Primacy Risk Services brings an effective medical component to Workers’ Compensation claims. In an industry where insurance adjusters are responsible for as many as 200 cases at a time, adjusters’ precious time is often taken up with administrative functions. Or, the adjuster may not have access to the medical research allowing them to question a diagnosis or causation.
The typical scenario has the adjuster relying on a nurse or a doctor’s office (admin person) to pass along the medical exam outcome and diagnosis. This exchange of information often results in the adjuster accepting as “gospel” what has been explained by the injured worker as opposed to having the ability to posing questions that can minimize the medical costs and the duration of disability.
Anticipation
In Workers’ Compensation claims, we cannot rely on those who gain financially for accurate and truthful information. The whole story needs to be revealed. Statements need to be challenged.
To impact the outcome of the claim, Primacy does two fundamental things:
First is an immediate and deep investigation beginning with an in-depth digitally recorded statement. Second is medial research coupled with the investigation that will detail whether the facts as reported, and the alleged injury, are in fact plausible. Oftentimes questions of causation and mechanism of injury will be the best guide for the WC Adjuster.
Our investigations include anticipating that some or all the reported information may be less than truthful and accurate. We are not, by our approach, incriminating the Employee, rather, in order to protect the financial interests of our Customer we approach each case knowing that we may uncover a reason for malingering or fraud. If our investigation and medical research reveals consistency, then our Customer can be rest assured that the medical treatment and diagnosis are appropriate based on the reported accident.
Our expertise in the medical component of Workers’ Compensation cases also allows us to assist adjusters in building a medical defense. When we believe there may be no mechanism of injury, it’s critical to understand all that is being alleged in order to scientifically and medically challenge each unrelated condition.
For Example
A Customer’s Employee, age 58, on the job and while driving a company vehicle and is rear-ended. The Employee seeks medical attention and advises the physician that he has shoulder pain, pain that he did not have previously. A torn rotator cuff is diagnosed by the attending physician. Rather than accepting this condition (rotator cuff) as an injury related to this event, we research the condition and diagnostic codes. We then present to the adjuster and the treating physician all the necessary medical evidence that this is NOT a condition that is brought on by a rear-end accident.
From the outset, we anticipate that the Employee may seek to build up his or her medical bills in order to present a larger 3rd Party injury claim against the vehicle responsible and their insurance company. The recorded statement that we would immediately secure from the Employee would go into detail about the impact, the movement of the body and alleged injuries that resulted. We also rule out parts of the body in order to reduce the likelihood that later the Employee may attempt to add other injuries. Simultaneously, our investigation would likely uncover prior treatment on the shoulder by way of a medical canvass.
The thorough investigation process and our knowledge in medical cases allows us to quickly and effectively assist our customers to reduce the medical indemnity as well as the likelihood of litigation.
