Are You Making These Claims Review Mistakes?

Claims reviews with your TPA or carrier can help identify high-cost claims, streamline claims processes, establish proactive risk assessments, and resolve claims faster. However, efforts to meet these goals require a certain level of collaboration from all stakeholders, including claims adjusters, employers, carriers, and, when necessary, legal counsel.

“It can be easy to fall into certain traps like the blame game when a claim is not turning out the way anyone expected,” said Tara Klemm, Client Engagement Manager at Safety National. “The most effective mindset in these situations is to allow for a space that is honest, where each participant can engage in open discussions and truly collaborate to get the claim progressing in the right direction.”

Getting the most out of your next claims review requires avoiding these pitfalls that can undermine progress and stall outcomes.

1. Relying solely on claims notes. Review all supporting documentation. Listen to the recorded statements, examine relevant records, and calculate the benefits.
2. Assuming all claims are the same. Each claim is unique and should be evaluated based on its specific circumstances. Avoid applying a one-size-fits-all approach.
3. Using mistakes to assign blame. Mistakes should be treated as opportunities for learning and improvement, not an occasion to point fingers. An issue only truly becomes a problem when it is repeated without a resolution.
4. Focusing only on the largest files. Do not overlook smaller or mid-sized claims that may escalate in severity. Identify files with the potential to become complex and costly.
5. Holding a claims review without clear objectives. Reviews should be meaningful and impactful for all parties. Skipping reviews is acceptable if one is not necessary, as the frequency of meetings should never outweigh their impact.
6. Lacking a thorough understanding of your claims. Be fully informed about your claims and prepared to offer input or recommendations during reviews. This ensures proper handling, adequate reserves, and sound action plans.
7. Including unprepared participants in claim reviews. Adjusters or supervisors attending must be familiar with the claim and not simply reading from claim notes, financials, or system-generated data, like an insurance carrier claim database or risk management information system (RMIS).
8. Skipping the preparation of a detailed claim status report. Require the adjuster to provide a comprehensive status update in advance of the review, especially for attendees who are not involved in the day-to-day claim handling.