By Donna Motley, Vice President of Claims

What is entailed in processing a Workers’ Compensation injury claim? Once the claim form is submitted and set up in our system, it is more than just processing and paying the medical bills. In most cases the injured worker is treating with the employer’s Occupational Clinic. It is the Claims Adjusters’ responsibility to assure the employee is receiving proper treatment, with the appropriate medical personnel; and if necessary, have treatment of the injured worker transferred to a physician specializing in said injury. Orthopedic physicians specialize – back, shoulder, knee, foot, elbow, hands, etc. A mucular condition would be referred to a Physiatrist.
We monitor each and every doctor appointment the employee attends. If an appointment is missed or rescheduled, we want to know why. We follow up for the necessary disability slip the injured is required to submit to their employer.

We verify prescriptions that are written and filled to assure they are related to the claimed injury. A prescription for an anti-biotic should not be filled for an alleged back injury. We monitor the amount and duration of opioids that are prescribed. Current Michigan Workers’ Compensation law is written that allows us to request a letter of “Medical Necessity” if an opioid is being prescribed after 90 days. If the doctor does not comply with our request, we can refuse treatment and payment.

If medical equipment is ordered, we make sure it is necessary and applicable to the claimed injury under the Workers’ Compensation Act. Workers’ Compensation is different than Automobile Insurance in that Workers’ Compensation does not pay for “Replacement Services”. If necessary, we contract to have a ramp installed at someone’s home, order wheelchairs, roll-abouts, a hospital bed, tub transfers, etc., and make sure equipment is picked up when no longer required by the injured worker.

If physical therapy is ordered, we monitor the number of visits, questioning if a visit is missed or rescheduled, and verify through medical notes that progress is being attained.
When an employee submits a request for mileage reimbursement, we have to verify the employee did attend an appointment on the day indicated and also verify the distance traveled to and from the appointment. Mileage to pick up a prescription is not allowed under Workers’ Compensation.

We review all medical reports submitted by the treating physicians. We look to see if the diagnosis has changed or a diagnosis been added? Did the employee provide an accurate description of “how” the injury occurred? Is the current condition for which the employee is treating still related to the claimed injury? Are there co-morbidities? Is the employee making excuses to the physician why they can’t return to work, missing appointments, or not going to physical therapy? Is the employee painting an unrealistic picture of their job duties? Is it time to find a different doctor because there has been no advancement in treatment and recovery?

We monitor our Medical Bill Review vendor, our Investigators and our Attorneys.

The end result is to have a successful recovery for the employee, have the employee return to work, and save the employer money!