Claims

When claims occur, our specialists and business partnerships deliver tools, resources and services that will help you successfully manage them through closure.

Medical Provider Network (MPN)

Our proprietary MPN was established in accordance with the SB 899 reforms that occurred in April 2004, and can provide employer control over the injured worker’s medical care through the life of the claim.

The EIA has developed its own Medical Provider Network (MPN) with the assistance of a contracted administrator (WellComp). The MPN was established in accordance with the SB 899 reforms that occurred in April 2004, and can provide employer control over the injured worker’s medical care through the life of the claim. The MPN is required for members of the PWC Program and available to all EWC Program members should they desire to use it. The network includes Kaiser Occupational Health, Sutter at Work and various individual physicians nominated by the EIA membership. The EIA’s network contains more than 5,700 physicians statewide. The Medical Provider Network can be accessed through the MPN website. If you have any suggestions for additions or changes to the network, please contact Paul Stanley or call (916) 850-7305.

24/7 Nurse Triage Services

24/7 access to a first call first reporting system from Company Nurse that provides both a medical needs triage at the time of injury and a means of completing the first report documents for the member.

Company Nurse is a first call first reporting system that provides both a medical needs triage at the time of injury and a means of completing the first report documents for the member. As a result, more injuries are designated as first-aid while others are immediately directed to the appropriate level of care. The EIA has negotiated a discounted rate that is available to all the members of the PWC Program. EWC members will also receive a discounted rate if, when they negotiate their contract with Company Nurse, they notify Company Nurse that they are a member of the EIA. For more information on Company Nurse, please contact Kathy McLean at 916-850-7300.

Return to Work Program

Pre-identified temporary work assignments from the OUR System help employers return employees to work, increasing employee satisfaction and decreasing the cost of the claim.

Returning employees to work early in the life of a claim can be one of the most effective cost-control techniques available. Results have shown that early return to work programs can reduce indemnity and medical costs for employers. They also assist the employee to emotionally heal from their injury by returning them to the environment they know. To assist with this process, the EIA has contracted with Norm Peterson and Assoc. (NPA) to provide the OUR System to our PWC Program members at a discounted rate.

The OUR System effects early return to work by identifying “bridge assignments”, which focus on the employee’s abilities, not on the physical restrictions caused by an injury. If EWC members decide to enter into their own contract with NPA for these services, they should notify NPA that they are a member of the EIA. This will allow the EWC members to receive a discounted rate. For more information on the Return to Work Program, please contact Kathy McLean at 916-850-7300.

Medicare Reporting Services

Preferred rates are available to EWC, PWC, PGL, GL1, and GL2 program members through a contract with ExamWorks.

Due to the significant reporting requirements that exist and penalties that can be assessed for failing to comply with the Medicare Secondary Payer Act (MSP), the EIA has coordinated with ExamWorks to provide CMS (Center for Medicare/Medicaid Services) query and reporting services. To coordinate these services with ExamWorks at EIA preferred pricing, please contact Robert Arrieta. If you have any question regarding MSP compliance or ExamWorks as a vendor, please contact Kathy McLean at 916-850-7300.

Subrogation Recovery Services

Specialized subrogation claims adjusters’ help you recover claims expense incurred by a third party.

Subrogation is the legal process of recovering costs for losses caused by other parties or entities. Recoverable costs can come from a variety of sources. To assist EIA members with their subrogation needs, the EIA has partnered with George Hills Company. They know the legal process to aid in securing recovery of costs from responsible parties and can also help identify costs incurred that are prime for recovery. This service is available at preferred rates for EIA members.

A list of common examples of potential recovery cases include (but are not limited to):

  • Auto Debris Cleanup Damage
  • DUI Fees
  • Electric Pole Damage
  • Environment Spills
  • Fire Hydrant Damage
  • Graffiti/Code Enforcement
  • Sign Damage
  • Streetlight Pole Damage
  • Traffic Signal Damage
  • Transformer Damage
  • Underground Service Alert Damage
  • Vehicle Damage

For more information on Subrogation Recovery Services, please contact Heather Fregeau at 916-850-7300.

C.A.R.E.S. Program

This program walks your injured employee through the surgical process and ensures pre and post-surgery needs are fulfilled.

A dedicated Telephonic Nurse Case Manager (TCM) is assigned to perform a triage call with the injured worker upon authorization of a surgical procedure. The TCM will act as an extension of the employer, and the claims examiner with the focus being on educating the injured worker about the post-operative limitations and what adjustments the injured worker will have to make temporarily to their daily living activities. This is an optional program that is available to PWC members.

Contact Jen Hamelin for more information about this service.

Express Scripts Pharmacy Benefit Management Program

Essentially a PPO for pharmaceuticals providing preferred pricing, ease of access, and authorization and medication interaction oversight.

For more information on this program, please contact Jen Hamelin at 916-850-7300. 

Acute Care Services

A post-acute and post-surgery care and rehabilitation facility for severe injuries.

Care Meridian provides a post-acute care and rehabilitation facility for severe injuries such as to the brain or spinal cord. It also provides this service for persons who are post-surgical. For more information on this program, please contact Jen Hamelin at 916-850-7300.

Soft Tissue Diagnostics

A diagnostic tool created by Med-Tek CMAP helps to determine the existence of soft tissue injuries, their precise locations, and relative age.

This Med-Tek CMAP tool assists with accurately diagnosing and treating these types of injuries.  Contact Amy Foster at 916-367-2745 for more information. 

Prescription Addiction Management

Drug review program designed to reduce injured workers' addiction to narcotics.

PRIUM Medical Cost Management Services is a drug review program that reduces the potential for injured workers to become addicted to narcotics and decreases the use of unnecessary or inappropriate drugs.  Contact Mark Pew at 888-588-4961 ext. 201.

Managed Care Consulting

Members of the PWC program have access to pre-negotiated rates from David Donn Consulting, Inc. to provide oversight of your managed care program to ensure maximum savings at minimum cost.

David Donn Consulting is a restructuring firm that optimizes the financial (and operational) performance of WC managed care programs.  DDC doesn’t provide managed care services; rather works with clients’ existing vendors –identifying areas for improvement in their process and resources, fixing those weaknesses, and auditing ongoing performance to make sure the vendors stick to the high performance commitments they negotiate.  The goal is to optimize programs in two ways: through restructuring existing programs, and through putting programs out to competitive bid.  For small and medium sized payers, the financial impact can be hundreds of thousands of dollars a year in reduced medical and managed care fees.

Contact David Donn at 415-409-3666.

Claims Audits

Contracted independent claims auditors review your book of claims helping to increase TPA performance in accordance with EIA best practices and contracted administrative standards.

If you participate in our workers’ compensation or liability coverages, you’re required to have a claims audit completed every two years per the EIA’s Policy Statement on EWC and GL1 Member Audits and Underwriting and Claims Administration Standards and Guidelines.  In Workers’ Compensation, the EIA has contracted with 5 auditors to perform audits (ALC, AON, BRS, NBA and Susan Wright).  In Liability, there are 2 contracted auditors (Ken Maiolini – RMS and Praxis Consulting). 

Claim System

Members can benefit from EIA's partnership with Systema for their claims processing needs by leveraging pre-negotiated claims system rates at a potentially substantial discount.

The EIA has converted to a new claims system called SIMS Claims by Systema Software. Utilizing the contract that was negotiated, we have the ability to offer members the same system for use as their primary claims handling system. The annual fees and conversion/implementation cost structures have been negotiated as part of our agreement and provide significant discounts over purchasing direct. While discounts exist for any member, smaller entities with fewer than five users will be supported by EIA which reduces their annual maintenance. In many cases, this program will enable members to utilize an exceptional claims system for a cost much less than what would be available to them otherwise. If you are interested in obtaining information about using the EIA’s claims system, please contact Jason Watson at 916-850-7300.

ISO Claims Search

The EIA funds an annual contract with the ISO to cover all index reporting and inquiries for our members. 

Indexing is beneficial in identifying prior or subsequent injuries that may be exacerbating the problems demonstrated in the subject accident.  This removes the need for members and their claims administrators to pay for each submission. If your organization is not currently using this service, please contact Ashley Crichton at 916-850-7300 to enroll your entity or claims administrator.

Catastrophic Claims Management

Paradigm Outcomes connects catastrophically injured workers to medical experts, high quality providers and clinical support infrastructure to achieve better medical outcomes and lower claims cost.  

Paradigm assists when a catastrophic claim occurs by providing access to claims professionals whose sole purpose and expertise is to manage the claim. This is achieved by bringing medical benefits to the injured worker, and assigning experienced clinicians to their case. Paradigm Outcomes has managed over 15,000 catastrophic claims over the last 25 years, and provides a unique opportunity to “sell” the medical components of the claim, thereby creating a contractual negotiated limit on the medical exposure to the claim. Contact Kathy McLean at 916-850-7300.

Gitter & Associates, Inc. are specialized claim negotiators that identify complications preventing claims from resolving, and work with all parties to bring claims to closure.  Contact Greg Gitter at 877-448-2772 for more information.

Because the EIA claims staff monitors claims of all nature and variety throughout California and frequently interact with our reinsurers’ claims professionals, we serve as an excellent resource for members and their claims administrators. The EIA claims staff are available to identify specialists (attorneys and otherwise) and complete research on laws, statutes and precedents that might affect the value and resolution of your claim. We invite you to contact our Claims Specialists for assistance with any claims-related matters. 

RPM Lien Resolution is a lien negotiation service that will close out old liens that are keeping your claims open. RPM will also walk your settlement papers through the WCAB at rates significantly less than those charged by attorneys. For more information on this program, please contact Jen Hamelin at 916-850-7300.

Brokers specializing in resolving complicated workers’ compensation claims via annuities.  Contact Noah Schwartz at 916-649-7585 or John Pinto at 916-955-9120.