CLAIMS

The Employers Direct Insurance Company Claims Department facilitates the timely determination of compensability, the furnishing of appropriate medical care, and returning the injured worker back to work as soon as it is medically feasible.

These goals are accomplished by:

• Triage of all new reports by the supervisor
• Dedicated claim team assigned to each employer
• Prompt 3-point contact
• Claim professional assigned to all lost time and disputed cases from inception to resolution
• Compensability and causality immediately investigated to ensure prompt payment of benefits or appropriate delay/denial of benefits
• Manageable and controllable caseloads - the lowest in the industry
• Lost time claims reviewed regularly with communication to employer, injured worker, and medical provider
• Partnering with policyholder customers to develop early return-to-work plans
• Claims with ongoing disability are reviewed and analyzed for expedited issue resolution with supervisor everyday
• Telephonic toll-free reporting available 24/7
• Online access to claims information, policy information, and loss runs 24/7 via a secure portal

Employers Direct has a zero tolerance policy for fraud and abuse and maintains strict standards and procedures when investigating fraud. The policy includes:

• All lost time claims are indexed for prior claims
• Investigation process is integrated with claims
• Zero tolerance for fraud

We investigate all claims that our policyholders believe to be fraudulent. But, we do not stop there. Our highly trained and experienced claims examiners sniff out fraud and abuse and stop it in its tracks. While keeping our policyholders informed, questionable claims are denied, and claimants, applicant attorneys, and medical providers who attempt to defraud the system are turned over to law enforcement for prosecution. We then assist law enforcement with their confidential investigation.

Employers Direct provides policyholders with quality assurance tools specifically designed to obtain optimum results. The tools include:

• Supervisory oversight
• Multidisciplinary case conferencing as appropriate
• Monthly self-audits conducted by claims management
• Formal internal ongoing training programs
• Continuing education classes and seminars

Employers Direct's litigation management program manages claims effectively. We are committed to minimizing litigation and reducing overall costs. Our litigation management tools include:

• Quality in-house and outside counsel with negotiated rates
• Aggressive agreed litigation programs developed with litigation representative
• Subrogation identification and recovery plans

Employers Direct's integrated managed care strategy supports our claims program to ensure that employees receive the treatment that they need. Managed care includes:

• Two Medical Provider Networks (MPNs) with occupational medicine providers, physician specialists, hospitals, surgery centers, and other ancillary providers
• Integration with claims for provision of high quality, cost-effective treatment plans
• Professional medical expertise
• Peer review physician specialists
• Registered nurses
• Utilization review for all medical care
• Bill review of medical services to ensure appropriate charges are paid and discounts are recognized and applied

For more information about the capabilities of the Claims Department at Employers Direct, please contact us.