Self Insurance Claim Administration
Penser North America’s Workers Compensation Administration philosophy and goals are very simple: We want to minimize overall claim program costs while at the same time providing an efficient and timely benefit delivery to the injured workers.
Over the years Penser has been very successful in accomplishing these goals. This success can be largely attributed to the following:
- Working very closely with our customers and developing programs designed specifically to their needs.
- Our commitment to hiring, training and retaining the best people in our industry.
By utilizing the elements mentioned above we have been able to execute our four-pronged Workers Compensation Service Program.
The four components of this program are as follows:
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 steps:
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 the following:
- Employee (When there is lost time)
- Attending Physician
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 of reserves.
- 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 management.
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 elements:
- 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.
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 Services.
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 if desired.
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.
Unsurpassed Client Satisfaction
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