We have been in business for more than 30 years and are extremely knowledgeable in Louisiana and Federal requirements in regards to Workers’ Compensation claims administration. Our staff stays abreast of the latest compliance and industry updates through industry newsletters, constant researching of case law and review of current legislation both pending and approved.
In order to “properly control” worker’s compensation claims, constant contact is maintained with medical providers and the claimant. When needed, adjusters for Gulf South will attend appointments with medical provider’s to get an accurate assessment of the claimant’s medical condition. Follow up will be made with the claimant to make sure that they are adhering to treatment practices recommended by the treating physician and to rule out any possible fraudulent activity.
All claims involving lost time accidents will be “indexed” with the ISO. If the return from the indexing indicates prior medical treatments or other information not obtained in the investigation of the claim, records will be requested from the provider. Our general practice is to obtain a health questionnaire outlining prior medical conditions, a medical authorization and information regarding prior occupational injuries or illnesses. In doing so, we can verify that the injury is in fact new and not a continuation of a prior problem.
With workers compensation claims, the same procedure for defense budget would be established. Nurse case management services may be utilized in the event of catastrophic work-related injuries or illnesses. The nurse case managers will develop and identify treatment plans and protocols and insure compliance with these plans by the treating physicians and facilities. Medicare guidelines are followed, however when Medicare is silent on an issue, Milliman Care Guidelines and Official Disability Guidelines are used.
In all cases of surgical intervent, second opinions are required. With cases of questionable disability or a disability which does not seem to justify the injury, second opinions are requested. Upon completion of the second opinion, if there is a conflict from the treating physician and the physician of our choice, an additional IME may be done using the state’s doctor.
Regarding legal case management, adjusters monitor monthly billing from client law firm to determine accuracy of billed charges versus worked performed. In addition, a litigation plan for large complex cases is completed by the client law firm and a defense budget is established and mutually agreed upon by all parties.
All workers compensation lost time claims are reviewed weekly prior to issuance of weekly indemnity benefits. A weekly “comp” meeting is conducted every Thursday before weekly indemnity checks are printed on Friday.
Gulf South Risk Services Approach + Methodology
At the cornerstone of our success is our individualized and custom-tailored methodology. We bring personalized attention and a hands-on approach to claims management. It’s not enough for active claims management and administration – we strive for proactive claims management and administration. That means that we are constantly searching for ways to streamline the process and identify effective cost-saving measures. Our dedicated, hands-on approach directly translates into improved customer satisfaction and savings.
State + Federal Laws
We have been in business for more than 30 years and are extremely knowledgeable in Louisiana and Federal requirements in regards to Workers’ Compensation claims administration.
Assurance + Subcontractors
We take a proactive approach to claims management and administration. Proactive management not only translates into a swift resolution but also provides opportunity to streamline the claims process and identify cost-savings measures and techniques. We achieve quality assurance through constant communication with our clients via real-time data reporting through our online portal. We also continuously monitor and analyze data in order to provide our clients with cost-saving opportunities and suggestions for implementing various programs to streamline the return-to-work and claims management process.
New Claims Protocol
Initial contact is made with the injured party within 24 hours of notification of the claim. Our services includeon-scene investigation as early preservation of evidence in claim management is crucial. Photos and witness statements are taken at that time if needed.
Gulf South expects immediate notification in the event of a claim. Immediate notification is imperative to begin an onsite investigation at the scene of the incident and includes photographing, scene diagram and other pertinent information necessary to properly evaluate the claim. With worker’s compensation, we ensure contact within 24 hours after notification of the injury.
Claims Assignment
We establish a 3-point contact within 24 hours of an incident with the claimant. The standard for GSRS adjusters is 125 open claims.
Closing Ratios
Our philosophy is not based on an “average” of the claims count by adjuster. That is to say, the Medical Only can be closed on average in 60 days. We will close them, however those claims that require prolonged or protracted treatment will remain open to achieve the best result for the injured employee and the lowest net cost. We will not force settlements be it indemnity or medical simply to satisfy the average. If based on proper defense and duration of claim it is necessary then more adjusting staff will be utilized so as not to exceed the claim limit of 125 per adjuster.
We will not settle claims simply to satisfy this ratio.
Reserve Philosophy + Practices
All claims and/or cases are managed by the adjuster on a daily basis.
In providing the detailed investigation and recommendation to the customer, Gulf South will also make recommendation for reserving amount for future liability. Our reserving practices are to reserve the claims to the ultimate value and thereafter reduce reserves for any potential third party recovery or subrogation once accepted.
Fraud
In the initial investigation, each individual adjuster is trained to identify the necessary elements for a compensable claim such as employee/employer relationship, course and scope of the employment, furthering the trade business or occupation of employer at the time of the injury, and causal connection between injury/illness and medical condition.
Furthermore, it is the adjusters’ duty is to investigate the claimant’s prior medical history and determine if all is appropriate and compensable. The adjuster maintains contact with the employee and medical providers to assess the appropriate care and treatment for the injury or illness reported. In the event that the treatment does not fall within
State and National accepted guidelines, we will then look to determine if there are other motivations from the claimant. We do this via surveillance and prior claim history. If, after these investigatory steps, the adjuster feels the claim may be fraudulent, a report is developed and referred to the local District Attorney for prosecution. In lieu of criminal prosecution by the DA, we will often utilize this information to dismiss the claim in its entirety or threaten referral for prosecution.
Adjuster Professional Development
All new hires at Gulf South Risk Services undergo extensive on-site training with the claims manager. Each adjuster then becomes licensed through the State of Louisiana and enrolled in the certification program sponsored by the Louisiana Association of Self Insured Employers (LASIE). Through LASIE, they are required to receive the professional designation of a Certified Workers Compensation Professional (CWCP). Gulf South Risk Services offers continuing education opportunities for adjusters to maintain their CWCP certification. As well, adjusters are required to attend numerous conferences on industry topics along with in-services provided quarterly through a range of vendors such as law firms -which discuss legislative updates and current case law – vocational rehabilitation counselors to discuss current trends with judges or courts in various districts and medical professionals to review new and revised treatment guidelines by specialties such as neuro, ortho and anesthesiology.
MMSEA Compliance
We use ISO as a vendor and reporting is done to ISO on a daily basis. ISO then sends the claimant information on a quarterly basis which is the reporting requirement set forth by CMS.
Louisiana Office Of Workers’ Compensation
We handle reporting requirements for the State and First Report of Injury through Insurance Services Organization (ISO.) All other forms are mailed, or emailed when possible, such as start and stop payments or disputed claims. Annual reports for both Annual Summary and Second Injury Fund Assessment are prepared and forwarded to the State with a copy to Risk Management. We record in the electronic claim file transmittal of State Office of Workers’ Compensation (OWC) filings 1002, 1008, 1010, etc., and annual filing with the OWC such as an Annual Summary and Assessment for Second Injury fund is maintained in the client section of the electronic file.
Affiliations
We do not have any financial arrangements or affiliations with any services providers, other than Synergy Safety Health, which is a wholly owned subsidiary of Gulf South Risk Services. Synergy Safety Health provides medical bill review, medical bill negotiation, pre-certification and nurse case management services. We have no financial arrangements or affiliations with medical providers or any other entities.
Internal Audit Process + Procedures
All indemnity claims are reviewed weekly with the claims manager to determine ongoing indemnity benefits. In addition, Gulf South Risk Services provides quarterly stewardship meetings and conducts file audits prior to each meeting. The ongoing results are discussed at the meetings among other topics. Depending on experience and contracted authority with each individual customer, reserves/payment amounts by adjuster are limited per the claims manager. Any expenditures posted or exceeding the adjusters’ predetermined authority must be reviewed by the claim manager prior to the posting of the reserve or payment.
Louisiana Office Of Workers’ Compensation Reporting
Our system meets all reporting requirements for the Louisiana Workforce Commission Annual Reporting for the Second Injury Fund and Annual Claim Summary reporting for the purposes of assessing clients for bonding with the State. For multiple state jurisdictions we adhere to the International Association of Industrial Accident Boards (IAIBC) state reporting requirements and National Council on Compensation Insurance (NCCI).
Data Back-Up
The hard drive is backed up daily and stored at on offsite location. It is then downloaded to a remote server for backup. In addition, we create weekly master downloads from the worker server to the remote server.
