Self Insured Quality Assurance Standards

• Three-Point Contact
  • Measurement of process time of all three points of contact.
• Proper Investigation
  • Within 14 days to determine compensability.
  • Index check - updates at six-month intervals.
  • Proper referral for field investigations.
  • Secure statements when warranted.
• Subrogation/Recoveries
  • Subrogation potential recognized and pursued.
• Medical Cost Containment
  • Utilizing all appropriate cost containment measures.
• Disability Management and Vocational Rehabilitation
  • Utilization of disability management tools.
  • Return-to-work strategies focused on early return to work.
  • Timely and appropriate referrals to nurse case managers.
  • Independent medical exams, independent medical reviews and peer reviews as needed.
• Reserving
  • Reserves reflect current exposure
  • Review for stair stepping.
  • Rationale identified in claim record.
• Claim Payments
  • Payments are timely and accurately.
• Action Plan
  • Plan of action is created on every lost-time claim.
  • Initial plan of action timely (30 days).
  • Current plan identifies outstanding issues, resolution and expected closure.
  • Notes reflect appropriate follow up on all open items.
  • Supervisory involvement.
  • Updated as circumstances evolve but no later than 90 days.
• Communication
  • Appropriate and timely communication with employer, injured worker and physician.
  • Appropriate communication with counsel as required.
• Documentation
  • Appropriate and timely documentation.
  • Written in logical and sequential order.
  • Explains all actions and decisions.
• Litigation Management
  • Examiner maintains control, supports administratively and directs counsel when permitted.
  • Attorney referrals timely.
  • Secures updated status reports.
  • Proactive settlement and alternative dispute resolution.
• Adherence to Client Special Instructions
  • Total compliance reviewed.
  • Specific instructions based upon category.