Claims Management Services
Penser North America, Inc. recognizes that your specific claim
handling requirements are unique. During the implementation
phase, appropriate management staff from your organization will
be asked to join forces with the Penser team to discuss and
agree upon minimum claims handling requirements. This meeting
will establish solid communication lines to develop a positive
working relationship between Penser personnel and the client.
It is essential that each party understand their expected responsibilities
to achieve expected results.
The navigational buttons below will take you through the
components of our "claim standards" which represent our
normal claims handling practices. Penser will customize
these benchmarks to meet your specific program objectives
Penser has developed a systematic, aggressive, hands on, claims
management philosophy. Our claims people are given the tools,
the caseloads and the training, to carry out their jobs in a
very proactive manner.
Receiving a claim, and aggressively working on it early is key to controlling
claim costs. Early Intervention is a process that requires a collective effort
between the third party administrator and the employer. We work with your organization
and the appropriate people to ensure that they are, aware of, and trained on
how to report claims in a timely manner.
Upon receipt of the claim form, Penser, initiates the following early intervention
Supervisory review of all new claims upon receipt in our office
Identify "red flag" problem claims
Develop plan of action
Need for investigation determination
Evaluate return to work program need
Reserve recommendations made
Assignment of file to claim representative
Priority Contact within 24 hours of receipt of claim and communication with
Employee (When there is lost time)
After the supervisor has reviewed the file, made recommendations, and the initial
"three-point" contact has been made, the claim representative proceeds with
the following steps:
Claims Investigation Claims investigation is an integral part of Penser's claims management
service. Our claims representatives do an internal investigation on all
claims. The depth of each claims investigation is case specific. When appropriate,
our claims representatives obtain recorded statements from injured workers
and witnesses, do on-site inspections, and gather photographs. If the possibility
of third party involvement exists, claims investigation is vital to the
subrogation process and recovery of applicable claims expenses.
Early Return to Work Addressed Returning injured workers back to regular or modified duty as quickly
as possible is one of the most effective elements in controlling costs.
Through our initial 3-point contact, and subsequent medical and job offer
documentation (when appropriate), Penser is able to quickly assist workers
back into the workplace whenever possible. We work very closely with our
clients to assist in the creation and utilization of modified duty work.
Plan of Action Development Once the file is reviewed, and the initial contacts made, the claim
representative formulates their plan to bring the claim to closure. This
plan is a step-by-step outline of the issues that need to be addressed (and
the action to address the issues) to bring the claim to a successful resolution.
Initial File Reserve Established Reserves are established and entered into our computer system within
72 hours of receipt of the first report of injury. These reserves reflect
exposures commensurate with the injury, degree of disability, and any subject
factors that are appropriate. Each file contains a reserve calculation sheet
and/or comments in the computer system. The client will play an integral
part in the reserve philosophy, reserve establishment, and the ongoing review
Initial Claim Action Taken Once a claim is analyzed, the initial calls made, reserves set and the
plan of action formulated, the claim representative takes what steps are
necessary to move the claim forward to the next step to resolution. Whether
it be a custom letter to the doctor, the scheduling of a early second opinion,
or a vendor assignment, action is taken early in the claim process and then
documented in the system.
Diary Set for Next Action Step Once all of the initial work up is completed, a diary for next review
is set. The length of time before the next review totally depends on the
situation of the claim. The diary maybe in 30 days, or it may be in 24 hours.
The adherence to the diary system is critical to Penser success in claims
After the initial work-up of the file, the claim representative works off of
a diary system, or takes action if it becomes necessary prior to the scheduled
diary date. This phase of the claim process can be characterized by the following
Medical Management Penser's claim representatives are qualified to manage almost all medical
aspects of a claim. Because of this experience we do not have to send each
file out for a nurse review, or an IME instantly. We aggressively work with
the attending physicians on return to work, treatment and rating issues.
We do use nurse consultants in very serious cases, or cases where a particular
specialty is needed. IMEs are also used, but not as a routine part of the
claim process. When our claim representatives do schedule independent medical
examinations, they do so with great thought behind it, and often times schedule
directly with a physician's office, and not an IME panel. This saves thousands
of dollars for our clients over the course of a policy year.
Penser utilizes Genex Services Inc. as our vendor for enhanced bill review and PPO medical reductions.
Litigation Management Our claim staff works very closely with the injured employees to respond
to their needs and provide timely benefits. However, sometimes despite our
best efforts, occasionally workers seek legal counsel to assist them through
the claims protest, and appeal process. When this occurs, it is our responsibility
to advise you and recommend legal counsel. Our company has strong working
relationships with many of the best workers' compensation attorneys in the
area. Penser, in some instances, can and will represent their clients in
early stages of the Board of Industrial Insurance Appeals process. This
saves legal expenses on cases that can be resolved in the early stages of
the appeal process. If a case gets to the point where legal counsel is needed,
we assign the case to an attorney (with the client's approval), and then
actively monitor and manage the legal process to resolution.
Vocational Rehabilitation Management Penser works very aggressively in the modified duty return to work process.
We do not assign vocational counselors to run around and do claims leg work
for us, we take the extra steps that are necessary in an effort to try and
eliminate the need for an outside vendor billing. However, when return to
work is not possible with the employer at the time of injury, our claims
people work closely with qualified vocational consultants to work through
the vocational process. Our experience and understanding of the vocational
process have enabled us to be successful in limiting the dollars and time
spent in this very expensive aspect of claims management.
Claims Management Our claims staff manages each claim, and does not simply shuffle paper,
and assign outside vendors. We take the time to write custom letters to
doctors' offices when appropriate. We take the time to call a physician's
office to get a light duty release, we take the time to call the injured
worker and make sure the treatment plan is progressing. We proactively manage
the whole claim from the time we receive it to the time the claim is closed.
Our claim representatives maintain a strict diary system to always ensure
that every claim is moving the next step towards closure.
A critical part of making sure all claims are progressing towards closure in
the best manner, is to have monthly, or quarterly status meetings with the employer.
These meetings keep the focus of the program, and can act as a brainstorming
session on difficult cases. Also, by having regular status meetings, there are
no surprises to a customer on claim costs or outstanding reserves.
Loss Control Our loss control services are available to assist your organization
in preventing accidents while our claims department
works to contain the cost of injuries. Learn more about
Penser's Loss Control
Penser International utilizes a state of the art claims management
computer system. This system is not only user friendly for our
claims adjusters, and clients, it provides for a complete analysis
of an employer’s losses and consequently allows for a unique
tool in which to analyze workers’ compensation claims and to
develop programs for reducing associated expenses.
Standard to Penser's service is a variety of customer reports including weekly
check listings, monthly check registers and a monthly loss analysis. The standard
report package will detail the most current information on your account's activity
and the status of each open claim. Injuries and costs are summarized for all
specific locations as well as cumulative totals for the entire company. These
reports include medical and indemnity payments and estimated future costs, thus,
allowing for an accurate accounting of your workers' compensation program.
Our computer system provides for flexibility in the information that can be
reported. As a result, we can run a report on just about any type of information
that is entered into the database. For example we can run multiple claim lists,
injury specific reports, over dollar amount (claims which exceed a set dollar
amount) claims logs, plus many more.
With our on-line capability option, a customer is able to have all of the claims
information at his or her fingertips, in real time. This option allows a customer
to view the same information the adjuster is working on. Instantly, you can
have access to the claim notes, payment detail, reserve history, etc., on each
individual claim. This option also allows the customer to run their own reports
Client Services Penser recognizes there are many services that are very
important to operating a self-insurance program, that do not
fall under the headings previously mentioned. Our client services
program helps pull these miscellaneous items together to ensure
that your program runs smoothly.
To obtain more information about our self-insurance claims administration services please contact a Penser representative at
email@example.com, or call Phil at 1-888-437-5582