Compliance & Regulatory — Insurance

You process thousands of medical bills per adjuster: verifying treatment authorization, applying state fee schedules, identifying billing errors (upcoding, unbundling, duplicates), negotiating disputes, and managing pharmacy costs (formulary compliance, opioid prior auth, compound medications). PPO repricing adds another layer.

RTW is the single most important outcome driver: every week of delayed RTW adds $1,000–$3,000 in indemnity plus ongoing medical. You coordinate between the injured worker, treating physician, employer, and vocational counselor. The 12–16 week mark is critical.

You calculate indemnity benefits per state statute: TTD, TPD, PPD, PTD, and death benefits. Each state has different formulas, different AWW calculation methods, different max/min rates, different duration caps. Getting the comp rate wrong creates regulatory exposure and penalty exposure.