The 8th Thing That A Claims Investigator Needs…

from their worker's compensation or disability claims adjuster/examiner is a complete copy of

The Claim Notes or Adjuster's Notes on the Claim(s) under investigation

The claim notes on a file or companion files of the claimant can be a treasure trove of information that a claims investigator can utilize in process of their investigation.  Information for interviews or for surveillance.   Among the things the investigator may learn by reviewing the claim's notes are:

• Summaries of interviews taken by the adjuster with the claimant, witnesses, the employer, and/or medical providers which contain representations being made by each party in relation to the claimant, the incident, and/or the injury.
• Current disability/medical treatment status.
• When was the last time the adjuster or claims personnel had contact with the claimant, the employer, a witness, the medical provider(s).
• Is there any legal representation on the file?
• Are payments being provided to the claimant?
• Is the claim accepted, denied, or partially denied?
• What body parts are accepted and what parts are denied?
• Possible notation of prior claims history of the claimant.
• The adjuster's summary and current and past plans of action.  Where is the adjuster directing the claim towards?  What is the goal?
• Is there a third party or product that caused or contributed to the incident and resulting injuries?  Who is the third party?
• What injuries is the claimant claiming?

The 7th Thing That A California Investigator Needs…

from the worker's compensation adjuster is the last issued

Primary Treating Doctor's Progress Report (Narrative or PR-2)
or last medical report delineating any temporary or permanent work restrictions 

The Primary Treating Physician's (PTP) Progress report or (PR-2) is the standardized medical report format that a PTP is to report medical findings to the insurance company or designated claims administrator.  The PTP may submit a narrative report in lieu of the PR-2 form; however, pursuant to Title 8 California Code of Regulations Section 9785(f)(8), "If a narrative report is used, it must be entitled 'Primary Treating Physician's Progress Report' in bold-faced type, must indicate clearly the reason the report is being submitted, and must contain the same information using the same subject headings in the same order as Form PR-2."  The PTP must file a PR-2 or the narrative report at minimum of every forty-five days to the claims administrator.  The report is only to be filed by the Primary Treating Physician (PTP).  Secondary Treating Physician's must submit reports to the PTP in the manner requested by the PTP.  In a California Worker's Compensation claim there can only be one designated PTP.  The injured worker or the injured worker's attorney must select a Primary Treating Physician at the commencement of their claim.  The injured worker may change their PTP during the course of their claim; however, excessive changes are frowned upon.  The PTP is the only one of an injured worker's treating physicians that is technically able to determine an injured worker's disability, unless a dispute is initiated that requires an evaluation of the injured worker by a Qualified Medical Examiner or an Agreed Medical Examiner.

The PR-2 or appropriate narrative report can provide the claims investigator valuable information when conducting interviews, completing background investigations, and surveillance investigations.  The form is essentially separated into nine (9) sections of information.

In the first section the PTP must check the box or state in the narrative the reason that the report is being filed.  The options for the physician are as follows:

• Periodic report (required 45 days after last report)
• Change in treatment plan
• Released from care
• Change in work status
• Need for referral or consultation
• Response to request for information
• Change in patient's condition
• Need for surgery or hospitalization
• Request for authorization
• Other

The second section provides the patient's (injured worker's) demographics:

• Last name
• First name
• Middle Initial
• Sex
• Address
• City, State, & Zip Code
• Occupation
• Social Security Number
• Phone number

The third section provide the claims administrator's demographic and claim information:

• Name of the claims administrator
• Claim number
• Claims administrator address
• Claims phone number
• Claims fax number
• Employer name
• Employer phone number

The forth section is where the PTP relays what the injured worker's subjective complaints are relating to their experience of their claimed injury(ies).  Comments may include the frequency and intensity of any pain, numbness, or other physical symptoms.  This section may also include when and how these symptoms are increased or decreased such as with certain physical activities.  In addition, the clinician may describe what limitations as a result of their injury(ies) the injured worker has relayed to them.  The claims investigator can take the representations that the injured worker makes here and compare them with what the injured worker states in an interview with the investigator or perhaps what is depicted in surveillance video of the injured worker.

The fifth section is where the PTP includes any significant findings via their examination or review of records which are objective in nature.  Things such as tenderness, loss of strength, loss of range of motion, x-ray findings, other diagnostic testing findings (i.e. MRI, CT Scan, EMG/NCV, etc..).

The sixth section is were the PTP provides their diagnoses with associated ICD-9 coding. This is a section where the investigator may ascertain or confirm the claims injuries and/or body parts/systems claimed injured by the claimant.

The seventh section is the treatment plan section.  In this section, the PTP is to describe the medical treatment rendered to date, any current treatment, and any recommended future treatment.  The treatment plan should be described by the PTP listing the method, frequency and duration of the treatment.  The PTP should state the names of any contributing secondary treating physicians or the names of recommended consultations.  If there is any change in a previously prescribed treatment plan, the PTP must also describe the change and the reason for the change.  In this section, the investigator, may gain clues and leads for additional investigation for medical records at other facilities that may be obtained by the claims administrator or worker's compensation defense attorney.  In addition, this naming of other facilities may also serve the surveillance investigator in obtaining additional locations where surveillance may be undertaken.

The eighth section is the work status or disability section.

This section will indicate the injured worker's current disability status.  If the box "Remain off-work until ____" is checked than the injured worker is Temporarily Totally Disabled (TTD) and unable to work within the open labor market.  If the box is checked "Return to modified work on ________ with the following limitations or restrictions" the injured worker is Temporarily Partially Disabled (TPD).  This means they may return to some form of work within the prescribed work restrictions or limitations.  When conducting an interview of the injured worker, the investigator can determine if the injured worker is aware of their temporary work restrictions and question them on their compliance with the work restrictions prescribed by their PTP.  For the surveillance investigator, they may comment upon the injured worker's compliance with the work restrictions and to their physical observance of the them during discreet surveillance.  If the box is checked "Return to full duty on __________ with no limitations or restrictions" the injured worker is released to return to full duty work without limitations or restrictions.

The final or ninth section of the PR-2 is states the name and demographics of the PTP, their signature, and includes the mandated fraud declaration language pursuant to California Labor Code Section 139.3.  The demographics of the physician include the following:

• California License Number
• Place signature executed at
• Date of signature
• Name of physician
• Address of the physician's practice
• Phone number of the physician's practice
• Medical specialty of the physician

The PR-2 or PTP narrative progress report is another valuable resource for a claims investigator to utilize in the process of their investigation.

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The 6th Thing That A California Investigator Needs…

from their worker's compensation adjuster/examiner is an

EDEX and a Claims Index Report

So what is an EDEX?  EDEX stands for Electronic Data Exchange System.  This system is employed by the California State Division of Worker's Compensation as a means for permissible end users to request and receive data through purchase regarding worker's compensation cases that are under the jurisdiction of the California Worker's Compensation Appeals Board (WCAB).  The Worker's Compensation Appeals Board is the judicial administrative board that hears and resolves disputes on worker's compensatio cases between an applicant and the defendant insurance company or employer.  The WCAB also issues awards for benefits to those applicant's that are entitled to those benefits.

When I say "under the jurisdiction" of the WCAB, I mean only cases in which pleadings have been filed with the board (i.e. Application for Adjudication, Stipulation with Request for Award, Compromise & Release, etc.).  EDEX will only have data on cases in which these have been filed.  EDEX will not have any data on any claim that has not been filed with the WCAB.  Claims not filed with the WCAB may include incident only files (no medical treatment, no lost time), medical only files, files that do not have any settlement, and other new or ongoing indemnity claim files in which the claimant and the claims administrator may or may not be represented and have not filed any of the initiating documents named above.

Investigators may obtain the EDEX report from their adjuster clients but may also obtain them directly from the authorized approved vendors if they have a permissible reason.  See the vendors below (http://www.dir.ca.gov/dwc/edex.html)

Information brokers::

Company

Phone #

Fax #

Website Address

CompData EDEX & EAMS Services

P.O. Box 729
Seal Beach
CA 90740

(562) 493-4000

(562) 493-1550

http://www.compdataedex.com

Computer Services Group

1927 Harbor Blvd. #395

Costa Mesa, CA 92627

(800) 798-1880

(949) 646-7029

http://www.csg2000.com

EDEX Information Systems, Inc.

P.O. Box 665
Jackson, CA 95642

Toll-free

(866) GET-EDEX

(866) 438-3339

(209) 231-6700

http://www.edexis.com

Grey Wolf Laboratories Wolf Schubert

4006 Claitor Way
San Jose CA 95132

(408) 904-8731

http://greywolflabs.com

wolf.schubert@greywolflabs.com

Medical Lien Management, Inc.

P.O. Box 6829

Norco, CA 92880

(951) 808-3054

(760) 406-4807

http://www.dwcexchange.com/info@dwcexchange.com

SpeedComp EDEX & EAMS Services

P.O. Box 6886
Malibu, CA 90264-6886

(310) 457-3300

(310) 457-0500

http://wcabonline.com

Workcompcentral

1320 Flynn Rd.
Ste. 403
Camarillo, CA 93012

Toll-free

(866) WRK-COMP

(866) 975-2667

(805) 484-9322

http://www.workcompcentral.com

Inquiries are made with the EDEX system by submitting the claimant's Social Security Number and/or WCAB Case number (aka EAMS Number).  EDEX data can provide the following information:

Claimant's Name

Claimant's Date of Birth

Claimant's Gender

ADJ (EAMS #) or legacy WCAB Case Number

Body Parts Claimed

WCAB Current Case Status

The last five recent significant case events with dates.

A list of any hearings both past and future.

The official address record for each party to the case filing

Claims administrator

Insurance company if different from the claims administrator

Claimant's attorney

Defense attorney

Applicant's attorney or representative

Lien claimants

WCAB Jurisdictional Location (i.e. San Jose, San Francisco, Los Angeles, San Diego, etc.)

Date of the claimed injury

Type of injury (i.e. specific injury, cumulative trauma, occupational illness/disease)

The above vendors offer access to EDEX information as a fee for service.

The Division of Worker's Compensation also has a "free" public search tool to obtain similar information above but it is more limited in what it provides and depending on the credibility of the search criteria may not provide all available results.  This free search tool is called the EAMS (Electronic Adjudication Management System).

Information about the tool and its capabilities can be found at the following link:  (http://www.dir.ca.gov/dwc/eams/EAMS_PublicInformationSearch.htm)

The following is language is taken from the California DWC's Website regarding the public search tool:

"Requestors can search on all cases, including archived cases. If the case is archived the archived box will be checked on the general case information screen. If a Disability Evaluation Unit (DEU) case exists, the DEU box will be checked on the general case information screen. This is for informational purposes only—no DEU information is provided through this search.

Other criteria include:

Minimum search criteria is the EAMS case reference number or injured worker name

Partial name search is allowed

Date of birth, city, and ZIP code can be used with injured worker first and last name to refine search

Search result will be limited to 50 body part codes, active participants and events.

Since search results are limited to 50 it is best to be as specific as possible when searching. If the EAMS case number is not known, but the legacy case number is known, the EAMS and legacy case number lookup tool can be used to find the EAMS case number."

The search tool may be accessed by the following link:  https://eams.dwc.ca.gov/WebEnhancement/

On this screen the requester of the information must provide their information.  Their first and last name, a Uniformed Assigned Name (UAN) if one was assigned, their e-mail address, and then select a reason for their inquiry.  A private investigative firm will not likely have a UAN.  You would not have a UAN unless you have requested one.  These UANs are usually reserved for attorneys, law firms, insurance companies, and/or claims administrators.

After entering your information and clicking submit you will be brought to the next screen.  There are two tabs:  Case Search and Lien Search.  For the purposes of this blog posting we will only be presenting the Case Search tab.  There are six search fields.  Three of the search fields have an asterisk next to them.  At minimum you must enter an EAMS Case number or claimant's first and last name.  If you are searching by name you may input a partial name in either or both the first name or last name field.  The public information tool differs from the EDEX search in that you cannot search by Social Security Number.  In addition, as with all databases, if the incorrect information is initially entered or misspelled than it will be more difficult to find the information that you are looking for.

CLAIMS INDEX:

Obtaining a claims index report is a means to not only uncover prior worker’s compensation injuries but also uncover other personal injury claims that the claimant may have been involved with such as auto accidents, slip and falls, property claims, and general liability claims.   The claims index often also called ISO Claims Index because ISO is the largest vendor for this service.  The claims index is a database that many insurance companies and third party administrators subscribe to.  These members submit data on claims they receive from their insured, claimants and or third party claimants to add to the database.  Later they can search the database for claims history that may be pertinent to a current claim for the purposes of combating fraud, abuse, and mitigating loss on future claims that are filed.  One of the downsides of the index system is that not all insurers and claims administrations provide their claims data to the data base.

When a claim is submitted by an insurer or third party administrator the system searches the database and pulls claims information that matches any individual information or a combination of information submitted.  For example hits will be generated if there are matches in the claimant’s name, claimant’s address, claimant’s phone number, claimant’s date of birth, Vehicle Information Number, Vehicle license number, tax identification number, other parties to the loss, and/or the claimant’s Social Security Number.

Typically claims index information is only available to insurers, self-insured entities, and third party claims administrators.  That is why this information should be obtained from your client insurer, self-insured employer, or third party administrator.

For more information on the ISO Claims Index check out the following link: http://www.iso.com/Products/ISO-ClaimSearch/ISO-ClaimSearch-Facts-and-Figures.html

Why are the EDEX & the Claims Index Important for the Investigator?

Can be used to identify possible fraud.  Can be used with questioning a claimant regarding prior claims and injuries to see if they are forthcoming regarding those claims prior to asking them directly about them.  Can identify claims history that may not necessarily uncover fraud, but provide an apportionment to a preexisting disability.  Can be used to identify prior or concurrent employment.

Posted via Blogaway

The 5th Thing That A California Investigator Needs…

from the claims adjuster is a...

Photograph Of The Claimant

Well if the adjuster does not have a photograph or copy of a photo ID of the claimant try to obtain one from the employer when you interview them.  In my investigations, I prefer to interview the employer contact or claimant's supervisor first prior to interviewing the claimant.  If the employer and the adjuster does not have a photograph available, obtain a physical description of the claimant prior to interviewing them from the employer.  Once you meet the claimant in person it is always best practice to verify your interviewee by viewing then scanning, copying or taking a photograph of the claimant's drivers license or other state photo identification.  I also recommend that you take current photograph of the claimant if they will allow you.  This is because some state photo identification cards have outdated photographs.  Be sure to also document the claimant's description, including what they wore for the interview in your investigation notes and in your report.

Below are some of the reasons you need to obtain a recent photograph of the claimant in the process of your worker's compensation investigation:

• To establish the identity of the claimant.
• To provide pre-subrosa intelligence to the surveillance investigator to aide in the quick identification of the claimant during a surveillance assignment.  This will reduce any wasted time and money trying to identify the right subject of the surveillance.
• For the adjuster or defense attorney to verify the claimant's identity at their deposition, medical appointments, and at WCAB appearances.
• To assist the investigator with their online investigations (i.e. Social Networking Searches) to identify the claimant in photographs, in profile pictures, and in online videos.  

If you would like to contribute any other reasons you feel that is necessary to obtain a photograph of the claimant, please share your thoughts in the comment section below.

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I like to use what I call a bridge camera with a high optical zoom like the Nikon above for my investigation photo needs.  A bridge camera has the best of both worlds (the small size and high optical zoom for this type of point and shoot & the versatility of the SLR).