We mainly think of an AOE/COE investigation as a means to determine whether the claimed injury or disability of an employee is industrially caused, and if it appears to be genuine. Such an investigation is a vital and necessary tool but it can also help in additional areas. As long as the AOE/COE investigator is being paid to be at the employer and/or employee location, the more things that can be done with that opportunity, the more "bang-for-buck" you can squeeze out of that expense. Here are some areas that the investigator can explore, to extract as much savings as possible for the file:
Subrogation - An AOE/COE investigator can conduct a subrogation investigation, as applicable, concurrent with the AOE/COE investigation. The investigator will usually be at the place of employment, and can observe the workplace area where the injury occurred, and be alert to any sources of subrogation recovery. He or she can then collect information, photographs, documentation and witness statements while memories and evidence are both still fresh.
Pre-Surveillance - It may be that some cases are eventually selected for surveillance. Surveillance is most effective when the surveillance investigator has as much information as possible about the subject, and a clear idea of the restrictions and claimed disabilities. An AOE/COE investigator can obtain a photograph of the employee at the time the employee's statement is taken, and can nail down information as to their current address, their daily routine, what activities they used to do, but now cannot, etc. This can help establish a "baseline" of what the employee's representations are regarding their claim, so that any departures from that which are seen in surveillance can clearly be seen as a potential misrepresentation. Knowing the employee's general routine and habits allows the surveillance investigator to choose the most potentially effective times for investigation, thus saving money on surveillance expenses.
Detect Potential Medical Provider Fraud - Medical provider costs in workers compensation claims are an area of potential fraud and that fraudulent activity can be very costly. Sometimes providers do not render all the treatment for which they bill. Sometimes providers have unlicensed or unqualified persons administering the treatment. In cases where the employee is treating at the time their statement is obtained, it can be revealing to ask about what kind of treatment they are receiving, what the frequency is, and who exactly is providing the treatment. When you receive the medical bills and reports, you are somewhat forced into the position of taking the medical provider at his/her word regarding what procedures were done, who provided it, how often they were done, etc. By checking with the purported recipient of this treatment, you may find that procedures that were billed for were not actually performed, or that procedures were performed by unlicensed, unauthorized persons, or that certain procedures were "upcoded" (a more expensive procedure was billed for than what was actually performed).
Mitigate the Claim - One of the best ways to reduce the cost of a claim is to create a cordial, cooperative and non-adversarial frame of mind with the employee. Having an investigator
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investigator
meet with
the employee, establish a rapport, and create an atmosphere where
the employee feels that his/her claim is being given all the importance
it is due, can go a long way towards reducing the overall cost of
a claim.
Deter "Claim Creep"
- We've all seen cases that start small and keep growing. A sore
finger can then becomes a sore arm, then the shoulder is included,
and so on. A statement of the employee as soon as possible in
the claim can inquire about all possible presenting symptoms,
complaints, and disabilities. The statement can also rule out
any other symptoms than those being presented. This helps to cement
and solidify the employee's complaints, which may help to prevent
"claim creep" where additional complaints and disabilities
are added on as treatment progresses. Some of these later complaints
may not be clinically consistent with the lack of any symptoms
at the time of the statement. Additionally, a face-to-face statement
in a timely fashion by an investigator who can generate a rapport
with the employee can make the employee feel that they are getting
appropriate attention to their claim, and thus help generate a
cooperative tone to the claims process.
Everyone is looking to save
money and expenses in these restrictive economic times. Getting
an AOE/COE investigation done that covers all the angles may be
one of the best investments you can make. DMA Investigations is
capable to exploring and nailing down any or all of these claim
elements to assist you in making fast, fair settlements.
Brad Balentine
VP Investigations
DMA Claims Services
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