Quality Control Claims Review

Submit an individual claim (or several claims) to us for review by a medical doctor or claim expert. We provide an impartial review, but do not serve as expert witnesses.

The review will include evaluation on file handling. Suggestions for improvement will be noted. Below are the two types of Quality Control Reviews we offer.

Quality Control Medical Review: A Medical Doctor (MD) will review, evaluate and comment on a sampling of your claims to determine use of Industry Best s by insurers, claims administrators, clinics and medical providers, including:

  • Over and under-utilization of services such as medical treatment, physical therapy, chiropractic, diagnostic procedures and surgery
  • Effectiveness of medical cost containment services, including Nurse Case Management
  • Completeness of cover letters to Independent Medical Examination Doctors
  • Effectiveness of Independent Medical Exams
  • Doctor cooperation with Return to Work Program and Transitional Duty
  • Accuracy of diagnosis and causal relationship to workplace
  • Recognition of subtle medical language indicating symptom magnification
  • Whether the injury was caused or aggravated by work or whether other possible causes should be explored
  • With older files, additional opportunities for Second Injury Fund reimbursement are found
  • Percentage of claims where length of disability is proportionate to time out of work

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View Quality Control Claim Report Sample Page (PDF)

Quality Control Claim Review: Our Claim Experts review, evaluate and comment on your claims to determine whether sound, aggressive claim management is focused on timely and positive resolution of the claim including:

  • Investigation
  • Compensability Determination
  • Policy Coverage
  • Benefit Administration
  • Supervision
  • Case Management
  • Medical Management
  • Return to Work Management
  • Claim Resolution Efforts
  • Negotiation & Settlement
  • Subrogation/Recovery
  • Financial & Reserving
  • Outcome
  • Litigation Management
  • File Documentation

 

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