Fall 2016 Volume 26, Number 4 | |||||
Meet Your Insurance Professional: Claims ExaminerWorkers’ compensation insurers and some self-insured employers have employees who examine claims after they are submitted for payment. In workers’ compensation, benefits are mandated by law, so examiners who work for workers’ compensation insurers review a claim to ensure it meets the law’s definition of a compensable work-related claim. If a claim meets that definition, the examiner will review it to ensure claimants receive any lost-time benefits due to them.
Claims examiners also review the medical portion of workers’ compensation claims. Once a physician or other medical practitioner submits a claim for treatment of a work-related injury or illness, it might go to an examiner for review. Examiners will ensure that physicians are following recommended treatment guidelines for the condition and whether the costs are reasonable, given the diagnosis. After they review the claim, they authorize appropriate payment, deny the claim, or refer the claim to an investigator if they suspect fraud. Either claimants or medical providers may commit workers’ compensation fraud. |
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How Evidence-Based Treatment Saves Money What to Do When You Get a “Reservation of Rights” Letter The Liability Coverages Every Business Needs Meet Your Insurance Professional: Claims Examiner
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