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Using Nurse Review on Third Party Claims: When, Why and How

—June 28, 2017
Using Nurse Review on Third Party Claims: When, Why and How

By Monica Zylstra, Vice President, Service Operations, Mitchell Casualty Solutions

When third party auto casualty claims are extremely complex, for example, when multiple providers are treating a claimant, the claimant has pre-existing conditions or the claim has been open for an extended period of time, insurance carriers benefit by bringing in medical professionals to perform claim reviews. An organization of trained nurses can be an invaluable tool in a third party adjusters’ toolbox. Not only can a nurse provide detailed analysis of the claim and flag issues, but they also can help prepare the adjuster to successfully explain and negotiate complicated medical issues.

Using Nurse Review Effectively

While nurse review can be valuable on many third party claims, it’s important that adjusters make good decisions about which claims to send to a nurse for optimal results. For example, a claim where the medical expenses have reached $20,000, the claimant has pre-existing conditions and the claimant was treated by a primary care doctor, a chiropractor and a neurosurgeon, is a much better candidate for a nurse review than a claim with $1,000 in medical bills and one treating physician. A complex or high-dollar claim is more likely than a simple claim to have issues that a nurse can flag and often yields stronger recommendations. It’s important that adjusters can make this type of good judgment in triaging claims to nurses, since the true value of nurse review is when nurses are able to provide comprehensive results that greatly impact the final settlement paid.

A Nurse Reviewer’s Value

When a nurse review is executed correctly, it can help insurance companies achieve significant cost containment on third party claims. In fact, some companies using nurse review have avoided paying hundreds of thousands of dollars for treatments nurses have determined are unrelated to auto accidents or related to a pre-existing condition.

An experienced nurse will personally look closely at all of the details of a claim and medical records instead of just doing a cursory review of the billing or using algorithms to do the job for them. A nurse review service provides adjusters with invaluable information to help them achieve a deep understanding of the medical components of the claim without having to have extensive medical training. By receiving recommendations in the form of clear, concise negotiation points written in easy-to-understand terms, adjusters at all experience levels are able to not only understand the injuries, but also explain and rebut key points to a claimant or claimant attorney more effectively.

Nurse-Adjuster Collaboration

In addition to providing detailed, easy-to-understand recommendations, a nurse adds additional value through their flexibility in working with adjusters. At times, adjusters need additional clarification or help understanding recommendations. For example, an adjuster could need a more detailed explanation for a condition he or she has documented. An effective nurse review team will include the nurse’s contact information and make their nurses available to answer adjusters’ questions. This type of access to nurses helps adjusters be as prepared as possible for the negotiation process. A well-prepared adjuster with a full understanding of the medical treatment associated with the claim can negotiate a better outcome than an underprepared adjuster.

Nurse Review in the End-to-End Workflow

In order to realize the full benefit of a third party nurse review, it is important that the nurse’s recommendations are integrated into an adjuster’s regular third party end-to-end workflow.

Ideally, an adjuster should be able to easily request review and receive recommendations in a format that fits their specific workflow needs and preferences – whether that means through their expert claim workspace, bill review platform, claims system or just in their inbox. By providing recommendations back into the adjuster’s typical workflow, the adjuster will be able to effectively apply and negotiate the points from the nurse’s review, ultimately helping to improve outcomes on third party claim settlements in a user-friendly, efficient manner.


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