Most importantly, there is the investigation that is critical to quality. As a rule of thumb, there are 12 critical rocks that must never be left unturned.

The police report. Was there any mention of an injury at the scene? Was the injured party transported to a medical facility? Was there any mention of contributing factors against the claimant? Were any witnesses identified? Did the police respond, or was a counter report filed after the fact?
Liability – Who is at fault for the accident? Insurance adjusters assess comparative negligence on just 3% of all claims, a vast understatement of what should truly be assessed. Leveraging tools such as ClaimIQ can provide adjusters with the critical elements needed to properly identify duties owed and breached.
Vehicle photographs (auto claims). Does the damage match? Are there paint transfers? What is the directional force of impact? Is the damage such that the injury being claimed may be related? In addition, point of impact plays a significant role in the assessment of comparative fault.
The accident scene. Are there any other potential tortfeasors? Overgrown bushes, signal outages, missing or blocked signage, absentee third parties, and similar factors should always be investigated. Does the movement, as stated by the parties, correspond to what is being visualized?
Emergency room records. What was said to the EMT's at the scene and during transport? What does the ER admission statement say? What type of pain was related to the treating physician? Was there a mention of symptoms other than what may be related to the accident? Is there any indication of drug or alcohol usage that may have contributed to the loss?
Medical treatment patterns. How soon did treatment begin? Were there gaps in treatment? Was treatment provided on evenings and/or weekends? Were you able to verify treating physician office hours?
Provider type. Was the claimant seen by a chiropractor or medical doctor? If the latter, then what was his or her specialty, such as neurology, orthopedics, and so on? What are the medical professional's credentials? Is his or her licensure current? Are there any prior or pending disciplinary actions with the current state, or in prior states? Can the claimant describe the doctor, medical facility, staff and provide directions from their home to the facility?
The duration and frequency. When did treatment start? How long did it last? Was it active or passive? Was it longer than an anticipated expected recovery date among the general population for a similar complaint?
Objectivity. Were there objective findings, such as those from an x-ray, MRI, or CT scan? Were the records and films obtained and reviewed by an independent medical expert?
Pain management. Did the doctor prescribe medication to ease the complaints of pain? If so, then what type (analgesics, prescriptions, injections)?
SOAP notes. Does the treatment being provided and billed match the medical providers SOAP (subjective, objective, assessment, plan) notes which can be a great indicator of not only what treatment really occurred, but also a red flag for CPT coding and modifier abuse.
Index and Priors – Did the claimant have prior claims or injuries? Let's face it, there is a percentage of the population that will use claims in an attempt to get compensated for every malady. Adjusters need to do a detailed investigation, including seeking out prior providers, reviewing prior indexes, requesting medical authorization and reviewing old claims. This can be time consuming, but then again so is panning for gold. Digging deep during investigations is not only a requirement of the job, but it is part of the duty of being a fiduciary for the insured, in order to pay only what is owed.

While there may be many additional steps, depending on the type and complexity of the investigation, these are designed to provide a roadmap for success. By focusing on the basic fundamentals, leveraging the triad of people, processes and the right technology, insurers will find that they can effectively combat the rise in BI severities.

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Fighting Back Against Rising BI Severities

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