Why Urgency in Reporting a Catastrophic Claim Matters

Reporting a catastrophic claim promptly offers several benefits because it allows the carrier to utilize their extensive resources to assist the insured or TPA. This helps to ensure that the injured worker is receiving the best care to achieve the best possible outcome.

“Catastrophic claims are extremely complex,” says Jessica Unser, Medical Manager. “Not only does the rarity of these claims make handling them challenging for some adjusters if they haven’t encountered them before, but they can also have can have a significant impact on an employer’s workers’ compensation costs.”

These steps can assist in managing a greater outcome, while minimizing costs.

Timely Investigation

The adjuster cannot start investigating the compensability of the claim until the claim is reported, therefore the employer should always urgently report the claim to the TPA. With catastrophic cases, the adjuster or employer does not have the luxury of waiting for medical reports before reporting the claim. Sometimes, the medical information takes several days to obtain. Reporting all of the key information can be difficult, but provide the information that you can, like what is known about the incident, the extent of the injury, where the worker is hospitalized or staying, the age of the worker, adjuster and field case manager (FCM) information. Reporting within 24 hours of the incident is a good rule of thumb.

Identify Stakeholders & Key Parties

Identifying all individuals from the carrier, TPA and employer that will be involved and connecting with them early in the process opens the lines of communications and helps keep everyone updated. It also introduces the team to one another, which is essential to all parties working toward the same goal.

Assign a Field Case Manager

Assigning an FCM as soon as possible allows the greatest impact in continuity. This individual helps verify the severity of the claim, obtain medical records, identify any problems and meets with the family. The FCM builds a report with the family, ensuring they have a point person to communicate with, making them more comfortable. Due to the intense nature of a catastrophic claim, you want to assign an FCM who specializes in these types of claims, helping to optimize outcomes.

Retrieval & Review of Medical Records

Reviewing the medical records associated with the claim can assist in identifying exposures and enable further team collaboration to ensure the best care possible of the injured worker. The review process can involve expert medical opinions to consider if current treatment is the right course of action or if the injured worker should be moved to a Center of Excellence.

Litigation Involvement

Attorney involvement may not be top of mind when focusing on the care of an injured worker, but the early assignment of a defense attorney can provide tremendous benefits. Early on, they can help determine the compensability of a claim. They can also assist with any issues that arise when considering vehicle and home modifications necessary for the injured worker.

Vendor Referrals

Utilizing vendors can help control the high-dollar costs associated with a catastrophic claim. Vendors can provide valuable insight that assists the adjuster in investigation and compensability. Actively involving the TPA on the team should always be a priority and can also help control costs.