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The TPA, Defense Counsel and You Part II

Friday, February 14, 2020

This is being written in follow up to my last post where the Third Party Administrator attempted to advise the Self- Insured Employer and his attorney that the only person with decision making authority was the Claims Adjuster.  It again becomes clear in this post that the TPA is not interested in doing what is best for the Self-Insured Employer or the claim.  


Self-Insured Employers each have service instructions about vendors to be used.  It is a Self-Insured Employers right to designate what vendors are to be used.  The TPA must abide by those service instructions.  If you are seeing counsel, or IME physicians or surveillance companies being used  in your claims that you are not familiar with the best place to start to look is what instructions you have given the TPA in working on your claims.    If you do not assign appropriate vendors as this TPA said here, your vendors will be picked for you.

The Self-Insured Employer who was involved in this TPA driven claim, requested that the service instructions be changed to reflect that litigated claims were to be sent directly to counsel and that the counsel would be handling the disputed claims and that counsel would select the IME physicians and the Surveillance company.   The TPA refused to put this counsel’s name  in the service instructions and would only list “Ohio counsel.”  The service instructions were amended to include that “Ohio counsel” would have the right to pick the surveillance company and the IME physician.  Yet again, a TPA interfering in a business relationship between the Self-Insured Employer and counsel.  Let me reiterate the Self-Insured Employer has the right to alter those service  instructions to reflect the wishes of the company. 

The Self-Insured Employer advised that on this particular claim they would not be using the TPA vendors.  The TPA’s response was that they would not pay those vendors through the claim.  The Self-Insured Employer stated that all bills for the IME and the surveillance company be sent to them directly.   Tracking costs of the claim, seems a task appropriate for a TPA but this one will only do it if the Self-Insured Employer uses their vendors.    TPA’s are more interested in doing tasks that are beyond them, i.e. the practice of law and creating cost centers for their company rather than doing the tasks that they are specifically paid to perform.

When all was said and done,  based upon the recommendations of counsel for an IME physician and excellent work done by the Investigative Company including WEBtap, video surveillance,  the Self-Insured Employer secured a win across the board,  winning at both DHO and SHO Hearings.

The message is clear here,  if Self-Insured Employers want to be successful in litigated claims they need to become informed enough to make decisions for their company and have those trained to practice law take the lead.

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