Again, there are three possible outcomes:
E There are damages and they are related
to the accident.
E There are no damages.
E There are damages, but some or all of
them are unrelated to the accident.
Like liability, the path of least resistance
often yields the wrong answer, as claimed
injuries are not always related to the accident. The challenge to insurers is ensuring
that both liability and damages are investigated concurrently. Commonly one or
both are either overlooked or incomplete,
thereby adversely impacting outcomes.
Consider that, on average, comparative
negligence by insurers nationwide is assessed on somewhere between 3 and 5
percent of all claims. Let’s also consider the
fact that research on jury verdicts indicates
that around 55 percent of all claims adjudicated involve scenarios other than clear
liability. These may include intersection
accidents, sideswipes, slip-and-fall accidents, and liquor liability. In other words,
myriad opportunities exist to improve basic blocking and tackling skills in the comparative negligence arena.
Consider the situation
where an adjuster is
reviewing a lumbar MRI
that was billed under CPT
codes 72148 and 72149 for
$3,000. Without the proper
tools to assist in medical
bill repricing, they likely
wouldn’t realize that this is
an unbundling scheme that
should have been billed as
CPT code 72158 for $1,900.
In addition to liability, there are im-
mense opportunities for improving the
accuracy and efficiency of claims inves-
tigations, evaluations, and negotiation
strategies. At the outset of any claim, all
involved parties should be contacted, in-
cluding those who are claiming injury. If
they are represented, then a request for a
statement should be made through legal
counsel, even though the request may
not be granted. It is an important aspect
of claims handling to document when
and why this request was made. The at-
torney needs to understand early on that
you have an obligation to thoroughly in-
vestigate injury causation as well as the
frequency and duration of treatment.