Claims — Workers' Compensation

You calculate workers' compensation indemnity benefits across multiple benefit types: Temporary Total Disability (TTD), Temporary Partial Disability (TPD), Permanent Partial Disability (PPD), and Permanent Total Disability (PTD). Each requires computing the Average Weekly Wage (AWW), applying state-specific compensation rates and caps, tracking Maximum Medical Improvement (MMI) determinations, and managing jurisdictional variations across 50+ states with different formulas, waiting periods, and duration limits.

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 indemnity cost plus ongoing medical. You coordinate between the injured worker, treating physician, employer, and vocational counselor. The 12–16 week mark is critical.

For Medicare-eligible claimants, you manage MSP compliance: Section 111 MMSEA reporting, CMS conditional payment lien resolution, and MSA establishment for settlements.

When a workplace injury is reported, you assess severity, direct the injured worker to an appropriate provider (in directed-care states), authorize initial treatment, and set the claim on a medical management track. You evaluate whether it's medical-only or indemnity, check jurisdictional waiting and retroactive periods, and identify claims needing nurse case management early.