March 23, 2016 – NEAMI Claims Department Receives SUPERIOR Ranking!

Claims pic

Every two to three years, NEAMI client PERMA hires external auditors to perform an audit of the NEAMI claims department to ensure claims handling is meeting PERMA standards.

Last May, the PERMA Board hired Bickmore, a public entity claims consultant, to conduct an audit of NEAMI’s claims operations. Bickmore was founded over 30 years ago and conducts both private sector and public pooling audits throughout the country.

The claims audit consisted of a review of policies and procedures, staff interviews and PERMA claim file reviews. Bickmore randomly selected 210 claim files and reviewed them for 69 criteria in 12 component areas including initial contacts, medical management, fraud, reserves and resolution. As part of the review, auditors were in the NEAMI office for two weeks last August.

Jo Ann Wood, manager of Claims Consulting Solutions for Bickmore, shared the results of the audit at the October 2015 PERMA Board meeting. The best practice level target score is 95%. NEAMI claims handling received an overall score of 98%, achieving a “superior” ranking. Bickmore ranks NEAMI in the top 3% of audits they’ve performed.

The auditors felt that NEAMI’s team-based approach, including assigning claims to the case analyst best equipped for the specific loss, as well as using patient advocates on lost time claims from the beginning of the claim, helped reach optimal outcomes and mitigate claim costs.  It was noted that the NEAMI staff is well qualified, very experienced and well trained with an average tenure of 13 to 14 years.

The claims team received a superior ranking (95% or higher) in the following areas:

Claim intake – including timely set up and assignment of new claims;

Initial contacts – including timely, thorough, and well-documented investigations;

Compensability determinations – whether a claim should be accepted or litigated if it did not appear to be covered under workers’ compensation;

Medical cost and disability management – how patient advocates help control costs and facilitate return to work for injured workers;

Reserving – timely and accurate reserves reflect the likely exposure on each claim. The recommended reserves by the auditors had less than 1% variance from file reserves established by the case analysts;

Claim resolution – files are handled aggressively with action plans developed to bring the claim to an endpoint. Settlements directly between the client and the claimant (commonly referred to as Section 32) were noted to have a positive impact on overall claims costs;

Fraud – an aggressive stance was noted as well as effective use of surveillance;

Subrogation – efforts were made to recover from a third party whenever there was an opportunity;

Documentation – claim files were thorough and easy for others’ to follow;

Caseloads per adjuster were noted to be optimal allowing for proper claim investigation, handling and resolution.

NEAMI management is proud of the claims team. The audit reviewed the work of the last three years, but the result is due to many years of hard work prior. These scores represent the dedicated efforts by all of the claims staff – claims coordinators, adjusters, nurse case managers, and claims management – to deliver the highest level of service. Although we are all very pleased with the audit results, we are not resting on our laurels. We are pushing ourselves every day to strive to be even better.