How independent review organizations can improve the workers’ comp claims process

When an employee becomes sick or injured on the job, workers' compensation can be a lifeline.

A type of liability insurance, workers' compensation pays for the medical fees and lost wages of employees with work-related illnesses or injuries, which can help them stay afloat financially while they recover. Workers' compensation also provides survivor benefits to the dependents of people who die as a result of workplace incidents.

In 2015, the most recent year for which data was available, "benefit payments under workers' compensation programs totaled $61.9 billion," according to the Social Security Administration.

The Bureau of Labor Statistics' Survey of Occupational Injuries and Illnesses showed that "private industry employers reported 2.8 million nonfatal workplace injuries and illnesses" in 2019. That same year, 888,220 nonfatal illnesses and injuries resulted in a private-industry worker missing at least one day of work, the bureau said.

Bureau statistics also show that 5,333 employees were killed on the job in 2019, according to the Insurance Information Institute (III).

"Transportation-related accidents (including vehicle crashes) were the leading cause of workplace deaths in 2019, with 2,122 fatalities, accounting for 40% of the total," the institute reported.

Most state laws require companies to have workers' compensation insurance, and the benefits employees receive depend on the geographic area where they work. States; Washington, D.C.; Puerto Rico; the U.S. Virgin Islands; and the federal government each have their own workers' compensation programs.

Workers’ compensation claims

Generally, employers should collect basic information about the incident that caused the injury or illness, such as the date and time it occurred, how it happened, and what injury resulted, according to the insurance company The Hartford. That information then goes into the claim employers submit to their insurer.

An employee looking to receive workers' compensation benefits fills out paperwork, as well, which his or her employer then submits to its insurance carrier. This paperwork includes a medical report from the health professionals who treated the employee for the injury or illness in question.

"Once the necessary information is collected, you should file the claim with your insurance company as soon as possible,” The Hartford explained. “States may impose a window of time business owners have to report the matter to their workers’ compensation insurance carrier.”

It's then up to the insurer to approve or deny the claim. According to the III, most workers' compensation claims are solely medical, "but lost-time claims, those with both medical and lost-income payments, though few, consume most resources."

"Claims are categorized according to the degree of impairment — partial or total disability — and whether the impairment is permanent or temporary," the institute added.

How IROs improve the process

While it may take several steps for claim resolutions, independent review organizations (IROs) like the MLS Group of Companies can help make the process easier. MLS uses its nationwide network of physicians — a group well-versed in local, state, and federal workers' compensation laws — to do peer reviews and independent medical examinations of workers' compensation cases.

By providing "objective, unbiased medical determinations that support effective decision-making," independent medical review organizations like MLS "deliver conflict-free decisions that help clinical and claims management professionals better allocate healthcare resources," explained the National Association of Independent Review Organizations (NAIRO). And organizations understand "that they can get an objective, non-conflicted decision and fast turnaround on quality-of-care issues" by bringing in an independent review organization, NAIRO said.

And for injured or ill workers who need medical care and money to keep them going until they can return to work, time is everything. Expediting the claims process can help them get what they need faster — and avoid unnecessary medical steps.

"By applying independent medical peer review, patients and insurance companies can often avoid repetitive, unnecessary or invasive procedures that ultimately do not benefit the patient," NAIRO said. "As the complexity of medical treatment increases, medical peer review and IROs are becoming a valuable resource for insurance companies and their patients."

MLS focuses on streamlining the review process, ensures that an appropriate physician reviews the case with care, and presents a final report with clinically accurate determinations.

To find out more about how MLS Group of Companies can help you with your workers' compensation claim, contact us today.