June 16, 2021
Nearly 130 million workers in the United States are covered by workers’ compensation. Established more than a century ago, this crucial program provides income and medical support to workers who are injured or become ill in the course of their employment regardless of fault. It also provides cash benefits to the survivors of workers killed on the job.
Although systems and laws vary by state, employers pay for workers' compensation through payments to an insurance company or premiums to a state-run insurance program. Occasionally, these benefits are paid directly to employees. Under the Federal Employees' Compensation Act, claims for workers' compensation must provide medical and factual evidence to establish the following five basic elements:
According to the National Council on Compensation Insurance (NCCI), the most costly lost-time workers’ compensation claims by cause of injury are the result of motor-vehicle crashes, which average $78,466 per claim. The second most expensive claims for workers’ compensation are burns and falls.
Because of the complexity of workers’ compensation claims and the time necessary to administer them, many self-insured employers opt to outsource the process to a third-party administrator (TPA). As we mentioned in a previous blog, TPAs are independent organizations that handle and process insurance claims in accordance with state laws. Though the TPA handles the claims themselves, the insurance company or self-insured employer is still financially responsible for paying the cost of these claims.
Core responsibilities of TPAs include:
Unlike managed care organizations (MCOs), which provide medical management services for employers’ work-related injuries and illnesses, TPAs facilitate for employers the administrative and financial aspects of workers’ compensation claims. In addition to providing self-insured employers with improved claims outcomes, reputable and reliable TPAs help reduce workers’ compensation claims costs and future claims, as well as increase claims processing efficiency, decrease risk, process appeals and more.
Fortunately, there are numerous workers’ compensation TPAs throughout the U.S. Unfortunately, not all of them have the vast knowledge, experience and resources necessary to provide self-insured employers with the best outcomes possible. In this blog, we’re providing five tips you should consider if you’re in the process of selecting a TPA for your company.
Typically, when an employee submits a claim for workers’ compensation, he or she undergoes an insurance medical examination to assess the severity and breadth of his or her injury. Most TPAs collaborate with an independent review organization (IRO) to facilitate this medical review process.
As an IRO, the MLS Group of Companies employs a nationwide network of licensed physician reviewers who work with insurance companies, TPAs and self-funded employers to assess the clinical aspects of workers’ compensation claims.
MLS provides a variety of services for these cases, including independent medical examinations (IMEs), peer reviews, functional capacity evaluations (FCEs) and impairment ratings. This helps TPAs move claims forward and potentially expedites a return to work for the employee at the center of the case. But, most importantly, it results in a smooth process that benefits employers and employees alike.
Contact MLS to submit an independent medical examination or peer review referral, inquire about joining our physician reviewer network, or learn more about our services.
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