Meet Your Insurance Professional: Claims Examiner

Workers’ compensation insurers and some self-insured employers have employees who examine claims after they are submitted for payment. In workers’ compensation, benefits are mandated by law, so examiners who work for workers’ compensation insurers review a claim to ensure it meets the law’s definition of a compensable work-related claim. If a claim meets that definition, the examiner will review it to ensure claimants receive any lost-time benefits due to them.

Claims examiners also review the medical portion of workers’ compensation claims. Once a physician or other medical practitioner submits a claim for treatment of a work-related injury or illness, it might go to an examiner for review. Examiners will ensure that physicians are following recommended treatment guidelines for the condition and whether the costs are reasonable, given the diagnosis. After they review the claim, they authorize appropriate payment, deny the claim, or refer the claim to an investigator if they suspect fraud. Either claimants or medical providers may commit workers’ compensation fraud. So-called "workers’ comp mills" occasionally make the headlines and often involve collusion between medical providers and individuals posing as "injured" workers. 

 

Claims examiners must have familiarity with the state’s workers’ compensation laws and regulations and the insurer’s or self-insured employer’s claims-handling practices. They must also have a layman’s knowledge of the medical factors involved in injury and fatality cases and have the ability to understand and evaluate the specific facts and circumstances that make each workers’ compensation claim unique. 

For more information on what happens after an employee files a workers’ compensation claim, or how to better manage your organization’s workers’ comp claims, please contact the Programs Department at EPIC, Edgewood Partners Insurance Center, at (800) 234-6363 or visit epicbrokers.com.