Quantifying Bodily Injury
Another key component of the
While adjusters generally aren’t
medical professionals, they do
have the requisite training to iden-
tify questionable billing practices or
treatment patterns. Therefore, it is the job
of the adjuster to raise questions, often
documented with the assistance of third-
party medical billing review software,
such as Mitchell International’s Decision-
Point, to identify potential fraud, billing
errors, or improper edits.
When the BI demand is received, the
adjuster should review all contents to ensure that he or she can include the necessary documentation to complete the
injury evaluation. There should also be
a notation of any time limit demand requirements with the appropriate action
taken to ensure a timely response. Generally, this requirement is met by either
tendering an offer (when warranted) or
notifying the attorney, in writing, of additional documentation necessary to
complete the injury evaluation.
The job of the adjuster is to recognize
impediments to the case being presented.
For example, if the claimant is saying his
lower back hurts but he was sideswiped,
then where is the mechanism for injury?
Taking the time to seek out those
who may be able to shed light on the
possibility of pre-existing conditions
or intervening causes can prove in-
valuable in settlement negotiations,
arbitration, or litigation.
Blame Game | from p. 29
significant, separately identifiable
evaluation and management services conducted on the same day.
In some instances, the modifiers
are used as a provider solution to
get bills paid. However, it is important to recognize that improver usage can be considered abusive and
can amount to fraudulent billing at
times. Again, knowledge of coding
is critical to identify bundling and
When performed properly, BI
claims investigations, evaluations,
and settlements require significant
amount of time, knowledge, and
expertise. They require painstaking
attention to detail and a fundamental understanding of biomechanics,
medicine and medical bill coding. The most effective BI reviews
incorporate a variety of processes
to leverage the expertise of others
with a higher degree of proficiency
in these same areas. This in turn
bolsters the adjuster’s case while
dramatically improving outcome
accuracy. The result is an optimized
process that increases productivity
while reducing severities, a benefit
for carrier and consumer alike.
As you will see in the Liability
Survival Guide following this
article on PropertyCasualty360.com,
there is an overview of the ClaimIQ
process. A scenario is presented with
a series of questions relating to com-
parative negligence and assessment of
breaches. Be sure to test your knowl-
edge and find out how the results can
impact potential claims that are too
often assessed without shared liability.
Similarly, be sure to look for red flags,
such as a claimant stating he or she was
“rear-ended yet thrown forward,” thereby
defying the laws of physics.
Adjusters must also be cognizant of
the increasing opportunistic fraud, such
as certain deceptive billing practices. According to the office of the inspector general (OIG), modifiers 25 and 59 are used
improperly more than 40 percent of the
time, resulting in significant medical inflation. Modifier 59 is used to distinguish
procedures that are not normally reported together, while modifier 25 identifies
Certainly more than 3 percent of claims
should be considered for comparative negligence, depending on claimant credibility,
facts and jurisdiction. Mastery of this type
of negotiation actually begins with the hiring process. Managers build a foundation
of success by hiring curious minds. Although some are simply not cut out for a
career in claims negotiation, managers can
develop the right people by offering initial
training and ongoing career support.
During my tenure implementing solutions for a large multinational insurer,
for example, we leveraged tools such as
ClaimIQ, which supports adjuster decisions
throughout the claims process and provides
them with a framework from which to formulate a negotiation strategy.
Chris Tidball is a claims consultant
with Mitchell International and
published author. He may be reached at
firstname.lastname@example.org or 904-742-9031.