHC will become involved and may hasten the end of treatment. Upon completion of the review of a treatment plan, etc., a Intracorp nurse or physician issues a written "recommendation" indicating whether or not the treatment is medically necessary. It is the Claim Examiners responsibility to decide whether not that recommendation should be followed. Cases that are not compensable are not to be submitted to Intracorp for consideration.
Medical Bill Audit
The State of Wisconsin Stat. 102.42 states the "employer shall also be liable for reasonable expense incurred by the employee for necessary medical treatment’. The BSRM has contracted with CorVel Med Fee to conduct medical bill reviews using the Worker’s Compensation Division’s data base to establish that the fees charged are reasonable. CorVel Med Fee issues checks for direct payment of medical bills to the provider. An explanation of benefits form is returned to the Claim Examiner, which should be filed in the claim file. If a bill is paid directly from WCCS, which would normally be audited by CorVel, a written explanation in the file is required.
The UW-System Claim Examiner is responsible for the claims filed on the campuses assigned. When an application for hearing is received, the Claim Examiner is to provide a copy of the application to the Worker’s Compensation Manager to log in and to make comment on any special issues. The Claim Examiner is responsible for filing the answer within the prescribed time frame. If possible, the WC Manager will review all answers before they are filed. Any filing deadlines, and additional investigation is also the responsibility of the Claim Examiner. UW-System examiners prepare the file for litigation and obtain the needed information which will eventually be sent to the Department of Justice for the defense of the claim at hearing. When the file is sent to DOJ, the actual file is given to the Worker’s Compensation Manager. The preparation of the file by the Claim Examiner, outlines all the contested issues and claim exposures, including TTD, PPD, LOE and medical expenses claimed. The value of the claim as presented by the employee and the value or exposure to the campus and UW-System is calculated , based on claim and medical documentation. Reserves should be checked for adequacy at this time. It is also at this time when a settlement or defense strategy is developed. Claim Examiners are encouraged to keep the WC Manager advised of any special issues or concerns. It has been the practice that the Worker’s Compensation Manager negotiates all settlements with the employees or their attorneys. Claim Examiners may evaluate and compromise any claim up to a value of $25,000. All pre-hearings are attended by the WC Manager.
The appropriate reserve is the amount (based on current information, medical records and claim facts) needed to cover all medical, indemnity and expense costs. Reserves should not be increased repeatedly for a few payments, this is known as stair step reserving. The Claim Examiner should anticipate the final cost of the claim. Case reserves are intended to reflect the ultimate exposure, or the cost of a claim, from creation through the life of the claim. UW-System in an effort to maintain consistent reserve practices, has established "Initial Reserve Guidelines", which are incorporated at the end of this manual. The claim file documentation should be entered to reflect the Claim Examiner’s rationale whenever reserves are adjusted. It is suggested that reserves be reviewed at least every 90 days and a comment concerning the adequacy should be enter into the claim file. The Worker’s Compensation Reserve Worksheet, which outlines the key issues in the reserving process, is available for use on all WC claims which have complex issues.
Reserves are to be considered each time the Claim Examiner handles a claim and issues a payment. Accurate and consistent reserving is an essential tool in determining the Worker’s Compensation Premiums charged to the campuses.
Occupational Illness and Disease Claims
Occupational Illness and Disease claims are often the most complex and challenging claims the campuses and Claim Examiners must handle. "Occupational Illness and Disease" is broadly defined as mental or physical harm that results from occupational exposure but that is not so sudden or traumatic as to fit within the definition of an accident. Examples of claims categorized as "occupational" are carpal tunnel syndrome, occupational back claims, hearing loss and exposure to harmful chemicals or toxins. Since these claims are not "accidental" they should be considered "preventable". Specifically this guide will address carpal tunnel syndrome claims, and suggested handling procedures. When a campus or Claim Examiner receives notice of a CTS claim, the first action taken should be to determine the exact cause. CTS can be caused by a variety of repetitive type tasks. Beyond the standard claim handling procedures, the Claim Examiner and the Campus should work together, in an attempt to identify the task which has caused the employee’s injury. Job task analysis may be necessary or it may be a simple as talking to the employee, while doing the job which may identify the offending cause. When the task, or harmful exposure is identified, steps should be taken by the campus to eliminate the exposure. If the employee is relieved of the CTS symptoms, but is returned to the same job tasks, the symptoms and problems are likely to recur. Whenever Claim Examiners receive reports from the campus of toxic exposures, air quality and ventilation problems, a report should be given to the University of Wisconsin System Administration, Industrial Hygienist and Worker’s Compensation Manager.
Late Report of Injury
Injuries that are reported late, by the injured worker, to the employee’s supervisor, are often the most difficult claims to handle. In an effort to establish the facts of the accident and clarify the issue of why a claim was reported late, it will be the practice of the Claim Examiner to assign every claim, for investigation, if the employee reports the claim more than 2 weeks after it allegedly occurred. The investigation should include, a recorded statement from the employee concerning the facts of the accident, any witnesses, activities since the injury and why the accident was reported late. The statement should include the exact location of the accident, and a description of how the accident or injury occurred, including premise defects, such as lighting, liquid or moisture on the floor or the exact weight or description of an item being lifted or activity performed. Photos of the scene of the accident or item handled, or activity performed, should also be obtained. The investigation should also include a statement from the employee’s supervisor and co-workers to establish if the accident or injury was ever mentioned prior to the report date and to establish the injured worker’s activities and work schedule since the date of accident. If the employee was off work prior to reporting the accident, a neighborhood activities check should also be conducted to establish the injured employees whereabouts after the alleged date of loss. Only after an investigation of this nature is completed and appropriate medical information and record are received, should a determination of compensability be made. To top
File documentation is done in the "Note" section of the WCCS electronic claim file. The following documentation requirements and suggestions are listed as they appear in the "pick list". It should be noted that although the categories are listed, all notes appear in the file chronologically.
This category should be used when the file is initially set up. Documentation should include the claim examiners initial thoughts concerning the claim, and the outstanding issues and planned course of action. If a claim is clearly compensable, notations such as, claim compensable, the expected treatment course and anticipated return to work date, should be documented. On claims where compensability is an issue, documentation should include the Claim Examiners plan to resolve the outstanding issues, i.e., "First report of injury indicates employee may have been injured chopping wood at home, will need to obtain statement from employee, witnesses and obtain medical records." This category should also be used by claim supervisors to recommend a course of action on contested claims.
Every claim should contain comments concerning compensability and any outstanding compensability issues. Issues such as; "arising out of and in the course of employment, causation, etc., are compensability issues. Reasons why a claim is not compensable should always be listed. Comments on compensable claims do not have to be detailed and can be as simple as, "employee injured when he slipped and fell in classroom, fracturing leg. This is also the category that should be used to document compensability disputes throughout the life of the claim, until the employee files a petition for hearing. Therefore comments such as; "the claim was denied because....", should be included in this section.
Compensable claims should contain comments in this section. Comments should include the length of disability and anticipated return to work date. Since Indemnity are the benefits paid directly to the employee, wage and rate calculations are also noted in this category. This category is also used to document permanent disability and loss of earnings issues.
This category should be used after an application for hearing is received. Initial comments concerning the issues in dispute and both the allegations and defenses. Conversations with the employee’s attorney, what efforts are being made to resolve the issues or solidify the defense. File activities such as, requesting additional medical records, scheduling IMEs, LOEC, DVR notes, ICI and SSDI record requests or offsets and filings with the Worker’s Compensation Division should be noted in this section. This section should also be used to outline negotiations and negotiation strategies, case strengths and weakness, settlement values and offers and demands. This section is also to be used to document Medical Fee Disputes and Necessity of Treatment cases. This category can be used to document any settlement made, even when there has been no application for hearing filed. Claim Examiners are also to enter the claim into the "Special Use" section entering YES upon receipt of the hearing application in the Litigation Section.
Documentation is this section should be limited to issues pertaining to the injured employees injury, medical condition and treatment plan, healing period, diagnosis, prognosis and objective and subjective complaints. Comments concerning utilization review issues, i.e., "chiropractic treatment now exceeds the window, UHC has denied further care to practitioner" are to be made in this section. IME information concerning the medical issues, when and IME is scheduled and the results should also be included.
University of Wisconsin System Administration Claim Examiners do not ordinarily use this Note category as telephone conversations can be documented in the category the phone call pertains to, however this section may be used to document any telephone conversation.
Any time after the initial posted reserve is changed, this section should be used to document the reserve rationale. Reserve documentation should provide an evaluation of the medical evidence, claim facts, return to work issues, prior claim or injury history or experience with the injured worker, campus department or medical provider, which affect the cost of the claim It is not necessary to use this category every time the reserve is considered, but not changed. Reserve adequacy comments can be made in any "Note" section, comments such as, "reserve appears adequate" or "will adjust reserve if necessary after receipt of additional information" is sufficient.
This section is to be used on all cases with extended periods of lost time and where Medical and Vocational Rehab specialists are assigned to manage the claim. When the Claim Examiner learns that the Campus department is unable to accommodate the employees work restrictions, a DVR referral should be sent. Documentation should include the return to work efforts, restrictions and retraining possibilities. Comments concerning VTD exposures, loss of earnings, can also be entered in this section.
Documentation in this section should be limited to subrogation investigations and third party recovery issues. The identity of the responsible third party and insurance carrier, defenses to negligence and the employee’s attorney. This section should be used when recovery is expected. It is not necessary to comment on subrogation when no possibilities exist. This section should also describe subrogation difficulties and why subrogation will not be pursued in cases where third party involvement has been identified. To top
Last Updated: 4/4/97