Claims

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Better Outcomes Through Collaborative Expertise

Workers’ Compensation Claims

Your business deserves the best possible results, and your injured employees deserve the treatment they need. If someone gets hurt on the job, you shouldn’t have to worry about figuring out what to do. Zenith’s dedicated team of employees will guide you throughout the claims process and keep you fully informed.

Our Claims department is recognized as the leader in workers’ compensation because we focus on delivering optimal outcomes, thereby protecting your interests and those of your employees. Our proactive approach to claims management can lead to lower premiums by improving your experience modification (ex mod) over time. The proof is in the numbers: for example, Zenith policies that started with an ex mod greater than 1.15, on average, experienced a 22% decrease in their ex mod over a recent five-year period.*

Here’s how we do it:

We invest in top-tier, internal resources who make it a priority to help your injured employees recover and return to work as quickly as possible. We do this using a team of Zenith employees that includes in-house claims specialists, nurses, medical bill review experts, and fraud fighters. We even have doctors who consult with our claims specialists and communicate with treating physicians to help optimize care and outcomes.

If an injury has legal implications, our in-house team of claims experts, attorneys, and former judges work directly with our claims adjusters to get a fair outcome.

We proactively keep lines of communication open between all parties to help make sure everyone has the information needed to make good decisions in the best interest of injured employees. Because of our employers’ diverse workforce, we use multilingual specialists who can speak to your employees in their native language, and field examiners who can meet with them at their home, doctor’s office, or job site.

We help injured employees get the medical care they need. When there are serious injuries involved, we deploy our specialized catastrophic injury response team to be on site so they can engage real time with doctors and nurses. This includes also spending time with employees and their families so we can understand their needs and how we can assist.

We start before you need us by identifying qualified medical providers to participate in our state-specific networks and panels. While laws and regulations relating to medical networks and panels vary, we take full advantage of the opportunity to select the medical providers who treat injured workers to the extent permitted by the laws of each state.

We identify medical providers who regularly treat patients with workplace injuries and illnesses and who understand the importance of collaboration among you, your employee, and our specialists throughout the course of treatment. We evaluate our network and panel medical providers on their expertise, positive results, and fair billing practices. The review process is ongoing, with routine assessments and score cards. Our medical directors and claims leaders analyze outcomes and are involved in this process to help injured workers receive appropriate and timely care from network and panel providers.

We encourage you to find and build a relationship with a medical provider before an injury occurs. The more your medical provider knows about you and your business, the clearer the path to returning an injured employee to work, especially if your provider is aware of your return-to-work options. Your provider may also maintain your post-incident drug testing files.

On those occasions where medical providers deliver unnecessary or inappropriate medical treatment or bill excessive amounts, we contest these charges. We have a specialized team that reviews treatment and bills to help ensure that we only pay for reasonable and appropriate treatment. We aggressively dispute liens and other claims for payments not justified.

Note: The panel or network of doctors from which your employees can receive treatment will vary based on the state where they live. To learn more, visit Find a Medical Provider.

Our skilled Claims team is supported by proprietary data and information which helps us to make evidenced-based decisions and seek the best possible outcomes for employers and their injured employees. This includes modeling anticipated treatment and claims outcomes, reviewing medical trending data, and evaluating medical providers.

Your employees are vital to your business. When they’re injured, you want them to recover and return to work – and so do they. We work closely with you at every step of the claim to help you develop transitional work assignments within your employee’s abilities.

A strong return to work (RTW) program positively affects your business. Statistics show that employees who return to work generally recover more quickly because they remain active, productive, and connected to their workplace. You’ll also likely boost employee morale because they’ll understand how much you care. As a result, you could lower your experience modification and better control insurance costs over time. You may even be able to reduce business disruption and expenses from lost production, need for replacement workers, and added administrative time.

We take a proactive approach and have developed light duty, transitional work assignment lists for more than 50 industries. We work with your injured employees, their doctors, and you to identify strategies to help employees ease back into the workplace and experience an optimal recovery.

We’ll show you how to implement an effective RTW program and provide the tools and resources to help make your efforts a success. Log in to the Zenith Solution CenterSM to access:

  • RTW program resources
  • Comprehensive library of functional job descriptions
  • Transitional work checklists and examples

A fraudulent claim that goes unchecked is costly, disruptive, and can put your business at risk. Not only does it impact your operations, it can also increase claim costs with unnecessary medical and disability payments. This often results in a higher experience modification, which can raise your premiums for years to come.

Zenith’s investigative team helps to uncover and fight those taking advantage of you or your employees. We do it by analyzing lost-time claims, treatment, and billing for exaggeration and fraud – by both employees and providers.

Insurance fraud isn’t easy to spot, as business owners don’t always know what to look for. Our in-house Special Investigation Unit (SIU) helps expose and fight those seeking to take advantage of you, whether it’s an employee, medical provider, lawyer, medical billing firm, or others who feed off the workers’ compensation system. If you see any of the red flags that typify workers’ compensation fraud, call our SIU at 866-296-4748.

We also investigate providers for excessive treatment and exaggerated billing. When an investigation indicates fraud, our SIU teams up with our claims and legal specialists to prepare and submit a detailed report for law enforcement agencies that investigate fraud. Over the years, the fraud cases we’ve submitted have led to hundreds of arrests and convictions. (Zenith is required by law to report all incidents of suspected fraud. Decisions on whether to prosecute are the sole responsibility of the authorities.)

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