Supporting Your Client Through the Claim Process

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Supporting Your Client Through the Claim Process

Managing a claim can be a complicated process. Hopefully, your clients will have few or no claims, and will never become experts at this process. This lack of expertise can also mean that the claims process will be intimidating. Luckily, you, their broker, are there to help.

It is our goal to make the claims process simple for everyone. Below, we have listed the different stages of the claim process and how you can support your clients through all of them.

IN THIS ARTICLE

Before an injury occurs

Preparing for a claim starts at policy inception by ensuring employees are informed about workers’ compensation and how to get treatment. Your clients should display and provide these documents right after binding the policy:

  • Notice to Employees DWC 7 – This form must be posted at every worksite in a location that is easily visible to employees. If they have Spanish-speaking employees, the Spanish version will need to be posted. You should ensure your clients correctly post this notice to avoid a $7,000 fine.
  • Employee’s Guide to State Fund MPN – It is the responsibility of each employer to provide a copy of this guide to each new employee at the time of hire, and then again at the time of injury.

You should also encourage your clients to create a workplace safety program, otherwise known as an Injury and Illness Prevention Program, or IIPP. Cal/OSHA requires employers to have one; a proactive approach to workplace safety can reduce the number and severity of workplace injuries.

The easiest way to build an IIPP is through our IIPP Builder tool, which your clients can access through State Fund Online.

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When an injury occurs

When an injury occurs, the injured worker should get immediate treatment. This could include calling 911, visiting the nearest medical facility, providing first aid, or sending the injured worker to a physician in State Fund’s Medical Provider Network, or their predesignated physician.

Claims should be filed as soon as possible, within 24 hours is ideal, to ensure lowest costs and the best outcome for the injured worker. If the injury is serious and requires hospitalization, the injury must be reported to Cal/OSHA within eight hours of occurrence.

Ensure your clients know how to get treatment for their injured workers and how to file a claim by sharing these resources with them:

If assistance is needed in finding a physician or scheduling an appointment, encourage your client to contact their claims adjuster. If they do not yet have a claims adjuster, they can contact our Medical Access Assistants (MAA), Monday through Saturday, 7 AM to 8 PM.

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After the claim is filed

At this point, State Fund adjusters are hard at work collecting the information they need to help the policyholder, ensure the injured worker gets the treatment they need, and help them get back to work. Moving through this process quickly is incredibly important, because a delay in processing can mean a delay in treatment. This can cause injuries to get worse, recovery to be delayed, and costs to increase.

You can help by ensuring good communication between the policyholder and adjuster, and that they each have all of the information they need. State Fund Online provides you up to date information on all of your client’s claims. On new claims, expect updates anywhere between three to 30 days. Existing claims are typically updated every 90 days, but typically more frequently as the claim is managed. Some types of claims may be updated less frequently, so you should talk to the claims adjuster or claims liaison so you know what to expect.

It’s important to keep your contact information and the information on the Broker of Record up to date so the claims adjuster can contact you when needed. It’s also helpful to ensure that the policyholder information is up to date as well.

State Fund Online also includes a messaging service, which ensures efficient communication between yourself, your client, and the adjuster. The messaging feature can also generate automated messages, so you know instantly when certain changes occur on a claim.

To make full use of these features, ensure your clients are signed up for State Fund Online and the messaging features. Below are three guides to help them get started.

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Getting treatment

Injured workers must see physicians within our Medical Provider Network (MPN). The MPN includes a diverse group of qualified physicians and specialists who have experience in workers’ compensation injuries. They know the procedures and how to navigate the process to effectively and efficiently provide the best treatment. The MPN includes physicians, specialists, and pharmacies throughout California and includes both in-person and telehealth care.

Injured workers may use the tool to seek urgent care, find their Primary Treating Physician (PTP), and specialists. You can help by sharing these resources with your clients when needed:

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Return to work

When a worker is injured, it’s important to help them not only recover, but get back to work when the time is right. Our adjusters work with employers to find ways to bring the injured worker back to work in some capacity. This may include modified or alternative duties that can be performed prior to full recovery, as well as when the injured worker has become Permanent and Stationary (P&S), meaning their recovery has plateaued. Return to Work efforts are a key factor in reducing overall claim costs and can help recovery.

When a worker is injured, it’s important to help them not only recover, but get back to work when the time is right. Our adjusters work with employers to find ways to bring the injured worker back to work in some capacity. This may include modified or alternative duties that can be performed prior to full recovery, as well as when the injured worker has become Permanent and Stationary (P&S), meaning their recovery has plateaued. Return to Work efforts are a key factor in reducing overall claim costs and can help recovery.

Note: The injured worker's physician signs off when the injured worker is ready to return to work in any capacity.

Ensure your client understands how and when an injured worker can return to work.

Life after an injury

In cases of a severe injury, you can support the policyholder and injured worker by giving them resources that can provide additional help. We have put together a page of resources designed to help workers who have suffered a traumatic injury on our Traumatic Injury Resources page.

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