School of Workers' Compensation
Learning Objectives
The Compensation Principle
A workers’ compensation claims professional needs to have a general understanding of workers’ compensation law and how the law has evolved over time. No two states have identical laws, but the purpose/goal of workers’ compensation is the same in all states. This course teaches claims professionals the history and evolution of workers’ compensation and provides the basic fundamentals.
After completion, participants will be able to:- Explain the history of worker’s compensation and why it exists.
- Understand basic types of state WC plans and Federal plans.
- Understand types of workers’ compensation insurance or insurance alternatives.
- Have a basic knowledge of what regulatory agencies/law/statutes affect workers’ compensation .
What Is an Accident?
Before an employee can be entitled to benefits under a workers’ compensation program that the employee must have suffered an “accident.” The question at that point is, “How do you define an accident?” In this course, participants will learn the relevance of time and place with regard to an accident occurring in the course of employment; the necessity of the accident being related to the performance of job activities; and what deviations from job activities can affect whether or not an accident is covered under workers’ compensation. This course will additionally focus on the fundamentals of the employment relationship and the inherent points that must be present from the standpoint of the employer as well as the employee. Lastly, the course will focus on what distinctions will be seen between an “injury” and an “illness.”
After completion, participants will be able to:- Understand the employer-employee relationship.
- Understand how to define an injury as occurring within the course of and arising out of the employment.
- Understand the distinction between an injury and an illness from the standpoint of workers’ compensation coverage.
Determining Compensability
Claims professionals should have the training and knowledge to determine on each claim the scope of investigation required/proper analysis of the information obtained and then how to execute the decision on compensability. This course teaches the skills/steps necessary to put each claim in the best possible position to defend a compensability decision.
After completion, participants will be able to:- Identify the steps required to investigate a claim both at first notice and as new information is received regarding compensability.
- Be confident in their skills to obtain information in an investigation.
- Be confident in their ability to deal with plaintiff/applicant attorneys.
- Understand how to deny body parts/medical treatment/disability.
- Understand the basic steps needed to deny a claim and jurisdictional considerations.
- Be able to identify the information necessary to determine if any third party liability.
- Be knowledgeable regarding unfair claims practices and what steps to take to avoid this potential issue.
Managing the Claim
Managing the claim to bring forth the best possible outcome is crucial in the early stages, and ongoing, during the life of the claim. This course engages the learner by challenging them to think differently to achieve a superior claim outcome.
After completion, participants will be able to:- Understand why and how to make the right decisions in the claim handling process.
- Identify who the stakeholders are in a workers’ compensation claim; how to get to know and understand them, all while handling emotions in difficult situations and taking the appropriate action.
- How to develop trust with all stakeholders through integrity, collaboration and empathy.
- Understand who the leader is to manage the claim within the Relationship Model.
- Recognize the importance of a proactive road map to produce a superior claim outcome. This will be achieved by understanding the ASICME Formula which includes assessment, strategy, implementation, coordination, monitoring and evaluation of the claim file.
Forecasting/Reserves
Claims professionals must continually evaluate the financial exposures of the claim to ensure sufficient funds are set aside in reserve to pay for expected costs. Proper forecasting of the financial impact of a claim is essential to having funds available for timely benefit payment and the balance sheet of the company being represented. It isn’t simply a matter of stating how much money is needed, but rather ensuring the organization has adequate funds in reserve to cover the financial obligation tied to the claim. It is also important to understand the impact of the development factor applied by actuaries, collateral demands and financial planning. This course teaches claims professionals the importance of forecasting the primary components to consider in establishing the reserve fund.
After completion, participants will be able to:- Identify and understand key components of reserving.
- Understand their role in properly stating the financial impact to a company with regards to funding and the impact to the balance sheet.
- Understand reserve impact to actuarial assessments, collateral demands and financial planning.
- Understand that any significant variance in reserves is compounded by the actuary’s development factor.
- Understand why forecasting/reserving is more than math calculations.
- Understand timely payments and reserves go hand in hand.
- Recognize that there can be variations in reserve philosophies.
- Recognize the importance of being certain there is clarity around the claims professionals understanding of the company’s philosophy.
Medical Management
Medical cost in a workers’ compensation claim can get out of control quickly. It is essential to manage all aspects of the medical care in a claim from the onset and never take your eye off the ball. This course will provide you with tools necessary to improve the medical and cost outcomes of each case.
After completion, participants will be able to:- Know when to direct/not direct care.
- Identify past medical history and know how it applies to the work injury.
- Learn treatment and medical management approaches.
- Understand the importance of second opinions.
- Know how network providers impact cost and outcomes
- Understand that cheaper is not always better.
- Understand basic medical terminology.
- Know when HIPPAA applies and how to be in compliance.
Resolving a Claim
Resolving a claim with the best possible outcome for all involved is the delicate balance that exists in claims handling. Depending upon the claim, the stakeholders involved in the claims resolution will vary. This course will outline and review the steps that should be taken by a claim professional to successfully bring a workers’ compensation claim to resolution. Additionally, the idea that an injured worker who is entitled to workers’ compensation benefits in the state where they are injured is subject to the provision of exclusive remedy for that injured workers is a very important concept for the claims professional.
After completion of the course, the claims professional will be proficient in:- Proper claims handling techniques over the course of the claim’s life that would lead to successful resolution
- Understanding the dynamics of communicating to the proper parties settlement activities
- Where to find needed resources to identify all aspects of the claim’s value
- Identifying when resolution is wanted, but not possible
- Evaluating the economic value of the claim resolution
- Complete understanding of why and how the doctrine of exclusive remedy applies to workers’ compensation claims
- Review of specific cases where the doctrine has been thrown into question
- Understanding the difference between relying upon exclusive remedy for the injured worker and eligible subrogation.
- The benefits/risks to all stakeholders of the exclusive remedy doctrine
- The ability to articulate to the injured workers how and why the doctrine applies and what the injured workers is eligible for by statute in lieu of third party actions
