Who's calling me? The roles of workers' compensation claims, medical, rehab and legal professionals

"Who are all these people, and why do they all want to talk about my workers' compensation claim?"

After filing a workers’ compensation claim, a injured employees typically aren’t surprised to hear from a claims representative at the insurance company.

What they might not expect is hearing from others too, such as medical, rehabilitation or legal professionals.

Depending on the particulars of the claim, an employee may interact with any number of the following:

  • telephonic medical case managers
  • vocational rehabilitation consultants
  • disability case managers
  • field nurse case managers
  • attorneys

For someone unfamiliar with the workers’ compensation system, this can seem like an overwhelming amount of attention.

It’s important to know that everyone involved adds a significant and unique value to the process. Whatever differences exist between their job titles and training, each of them has the same goal: to make the process of returning to a normal life as quick and easy as possible.

What happens after a workers’ comp claim is filed

After a claim is filed, the employee's first point of contact will be SFM’s claims representative, and in some cases it’s the only direct contact the employee will have with SFM.

The claims representative begins the process by learning as much as possible about the claim. This involves not only learning the details about how the injury occurred, but gaining a complete understanding of the employee’s health before and after the incident.

In addition to gathering information from the employee, the claims representative establishes a role as the employee’s primary resource for information about the claim.

Regardless of who else gets involved, this relationship continues throughout the handling of the claim. SFM’s claims representatives are always available to assist the employee, which often involves introducing other professionals into the process to provide additional expertise.

Introducing the medical case manager

When an injured worker requires medical attention, SFM frequently assigns a member of its telephonic medical case manager team to a claim to make sure that the employee has consistent access to optimal medical care throughout the recovery process.

SFM’s in-house medical case management staff consists of highly trained medical experts who evaluate and adjust the course of treatment to make sure that it’s focused on getting the employee healthy and back to work as quickly and safely as possible. This may include anything from educating the employee about procedures available to scheduling an appointment with the right specialist. Once connected with a claim, the case manager is always available to make sure that there are no unanswered questions about an employee's recovery program.

The role of vocational rehabilitation

For claims involving more severe injuries or complications, an additional kind of professional may be brought in to facilitate the return to work. A service known as “vocational rehabilitation” comes in the form of a neutral consultant who will work as an intermediary with the employee, employer, insurer and health care system to identify and eliminate problems that may be preventing a return to full health and productivity.

A vocational rehabilitation consultant may meet with the employee in person to facilitate recovery. A vocational rehabilitation professional may go by any of a number of titles, often known as a qualified rehabilitation consultant (QRC), disability case manager (DCM) or field nurse case manager (NCM).

The specific responsibilities of the vocational rehabilitation consultant differ by job designation, and can vary greatly from state to state. For example, Minnesota statute requires that the insurer assign a QRC to any employee whose disability is expected to extend beyond 13 weeks. Once assigned to a claim, a QRC develops, administers and implements a rehabilitation plan to guide the employee back to pre-injury health and productivity. These activities are closely regulated by the state and the employee is required by statute to cooperate with the plan developed by the QRC.

A less formal option available within the realm of vocational rehabilitation comes from a DCM or NCM. Similar in training and expertise to QRCs, case managers are not regulated by any state agency. They can be called upon by either the insurer or the employer to coordinate care and pursue a safe and timely return to work.

Attorney involvement in a claim

Hearing that attorneys are involved in a claim may conjure up images of a courtroom drama involving a dispute between an injured employee and the insurance company, but that’s not usually how it plays out in reality. If a claim involves input from attorneys at all, it’s often in the form of providing legal expertise to others involved in handling the case.

Through its in-house law firm Lynn, Scharfenberg & Hollick, SFM maintains a base of specialized support for all matters related to workers’ compensation law. The attorneys are not only available to represent and defend SFM policyholders in the event of litigation, but to provide legal advice to employers whenever it’s needed.

Making it all work together

By getting the right experts involved at the right time, SFM strives to make sure that employees always have access to the resources that can help them the most. Every time that telephone rings, it means the claim handling team is working hard to get the employee healthy and back to work.

0 Comments

  • My son hurt his back at work. A Workmans Compensation claim was filed.The Orthopedic Doctor referred him to physical therapy. Appointments were scheduled during his work hours. Now that he has finished therapy they informed him appointments should have been before or after work and will not be paying him for the 2 hours he missed for each of the 12 secessions. He gave them a calendar of appointments before he started and a note from the therapist after every secession. Should the employer Be responsible for paying him for the time he missed from work?

  • Normally your son would either be reimbursed for the time he has missed for appointments or allowed to make up the time. If the employer does not pay for this time, the workers’ compensation insurer may do so. We recommend he talk with his workers’ compensation claims representative about this situation.

  • Thank you for all the information! True, it seems as if the phone rings 10 times more once you file for Workmans Compensation. Your suggestion about talking with an attorney who specializes in this area is very good advice, they can answer so many questions that will be asked during the process. And other suggestions for the employee:
    Get medical treatment immediately
    Follow doctors’ instructions and keep doctors’ appointments
    Seek any and all necessary follow-up care
    Create a report about your injury with a supervisor

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