Growing EDI Use Suggests Process Review

With the growing use of electronic data interchange systems by state workers’ compensation board, law firm Ice Miller is advising that employers and administrators check with their EDI vendor to ensure submissions meet the filing guidelines in each applicable state.
The firm cited a recent move by the Indiana state agency, which added the Application for Adjustment of Claim to the list of its required electronic forms.
“It will no longer accept paper versions of this form. The Board continues to emphasize compliance and has increased enforcement through penalties for late filings,” noted attorney Ann Stewart.
“Additionally, we recommend an internal review of administrative processes to ensure that all individuals responsible for managing claims have access to EDI-filed documents. In many organizations, a separate internal department, distinct from the claim adjuster, is responsible for administrative filings.”
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The Oregon Supreme Court ruled recently that injured workers are entitled to request their own exam if an insurer relies on results of its independent evaluation to contest the claim.
The ruling clarifies current state law that allows injured workers to request a second exam only when a claim is denied based on the compulsory first exam.
Plaintiff Thomas Cardoza (Matter of the Compensation of Thomas K. Cardoza) claimed that he injured his back while working for Werner Gourmet Meat Snacks Inc.
Company insurer SAIF Corp. denied that his injury arose from employment.
Upon his request for a compensability hearing, SAIF requested an independent medical examination, which concluded that a preexisting back condition was the major cause of any disability or need for treatment.
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AM Best has downgraded its outlooks on Forestry Mutual Insurance Company to negative from stable.
The revised outlooks to negative from stable reflect deterioration in FMIC’s operating performance metrics over several years, primarily driven by above average claims severity within its workers’ compensation exposures in the wood products industry, particularly logging and sawmills.
In addition, the company’s expense ratio is higher than average; however, this is reflective of FMIC’s considerable loss control practices, having 13 loss control field staff members composed of loss control engineers and safety trainers.
The rating agency affirmed the Raleigh, North Carolina insurer’s financial strength rating of A-.
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