What is the Purpose of a Workers’ Comp Claims Review?

Medical expenses account for well over half of claims costs, which directly impacts employer’s workers’ compensation total cost of risk. This exposure is only projected to increase as time goes on due to treatment costs that are unrelated to an injured workers’ injury. There are many reasons unnecessary medical treatment could occur. However, there are ways to manage these associated expenses and ensure patients receive the needed quality care without paying for what you do not owe. Completing a worker’s comp claims review is a great way to prevent rising medical costs.

The Ins and Outs of a Utilization Review

A utilization review will thoroughly examine medical services to better manage the quality and use of appropriate care. By implementing nationally recognized guidelines, a workers’ comp claims review will assess the medical provider’s treatment plan, care time frame, service scope, and the specific injury and patient factors to determine the effectiveness of the medical services. Typically, a review is completed before the services are performed, but it can also be done throughout the treatment or hospital stay or even after the service has been provided. The entire review process is generally conducted by a clinical professional such as a registered nurse who is employed by the carrier providing the service. If the nurse finds that treatment or procedure is appropriately applicable to the specific injury, the physician assigned to the patient will be notified that treatment is approved and should be conducted.

The Precertification

The precertification process for treatment is a vital component of the review. Precertification will examine the medical necessity of the medical services. It is the process in which a workers’ compensation carrier will determine if they will either approve or deny medical procedures or treatments before the procedure or treatment. When treatment is denied, precertification permits this medical professional to determine alternative assistance that is appropriate for the injured worker. The review process is meant to detect red flags and treatment issues on a claim, to learn how to better handle the subsequent claims. The improved claim navigation will greatly reduce costs due to avoiding unnecessary medical care, expedite the employee’s recovery, and offering them the best medical options for recovery.

An Augusta claims analysis review’s true goal is to ensure injured employees who make a claim will receive quality care. This workers’ comp claims review process relates to appropriate and medically necessary treatment, allowing the business to improve how they proceed with these types of claims. Therefore, less time and money are wasted in the future. This mindset will lead to a stronger utilization review and optimal recovery of the worker.

About SB One Insurance Agency

At SB One Insurance Agency, we have served the businesses and residents of New Jersey, New York, and Pennsylvania for more than 65 years. We are a wholly-owned subsidiary of Provident Bank, the region’s premier banking institution, and we are prepared to offer you personal, business, employee benefits, and risk management solutions. To learn more about our coverage options, contact our specialists today at (888) 990-0526.