Pick The Right Adjuster For The Right Workers Comp Claim

The experience and expertise of your adjuster will have a significant impact on the cost and life of a workers’ compensation claim.  Every employer must be absolutely certain the adjuster handling claims knows what, how, and when to do everything from the first report of injury to the final disposition.

 

Claim supervisors and managers need to be the most experienced, as well as have sufficient time to monitor staff and claim handling.  They also must teach, critique, and discipline all claim handling.

 

An adjuster needs to be part detective, part doctor, part lawyer, part father confessor, part director, and part politician.  Investigating facts and activities requires an inquisitive mind with questioning capacity.

 

Additional Adjuster Tasks & Responsibilities:

 

  • Adjusters must know medical facets of traumatic injury, healing periods and usual complications.
  • Proper medical care must be achieved.
  • Adjusters must direct and control the claim.
  • Complying with the law’s requirements and duties requires legal knowledge.
  • Listening, being empathetic, and addressing injured worker needs, is paramount to successful resolution.
  • Adjusters must be good communicators in spoken and written format.
  • Adjusters must have convincing gravitas to have people accept their proposals.
  • Adjusters deal with all walks of life. They must be comfortable in public dealings.
  • A college degree might be preferred, but it is not always necessary.

 

There are two schools of thought for selecting adjusters.  First, hire only experienced people.  Second, train your own.  Both have pros and cons. Each has had successes and failures.  Selection is a matter of choice.

 

 

Various Adjusters:

 

Medical Only Technician:

 

Medical-only adjusters, an entry level position, are trainees with little to no experience. They handle minor medical claims involving simple lacerations and minor strains/sprains not involving any lost wages or complicated medical injuries/conditions. When an employee has a few clinic visits the employer sends the claim in with the bills and the adjuster sets up the claim, processes the bills, and closes the claim.

 

Some issues a medical technician faces are:

  1. The history of the injury occurrence may only be addressed in the first reporting and billing.
  2. Aggravations for underlying pathologies may be casually addressed or not commented on.
  3. Often a treatment number is the only clue that the employee is being treated for more than the original injury.
  4. Treatment time and expense exceeds normalcy or claim unit authorities.
  5. Treatment may be going on that was not authorized.
  6. Missing permanent partial disabilities. Or paying permanent partial disabilities as a med case instead of an indemnity case.

 

Lost time/indemnity adjuster

 

Lost-time/indemnity adjusters are more experienced, with knowledge of local legal statutes and a high degree of medical training in handling occupational claims. Their expertise is with claims running past 90 days involving more severe injuries such as a complicated lacerations, level 2/3 sprain/strains, surgical repairs, or pending surgeries. When employers question claim compensability, the claim is immediately assigned to the lost time/indemnity adjuster.

 

Some issues that could hamper performance are:

  1. Assigned case overload impeding ability do a proper job
  2. Performing tasks that are better served clerically
  3. Failure to be analytical and innovative
  4. Have attitude issues that can cause cases to explode
  5. Failure to explore the worst case scenario
  6. Lack of empathy for the injured employee
  7. Lack of effort to resolve cases promptly and expeditiously

 

 

Litigation Technician:

 

Litigation adjusters handle claims involving lawsuits. These adjusters share the same level of experience as the lost-time adjuster. However, they have advanced training in legal issues and in investigating the compensability of occupational claims.

 

 

When a compensable claim is disputed, and the claimant retains counsel and files a Notice for a Hearing, the claim goes from the lost-time adjuster to the litigation adjuster. The litigation adjuster works with in-house or outside counsel gathering details on the injury, and appears for hearings and mediations to quickly resolve the claim at minimum legal expense.

 

 

Catastrophic adjuster

 

This level of adjuster is the most complex, handling very difficult claims, usually ones where the claimant has a severe injury requiring multiple surgeries, amputations, loss of sight, hearing loss, or internal medical issues such as asbestosis or chronic joint degeneration due to occupational exposure, etc.

 

General/catastrophic adjusters have many years of experience in the Insurance industry, combined with advanced medical and litigation training and experience. They also have advanced claim investigation training, and may possess a law degree or are licensed attorneys.

 

 

Summary:

 

It is vitally important for adjusters to have the proper intelligence, personality, and training to obtain maximum resolution of their claims.  Cases should be assigned  at proper levels of adjuster competence.  Supervisors, managers, and employers need to monitor adjuster activities to maintain maximum benefit for the claim.

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

 

 

5 Steps When Favorite Employee’s Workers Comp Claim Is Denied

The foundation of workers’ compensation is the employer-employee relationship.  Depending on the injury and the relationship, this can mean an awkward scenario if your favorite employee’s workers compensation claim is being denied. Your employee is coming to you for help, but you are essentially powerless. Or, you are the agent and your client is upset that the carrier you recommended will not cover this particular comp claim.

 

 

  1. Get both sides of the story.

If you are only listening to what your employee is saying, you are only getting one side of the story. This will show how involved you are with your claims. If you do not talk to your adjuster a lot, or if you do not know who your adjuster is, chances are you will be confused as well. But you cannot take the side of your employee without also hearing the facts from your adjuster — especially if this is a questionable, subjective claim to begin with. You may want to protect your employees, but both of you cannot team up against your carrier, who, by the way, is working hard to investigate all claims and make the proper decisions, which affect your overall premium.

 

 

Take the time and call the adjuster and get their side of the story. If there is something you do not understand, ask them to explain it. Make sure you really understand what the issue is and why it is there. This way you will understand what is going on, and you can explain it to your disgruntled employee. Carriers do not create the laws, they only abide by them. Each adjuster has different styles as well, so if a worker had a similar claim six years ago and it was accepted, and now the same thing happened and it is denied — find out why. Make sure the adjuster has legal evidence to back up the denial.

 

 

It is possible the claim has not been denied; it could be suspended pending results of investigation or upon receipt of medical records. Whatever the case, call your adjuster and talk to them about it before you start choosing sides on who is right and who is wrong.

 

 

  1. Meet and discuss in person with all parties and counsel.

The best way to decide who is right and who is wrong is to meet up. The employee can come as well, but it is probably best they do not — at least not at this point. But you, as the employer, should go discuss the case in person and roundtable it with all of the involved players.

 

If the case has potential for litigation, get local counsel or the house counsel the carrier uses involved. This way you can all discuss the file in a global aspect, and also plan for the ramifications should certain decisions be made. Going over pros/cons, future exposures, and the costs involved with all of those decisions helps not only you as the employer, but the adjuster as well. This forces him to get deep into the file, discuss monetary values, develop plans of action, etc.

 

 

  1. Find a middle ground for plans of action, if possible.

Just talking about the file and meeting up in person does not mean you will all agree on what to do.  If you are not satisfied with what you are hearing, see if there is a middle ground, or a non-aggressive approach to everyone agrees.  Considers options such as an independent medical examinations (IMEs), nurse case management, or a vocational assessment.

 

After you have compiled all the options, go over the pros, cons and monetary values of each one, then work to choose a strategy. Explore your options, and come out of the meeting with an agreed-upon plan. Not just agreeing to disagree.

 

 

  1. The adjuster knows best.

The adjuster has had medical and legal training, negotiation training, and is up to date with the current law changes and trends. Adjusters also have experience to know which doctors’ opinions are questionable or strong.

 

When push comes to shove, the adjuster and legal counsel likely know best about what option you should be taking. Thorough discussion should bring you to this point, but be sure to understand why they are taking a certain course of action.

 

 

  1. Leave your personal feelings behind.

The hardest part from the employer perspective is not to drag personal feelings into a decision. Whether the injured worker is your favorite employee or your worst hire, you cannot bring personal feelings into your overall decision on the file. You can alert the adjuster to these feelings, but you cannot let it influence your decision.

 

 

In the end, the decision must be fair, and backed by legal precedence. The carrier requires good reason to deny or accept a particular claim.  They understand that the worker may be your friend and you want to do what is best for them, but you cannot force the issue.

 

 

No matter who is injured, when they are injured, or what they were doing when they were injured, personal feelings often develop about why a claim should be accepted or denied. The best way to feel comfortable with the final decision is to understand all of the information through effective communication.

 

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Give Your Work Comp Adjuster A Hand To Achieve Better Outcomes

Adjuster Objectives:

 

Some objectives of every workers compensation claim adjuster should be to:

  • Promptly investigate.

 

  • Monitor medical care.

 

  • Process the workers compensation claim to a timely full disposition.

 

  • Maintain constant dialogue with employee, employer, and all other entities directly connected to the loss.

 

  • Secure any potential recoveries.

 

  • Develop the loss for the best outcome possible.

 

  • Be adequately educated, trained and continually self-educated for continued professional growth.

 

Additional adjuster objectives:

 

  • Clearly compensable claims should be paid promptly at the proper benefit rate, medical care should be the best available, and prompt return to work should be a priority.

 

  • The adjuster should be available to assist the injured employee as needed.

 

  • Good claim work results in minimal disability, good employee relations, and lower claim cost.

 

  • Conversely, claims that are questionable, malingered, fraudulent, or suspect for any reason, require the claim adjuster to be extra determined so that a good investigation and claim preparation can sustain declination and litigation.

 

  • Workers Compensation Claims are always under time guideline and handling pressure. Decisions and actions must be made or done quickly.

 

 

Employer Injury Coordinator & Assisting The Adjuster

 

The adjuster has primary responsibility for successful claim disposition.  However, the adjuster can only be as effective as the information gathered during investigation.  Therefore, every employer should strive to get the full facts, and supporting documentation to the adjuster as soon as possible after the loss occurs.

 

Every employer should have at least one person assigned to establish policy and procedures to implement when an injury occurs.  The person should know and understand all requirements of the workers compensation management program, including the employer and employee responsibilities.

 

One of the biggest responsibilities of the employer injury coordinator is communication with the claim adjuster.  This should be done as necessary, and during acute stages of a claim it may be daily.   As time passes on this claim this should continue on a regular weekly schedule.

 

 

Conclusion:

 

Worker’s Compensation Adjusters need to have good education, training, and the highest objective standards in order to reach proper handling and resolution of claims.  However, they cannot achieve this without proper employer support and interface.

 

Employers who designate an employee to be the workers’ comp injury coordinator to assist the claim adjuster will reap the benefits of better claim handling and cost.

 

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Guidelines To Determine Right Case Load For Your Work Comp Adjuster

When Workers Compensation Claim Adjusters have caseloads that exceed their capacity, experience, or training, the technical handling of the claim file can suffer greatly.  The resulting claim cost can be minimal to astronomical.

 

Problem:

 

An adjuster with a case load that exceeds their capacity, experience, or training can fail at the following:

 

  • Missing diary dates and following through on plans of action.
  • Allowing over payments of both benefits and medical bills.
  • Missing excessive treatments and prolonged disability.
  • Performing cursory investigations that allow the claim to be improperly processed to disposition.
  • Missing subrogation potentials.
  • Poorly documenting the file.
  • Poor reserving practices.
  • Allow subsequent involvement of underlying medical pathologies.
  • Fail to prepare properly for disposition.
  • Miss proper filings with the state that will incur fines and penalty.
  • Missing exaggerated or fraudulent situations.
  • Failing to establish professional rapport with the injured employee.

 

The list goes on…

 

 

Case Handling Guidelines:

 

Adjuster case load studies and independent claim audits generally reached similar conclusions as to what constitutes criteria for proper case work-loads.

 

They have found work should be distributed by level of claim needs, so the answer is not a one size fits all conclusion.  Jurisdictional requirements, adjuster experience, and ancillary support play a large part in determining claim personnel needs.

 

Here are some general guidelines by claim type:

 

Medical Only

 

Most claims only require medical care for short periods of time.  This ranges from 80% to 90% of the injuries sustained, and cases normally close within six months.  With current medical fees, the total cost should not exceed a $25,000 value.

 

There cannot be any lost time from work past waiting periods.  No permanent disability should be paid as a medical only.

 

In most jurisdictions, a medical adjuster can carry a monthly caseload as high as 250 to 300 claims.  (New cases should be assigned against closures.  Closures should be equal to or greater than new assignments.  Monitoring of open files must be a regular task to avoid cases remaining open that should be closed.)

 

A few jurisdictions require state approval before payment is made.   This may limit case count activity.

 

 

Active Lost Time Claims

 

Active lost time claims (indemnity cases) vary from a few days up to multiple years.  The adjuster’s active handling tends to slow within three to nine months, and most settle with minimal or no permanent disabilities.  The indemnity claims usually average between 5% and 8% of reported losses.

 

Depending on the jurisdiction, an experienced adjuster can handle a case load as high as 125 to 200 claims a month, and new cases should be assigned on the closure record. (Monitor that closures are current)

 

 

Fatalities, PTD, Catastrophic, Occupational Disease

 

The last category covers fatalities, permanent total disabilities (PTD), other catastrophic cases, and long term occupational disease that often require reinsurance intervention.  This level of adjuster typically has 10-15 years experience and handles multiple jurisdictions.  This adjuster will have a much lower case load because the claims are more complex.  Once the claim has settled into routine maintenance it can be assigned to a lighter experienced adjuster.

 

 

Summary:

 

The question of how many claims is too many claims for an adjuster does not have a one-size fits all answer.

 

To evaluate whether or not your TPA has assigned too many claims to the adjusters is often a difficult task as the TPA will be reluctant to admit the adjusters have too many files.  You can obtain a general idea as to whether the caseload is too high by reviewing the nature and type of claims, as well as the requirements of your states work comp act.  To know more precisely what the caseload should be, hire an outside, independent claims auditor to complete a Best Practices Audit of the TPA files.  The outside expert can assist you in identifying the issues impacting the claims quality and identifying the appropriate caseload for each adjuster handling your claims.

 

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

20 Things Your Work Comp Adjuster Should NOT DO

Most states have an Unfair Claims Practice Act that outlines what is considered to be unethical behavior by the claims adjusters.  The large majority of adjusters are ethical and have no interest in doing anything inappropriate.

 

Workers compensation adjusters have to deal with more fraud than other insurance lines.  This can cause the adjusters to become cynical about any claim that has a red flag anywhere in the claim process. The temptation to fight fire with fire can become strong, but the adjusters should know better than to get drawn into this trap.  Unfortunately, occasionally the adjuster gets too personally involved in the insurance claim and makes a poor decision.

 

If any of the following actions or behaviors by the dedicated or designated workers compensation adjuster is noted, speak up.  Ask them why they took any of the following actions:

 

 

  • Not contacting the employee (often with the false hope the employee will decide not to pursue a fraudulent claim and just go away)

 

  • Not returning phone calls (again with the false hope the employee will go away)

 

  • Not explaining the indemnity and medical benefits to the employee correctly

 

  • Denying a claim without adequate proof

 

  • Handling a claim with an employee they personally knew prior to the employee’s injury

 

  • Creating / having a personal relationship with an employee during the course of the claim, or after the claim is concluded

 

  • Intentionally not paying unrepresented employees for a permanent impairment rating

 

  • Purposefully under reserving a claim to avoid management review thresholds or reporting thresholds

 

  • Recording telephone conversations without the other person’s knowledge

 

  • Knowingly taking the recorded statement of an employee under the influence of any medication that impairs thinking

 

  • Intentionally not providing a copy of a recorded statement to the employee when requested

 

  • Intentionally not reimbursing mileage expense or other cost paid by the employee

 

  • Making an unrealistically low settlement offer to buy out future medical or indemnity benefits

 

  • Intentionally including incorrect information in the written summary of the claim

 

  • Allowing detrimental information about the employee that is not related to the claim to impact the handling of the claim (for example the employee has been arrested for spousal abuse).

 

  • Contacting an employee they know is represented by an attorney

 

  • Violating the privacy of the employee by sharing personal information about the employee with people without a need to know

 

  • Moonlighting/working for a plaintiff law firm as a second job

 

  • Intentionally misleading claims management or self-insured employers with the intent to get higher than necessary settlement authority (normally just to quickly get rid of the claim)

 

  • Any settlement sharing agreement with the employee or the employee’s attorney

 

 

When asking the adjuster why they did any of the above actions, they will normally state it was oversight (and sometimes it was) and the adjuster will then act to rectify the situation.  One oversight or ethical breach does not make for a bad adjuster, multiple oversights or breaches should result in the adjuster’s termination of employment.  If the adjuster’s employer does not terminate the unethical adjuster, you should terminate the relationship with the adjuster’s employer.

 

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

6 Ways To Maximize Your Work Comp Adjuster Relationship

The best ways to reduce workers’ comp costs is to reduce claim costs. A major factor in the cost of claims is the quality of claims handling provided by the workers compensation adjuster.

 

There are at least six things an employer can do to improve the results the adjuster obtains for you:

 

 

  1. Get Your Own Adjuster

 

Too many employers allow the insurance company or the third party administrator (TPA) to chose their adjuster. If you have more than just a few open workers compensation claims at any one time, you soon to begin to evaluate the effectiveness of adjusters working on your claims. When you know who is the best adjuster or the best two adjusters are, ask the insurer or TPA to assign all your future claims to the adjuster you have selected. Express appreciation for the adjusters not selected, but put some emphasis on why you are requesting a certain adjuster, whether it is better overall results, quality communications or some other reason.

 

 

In the claims office, when an adjuster handles all the claims for a particular client, but also handles claims for other clients, the adjuster is referred to as the designated adjuster. If you have 100 plus claims in one claims office, ask for a dedicated adjuster who handles claims only for your company. Know the difference between these two types of adjusters. The benefits of having either a “designated” adjuster or a “dedicated” adjuster include:

 

  1. Becoming more important to the adjuster as the adjuster knows she/he will be dealing with you frequently.
  2. The adjuster learns what you as the employer considers essential and tailors their work to meet your needs or desires.
  3. The adjuster learns more about your company and knows who to contact with questions or to obtain information, making the claims process flow smoothly.

 

 

2. Create a Partnership

The quickest way to spoil the working relationship with your adjuster is to treat the adjuster as an inferior. Instead of trying to tell the adjuster what to do on the claims, ask the adjuster what would be the best approach for both yourself (the employer) and the adjuster. With your company and the adjuster striving together to move the claim forward, greater progress will be made.

 

 

3. Timely Communication is Key

You do not need to contact the adjuster daily on each file. The best time to contact the adjuster is immediately after you learn some new information the adjuster does not have. This includes everything from calling the adjuster to discuss the details of the accident – which should be done immediately after the employee leaves the accident scene and is going to the doctor – to keeping the adjuster informed about off-work slips. If you learn today that the employee needs a MRI or some other test, notify the adjuster today, not tomorrow or next week.

 

 

Communication goes both ways. Let the adjuster know you expect the same timely communications. If the adjuster receives a surprise letter of representation from a lawyer or a medical report obtaining significant new information, the adjuster should be sharing it with you. If the adjuster knows you expect to be kept in the loop on a timely basis, he/she will do so.

 

 

4. Know What is Needed

In addition to calling the adjuster whenever you have new information, provide the adjuster with all information at your disposal to assist the claim. If the employee is going to be off work longer than the state waiting period, know how many weeks of earnings history are needed, and provide it on the appropriate state form without the adjuster having to ask for it. If the adjuster will need a job description to assist in getting the employee back to work, forward it to the adjuster before the adjuster has to ask for it.

 

 

By providing the information the adjuster needs with the minimal of delay, the adjuster will began to think of you as their favorite client/employer/insured, and the good will results in your files getting the adjuster’s attention first.

 

 

5. A *Real* Return-to-Work Program

Adjusters understand better than anyone the sooner the employee returns to work, the easier it will be to resolve the claim. Plan ahead when you have an employee off work due to an injury. Ask for the return-to-work restrictions immediately after the employee’s first medical visit. If you can accommodate modified duty for the employee, do so. It will make the adjuster appreciate you and your company (and it will save your company a lot of money in the long run). If you cannot accommodate the first set of restrictions placed on the employee, keep in touch with the adjuster and as soon as the medical provider raises the restrictions to a level you can accommodate, do so.

 

 

6. The Magic Words – Please and Thank You

The job of the adjuster is one of the most unappreciated jobs in the universe. If you want to make your adjuster’s day, try a heart-felt thank you when the adjuster investigates the questionable claim, or continues to pursue a modified duty release from the medical provider, or does anything better than it was done before on your claims.  Also, when you do need to make a request, a “Would you please call the employee?” goes a lot further toward getting something done than a command of “Call the employee.”

 

 

The results of taking these approaches – in working with your adjuster – will be workers compensation claims that get settled quickly and cheaply. This will translates into lower workers compensation cost for your company.

 

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

20 Unfair Claim Practices For Your Adjuster To Avoid

The workers compensation adjuster, who is often dealing with attorneys out to maximize the cost of the workers comp claim, or with employee claimants who are attempting to commit fraud, may be tempted to fight fire with fire. The adjuster should always handle the claim in a totally ethical manner.  If an adjuster is doing any of the following, stop everything and discuss the adjuster’s actions with the adjuster.

 

 

Unfair claim practices by the adjuster include:

 

  1. Failing to contact the injured employee (hoping the employee will not pursue the claim)
  2. Failing to investigate the claim properly
  3. Denying compensability without a valid reason
  4. Failing to file all necessary state forms
  5. Recording the employee’s statement when the employee is under the influence of medications or distracted by pain
  6. Failing to provide a copy of a recorded statement or written statement when one is requested
  7. Recording telephone calls without the other party’s knowledge of the call being recorded
  8. Knowingly documenting the file notes with inaccurate information
  9. Intentionally not returning phone calls of the employee or medical provider in an effort to discourage the claim
  10. Failing to pay indemnity benefits timely trying to coerce the employee in to returning to work prematurely
  11. Failing to authorize needed diagnostic testing without reason to not authorize
  12. Paying less than the workers comp statute calls for when settling a permanent partial disability
  13. Offering to settle and close out future benefits for an amount significantly less than what the adjuster knows to be fair
  14. Advising the employee not to hire an attorney
  15. Threatening to reduce the settlement of the claim if the employee hires an attorney
  16. Discussing any aspect of the claim with an employee known to be represented by an attorney
  17. Settling the claim before the extent of disability is known
  18. Overstating the damages and exposures so that the adjuster’s supervisor will extend excessive settlement authority, allowing the adjuster to make a quick (but overpaid) settlement
  19. Providing the employee’s personal information to parties who do not have a legitimate need to know
  20. Having a financial interest in any vendor utilized on the claim

 

 

Mistakes, Oversights, & Poor Claim Handling Are Not Unfair Claims Practices 

 

Mistakes, oversights, and poor claim handling are not unfair claims practices. The workers compensation adjuster often has more work to do than it is possible to get done. With the telephone ringing constantly, the e-mail flooding in, having numerous deadlines for filing forms, numerous deadlines to prepare for mediations or conferences, and numerous other items that need to be completed, it is normal for some things to fall through the cracks. When the adjuster does not contact the injured employee timely, or does not respond to a settlement demand from the employee’s attorney, it is normally because the adjuster has more to do than is possible to get done. It only becomes an unfair claims practice when the adjuster intentionally decides not to take a needed action in an effort to impact the overall outcome of the claim.

 

 

Almost all adjusters are honest and have the best interest of both the employee and the employer at heart. If you do notice any of the above issues occurring, stop and discuss the issue with the adjuster. Often there is an ethical and valid reason for the adjuster’s action which will become apparent when you learn more about the reason for the adjuster‘s actions. Only when the adjuster sets out to act dishonestly should you be greatly concerned.

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Be Thankful For Your Workers’ Comp Adjuster

 

Hello, Michael Stack here with Amaxx, so, it’s the week of Thanksgiving.  It’s really a great holiday, it’s one that I very much enjoy, it’s a nice time to take a break from our daily busy lives and spend some quality time with our friends and our family. And also really marks the official start of the Christmas holiday season, my wife and I have four young kids, so it is really a very fun and exciting time in our household.  But, this year, as you are going for that second helping of mashed potatoes, I want you to think about the individual that gets the least amount of appreciation and the least amount of thanks throughout the year, and that’s your work comp adjuster.

 

I want to talk about the role of the adjuster, because the more you can understand what they are doing on a day-day basis, the more you can appreciate it, and work with them as a valuable part of your team in your work comp management program.

 

 

Understand Your Adjuster’s Tasks

 

So, let’s first talk about the tasks, in general there is going to be about 15-20 tasks that an adjuster is going to be doing on a day-day basis as part of their job description. I want to go over some of the highlights.  The first is the 3 point contact, so within 24 hours of the injury, they are going to be contacting the employee, contacting the supervisor, and contacting the medical provider, so they can get as much information about that claim as possible. They are going to be establishing the reserves, and they are also going to be reviewing compensability, of whether that is a valid claim or not. They are going to be auditing and paying the bills from the various providers, the medical providers, any additional expenses, any vendors they are working with, making sure those are paid, reviewed, and paid on a timely basis.

 

Next thing is they are going to be documenting the claim file, anything that occurs, going to want to make sure that is recorded in the file so that all parties understand what is happening.  And finally, and probably most importantly, is they are going to be communicating with all of the relevant stakeholders, to make sure all parties are involved to continue that claim moving forward. And like I said, there are a lot more tasks that are involved in an adjusters day, but if you look at any one of these six that are on the board here, if one of these balls is dropped, then that claim, and the management of that claim is going to be affected.   So, very high important items, and if you are managing 150-200 claims at one time, putting priority on every one of the those, and managing them properly is a very difficult thing to do.

 

 

Coordinate & Resolve Conflicts

 

Next piece in addition to tasks, is they really coordinate, and they resolve conflicts. So, if you think about all the parties that are involved in a claim, there are a number of them. There is the employee, employer, medical providers, legal, and there are a host of vendors that may or may not be working on the case.  Every single claim…every single claim, has conflict, it is going to be either between the employee and employer, maybe the employer and the medical provider, maybe it’s the plaintiff attorney and the defense attorney, maybe it’s an issue with one of the vendors that are working on the case, but every single claim is going to have some form of conflict, it’s just the nature of the beast.

 

So, that adjuster needs to be working to coordinate all of different stakeholders that are involved in this claim, and resolve that conflict in order to keep that claim moving forward; certainly not an easy task, but a very important part of effective claims management, is working with all of those providers, and making sure that conflict is resolved in a timely basis.

 

 

 

Workload

 

Ok, so last piece here is workload.  And this piece is often only spoken about and evaluated in regards to a hard number.  How many claims an adjuster is handling at any one given time.  But, I want to encourage you to evaluate workload, not so much on hard number, but more based on performance.  So, that workload number can be such a variable based on a whole host of factors; certainly the experience of the adjuster, and the jurisdiction that adjuster is in as being two main components.  An adjuster with 20-30 years experience is certainly going to be able to handle a larger workload, and more complicated cases than a brand new adjuster.

 

And the only way to really evaluate what the appropriate workload is for that individual adjuster is to evaluate them based on performance.  How well are they completing those tasks that we talked about earlier?  Are they paying bills timely, are they completing their 3 point contact, are they doing a thorough investigation to determine compensability, are they hitting those claims management best practices?  And if they are, it’s possible to increase their workload.  But a caution, overloading an adjuster is one of the easiest ways to ensure that you are going to be paying too much for your work comp claims, so many negative things can happen, those tasks really start to slip, the bills don’t get paid timely, the communication starts to slip, people start to get frustrated, start to get angry.

 

And here is the second thing that happens, with an overloaded adjuster, as a defense mechanism, they are going to purposely keep your claim open longer to ensure that they are not being assigned new claims. It is simply a defense mechanism to make sure they can catch up with the work that they have going on.  So, ensuring that your adjuster is not overloaded, is a way to ensure that they are going to continue to hit those claims management best practices.

 

 

Dedicated / Designated Adjuster

 

Final tip here in regards to working with your adjuster, consider working with either a dedicated or a designated adjuster, so that you have the same individual, or group of individuals that are handling all of your claims; you can get to know them, they can get to know you, and you can really work with them as a valuable part of your team.

 

So, remember, in workers comp, your success is based on your integrity…and your thankfulness.  Happy Thanksgiving, be great!

 

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2015 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Dedicated Adjuster Is Key Team Member To Cut Work Comp Costs

Employers who accept any adjuster the insurance company or the third party administrator (TPA) assigns to their workers’ compensation claims pay higher insurance premiums than employers who have assigned dedicated adjusters to their account.

 

Randomly assigned adjusters have higher claim payments then dedicated adjusters, resulting in a higher severity level when the underwriter calculates the workers’ compensation insurance premium for the next policy period. This occurs even if the overall level of experience and understanding of workers’ compensation is the same for randomly assigned adjusters and dedicated adjusters.

 

 

There are four principal reasons for randomly assigned adjusters having poorer claim handling results.  They are:

 

  1. The randomly assigned adjuster does not know your claim handling preferences (and probably won’t take the time to read pages and pages of client specific claim handling instructions)
  2. The randomly assigned adjuster is not familiar with your company, does not know who to contact for what, and does not know your overall claim philosophy
  3. The randomly assigned adjuster is not familiar with your preferred medical providers, your medical triage program or your medical management program
  4. The randomly assigned adjuster does not know the details of your return to work program or types of light duty/transitional duty work your company can offer.

 

Dedicated adjusters – adjusters who handle workers’ compensation claims exclusively for one employer – are the best bet for employers who have enough claims to keep one or more adjusters busy full time.  Designated adjusters – adjusters who handle all the claims for one employer but also handle claims for other employers – are the best option for employers who do not have enough claims to keep one adjuster busy full time.

 

 

The benefits to the employer of having a dedicated adjuster (or a designated adjuster if the claim volume is too low for a dedicated adjuster) include:

 

  • Lower overall claim cost as the adjuster knows the employer’s requirements
  • The adjuster and the employer establish a closer working relationship
  • The adjuster develops a sense of loyalty and dedication to the employer
  • The adjuster becomes more proficient as the adjuster learns what the employer prefers in various situations and does not spend time finding out what the employer prefers or wants
  • The employer know exactly who to contact to discuss the details of any claim
  • The adjuster learns the nuances and preferences of the employer’s workers compensation program
  • The adjuster will know exactly how the employer’s medical management program is structured and how it works
  • The adjuster will know the internal details of the employer’s return to work program

 

The jurisdiction is a major factor in where you will need a dedicated adjuster or a designated adjuster.  The number of workers’ compensation claims an adjuster can handle will vary from state to state.  A workers’ compensation adjuster handling claims under the highly complex laws of California has a full case load with 100 indemnity claims.  An adjuster in a less complex and less litigated state may be able to handle 125 to 160 claims at a time.

 

 

Adjuster Case Load Important Factor

 

Often the number of workers’ compensation claims an employer has does not work out to a precise number of dedicated adjusters. This often results in an X number of dedicated adjusters, plus one designated adjuster to handle the odd number of extra claims.  For instance, your company has 300 open work comp claims and 125 claims is a full case load for an adjuster.  The insurer or TPA should assign two dedicated adjusters who handle 250 claims (125 X 2) and one designated adjuster who handles the remaining 50 claims.

 

If your workforce is large enough to produce a full case load for an adjuster, you should ask nicely (compel if necessary) for your insurer or TPA to assign all your future workers’ compensation claims to the designated adjuster(s) who will eventually grow into a dedicated adjuster position.

 

Insurers and TPAs will sometimes balk at the idea of dedicated adjusters due to their own business reasons.  The volume of claims in the claims office fluctuates.  Having dedicated adjusters removes the ability of the claims office to assign additional claims (from other employers) to your dedicated adjuster(s).  If the overall claims volume for the office decreases sharply, it is much more difficult for the claims office to terminate a dedicated adjuster (and damage their relationship with a major client) than it is to terminate an adjuster who handles claims for many different employers.

 

Once the employer has the dedicated or designated adjuster(s) in place, the employer needs to be vigilant against the insurer or TPA overloading the adjuster with too many claims.  The tendency is to assign all your claims to the dedicated adjuster(s) without watching the case load assigned to your adjusters.  The employer should track the monthly case load of each dedicated adjuster to be sure they don’t become overloaded. If the dedicated adjuster(s) on your account have a full load, additional claims should be assigned to the one designated adjuster in the claims office.

 

 

Downside is Replacing Productive Adjuster

 

The downside to a dedicated or designated adjuster is the replacement of the adjuster if the adjuster leaves the insurer or TPA, or if the adjuster is promoted to another position with the insurer or TPA.  Employers should let their dedicated adjuster(s) know how important they are to the employer’s program.  Words of appreciation and accolades should be shared with the adjuster’s supervisor and manager as well.

 

Overall, the use of dedicated adjuster(s) and a designated adjuster for excess claim volume is an excellent way for employers to influence their overall claim cost.  If your insurer or TPA does not already have dedicated adjuster(s) and/or a designated adjuster handling your workers’ compensation claims, we recommend you arrange with your insurer or TPA to do so.

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a monthly basis working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2015 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

4 Adjuster Tips To Deal With Change In Account Contact

Most of the time we focus on the adjuster moving from carrier to carrier or from one position to another.  Perhaps the adjuster moves from one account to the next one, changing teams at a TPA, adding jurisdictions, and so on.  After all this is commonplace within the claims community.  Rarely do you see an adjuster stay at one particular carrier for their entire career.

 

Lots of articles focus on the transition from the adjuster to the new surroundings, catching up on claims, and trying to fit in their new environment.  Each carrier has their own way of doing things, and this may or may not be the same for the adjuster when compared to the positon they just left.

 

 

Contact Change At Insured Can Be Huge Issue

 

There are also many times where the adjuster stays on the same account, but the insured’s work comp contact changes.  This change on the account side can become a huge issue—very similar to the adjuster change.

 

If you view this from the adjuster’s standpoint, a change in the account contact spells out pending doom.  That easy-going rapport you had established with your insured account is now gone.  Months if not years grooming a relationship, working through comp battles, dealing with the ups and down of claims, celebrating settlements and victories, all gone.

 

In comes the new person.  This person may run a tighter ship.  They may not be as casual in their email correspondence.  They may not like talking on the phone.  But you share the same goal: reduced work comp exposure and resolved claims.

 

Someone may think this relationship is not that important, but I think it is naïve to gloss over the interactions between adjuster and account.  That partnership can save a company hundreds of thousands of dollars, potentially in to the millions over the course of doing business, particularly if you have a TPA or are self-insured/self-administered.

 

Here are tips for adjusters to consider:

 

  1. Give the new person at your account some space. Resist the urge to bombard them with claim details and your life story. They are starting a new job and have orientation, training, etc.  Think of your own adventures starting a new job, there are plenty of tasks those first two weeks!!

 

  1. Sometime in the first 10 days call the main office number and obtain their email address then email over a short hello and your contact info, and advice of the role you have in their work comp program. It is a nice gesture is copy in the broker to show your hospitality.

 

  1. Within the first month, offer to set up an open-claims review, so you both can go over anything pressing or needing attention within the next 30 days. Again a good idea is to copy in the account broker, and invite them to come so everyone can sit down.  It is optimal to have the claim review in-person, either at the account or at the carrier, but telephonic or a Webinar will work if need be.  This meeting will help you explain the role everyone has, expectations of the program, and also open claim and the action plan of resolving those claims.  Remember the adjuster has no idea how the new person handles work comp, if they care about it, or if they have any work comp experience at all.  The new account contact could be a 21-year-old college grad with zero experience.  Even if this is the case, a sit down must be done, and roles/expectations have to be laid out.

 

  1. After 3-4 months have another meeting with the account and broker and iron out any issues now that you have worked some clams together. This is not the time to hide the fact that the adjuster has been doing everything and the account is no longer accommodating light duty.

 

Take the above in to consideration when new names and faces arise on the account end, or on the carrier.  A claims adjuster knows they have big boots to fill if they replaced the adjuster you had on your account for the last 5-7 years.  It comes down to communication; the roles have to be explained and defined, and it has to be reviewed at least a few times during that initial break-in period.  Before you know it, the work comp team will be firing on all cylinders again.

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, and founder of COMPClub an interactive training program teaching workers’ comp cost containment best practices.  Through this platform he is in the trenches on a monthly basis with risk managers, brokers, consultants, attorney’s, and adjusters teaching timeless workers’ comp cost containment strategies, as well as working with members to develop new tactics and systems to address the issues facing organizations today. This unique position allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

©2015 Amaxx LLC. All rights reserved under International Copyright Law.

 

Employers/Carriers/TPAs/Brokers/Vendors looking for additional information FREE resources for Workers Comp cost containment best practices are invited to access Amaxx Workers’ Comp Cost Containment Essentials training series

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Professional Development Resource

Learn How to Reduce Workers Comp Costs 20% to 50%"Workers Compensation Management Program: Reduce Costs 20% to 50%"
Lower your workers compensation expense by using the
guidebook from Advisen and the Workers Comp Resource Center.
Perfect for promotional distribution by brokers and agents!
Learn More

Please don't print this Website

Unnecessary printing not only means unnecessary cost of paper and inks, but also avoidable environmental impact on producing and shipping these supplies. Reducing printing can make a small but a significant impact.

Instead use the PDF download option, provided on the page you tried to print.

Powered by "Unprintable Blog" for Wordpress - www.greencp.de