9 Steps to Get the Best Out of Your Workers’ Comp Adjuster

Having a great claims adjuster can be invaluable. Claims are processed smoothly, timely, and satisfactorily.

 

But getting the ideal adjuster is not always possible, and employers often blame adjusters when things don’t go as efficiently as they could. Should you seek a different adjuster, or just accept that you’re stuck with a dud? Actually, you may be able to avoid both. By taking a step back to gain some insight into the adjuster’s world and using a few simple strategies, you may be able to turn things around.

 

 

Set Realistic Expectations

 

The adjuster’s role is the fair and reasonable settlement of claims. First step is to figure out what that means to you and how it fits in with your company’s claims handling plan. Setting up expectations is important. If there are no clear directions or goals, you really can’t blame the adjuster for failing to meet your expectations.

 

For example, do you want the adjuster to be in constant contact with you, or do you want communication only when absolutely necessary? You need to determine that and let the adjuster know.

 

If you expect the adjuster to resolve claims within a certain period of time, are you doing all you can to facilitate that? How soon are injuries reported? Is that on a consistent basis? Do you have a timeframe for when and how investigations are performed?

 

Other factors can also affect the resolution of claims. Not having a return-to-work program or light duty/transitional work can make more work for the adjuster, along with the lack of a fraud prevention program. Make sure your actions and goals are in line with your expectations of your adjuster.

 

 

Understand the Adjuster

 

It can be upsetting when the adjuster doesn’t get back to you when you think he should, or denies treatment on a claim with no explanation or approves a questionable claim. But seeing things from the adjuster’s standpoint can help.

 

Instead of lambasting the adjuster, consider what is happening on his end. Being an adjuster can be a thankless job;

 

  • There are constant questions, emails and phone calls, often from disgruntled employees, employers or others.
  • His caseload may be overwhelming.
  • There are constant deadlines that may or may not be achievable.
  • The turnover for the profession is such that his office may be understaffed at any given time.
  • While you might be easy to work with, others may not be.

 

You can find out what’s going on by talking with the adjuster.

 

Build a Relationship

 

Developing a bond with the adjuster can go a long way toward having a better connection with him. Working better with the adjuster can involve a few simple steps:

 

  1. Pay him a visit. A ‘chairside visit’ is a great way to establish a good relationship with an adjuster. For this informal meeting, you literally sit at his desk to understand the demands of his day. You can also take the opportunity to learn how he handles claims; the intake process, medical-only and lost-time claims, and catastrophic claims.

 

  1. Get to know him on a personal level. While you don’t need to be best friends, you can find out a little about him — his home life, kids, hobbies, etc.

 

  1. Realize he is the expert. Even if you don’t like the way he’s handling a claim show him respect. That said, find out his expertise level. If he’s new to the profession, he’s probably not the right person to handle complex claims. On the other hand, a highly experienced adjuster might be bored handling simple, medical only claims.

 

  1. Ask questions. There may be good reasons for the way he’s handled certain aspects of a claim. Don’t just get angry, find out why. Ask open-ended questions that are not accusatory. Putting him on the defensive won’t help your relationship, and it likely won’t get you answers.

 

  1. Give praise when warranted. If the adjuster does a particularly good job with a claim, tell him so. He’s probably much more used to hearing negative comments than true appreciation. Doing so will make things much easier when you later have concerns about a claim.
  2. Listen to what he says. You may have ideas to solve some of the challenges he’s facing.

 

  1. Offer to help. There may be things you can do that would help him expedite the claims process.

 

 

Conclusion

 

If you’re having problems with your adjuster, first look at your own program. Having an organized plan for claims handling and relaying that sets up realistic expectations.

 

Then, work with the adjuster. Develop a bond so you can easily find out the reasons for any problems and set up strategies to avoid future challenges.

 

 

 

Michael Stack - AmaxxAuthor Michael Stack, Principal, 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 & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

 

©2017 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.

8 Part Email To Send When Transitional Duty Doesn’t Work

8 Part Email to Send When Transitional Duty Doesn't WorkDespite your best efforts to get medical restrictions from all treating physicians and evaluate your employee on a weekly basis, there are times when the medical provider says the injured employee can do more than s/he thinks s/he can.

 

  • For example, a bus driver injured his right arm in a work-related accident. The doctor finds the muscles and bones have mostly healed and the patient should no longer be feeling pain and may return to work for four, rather than an eight-hour day.
  • But in your weekly reviews, the employee complains that opening the bus door is still so painful he cannot drive home at the end of the day.

 

In this situation, write an email from the injury coordinator to the adjustor asking if a functional capacity evaluation (FCE) may be needed. Also, consider options for alternate work for a while longer.

 

 

8 Part Email To Send When Transitional Duty Doesn’t Work

 

  1. Be sure to include claim number and all relevant addresses and contact information on the letter.
  2. Include the supervisor in any discussions.
  3. Clearly explain the situation: who is injured, what the injury is, what the current complaint is and what the physician says the worker should be able to do
  4. Explain the company’s medical advisor reviewed the reports and the employee’s complaints do not mesh with the current medical diagnosis.
  5. Acknowledge the pain could be imagined (but without judgment) or the result of the employee being fearful of additional injury. Be aware that the pain might be very real also, and don’t minimize the likelihood of this possibility. Anyone who has ever had repetitive arm injury knows how painful it can be and often even a small amount of use can trigger painful symptoms.
  6. Ask your adjustor if an (FCE) is needed and, depending on results, perhaps an off-site work hardening program is in order.  In work-hardening the employee is allowed to build up to his regular job capacity in a supervised setting, removing the fear of re-injury.
  7. Ask the adjustor for suggestions of work-hardening centers in the area.
  8. Acknowledge the difficulty of this claim and ask the adjustor for a timely response.

 

Real or imagined, pain while doing one’s job benefits neither the company nor the employee. There are programs designed to help your employee work through these issues.

Vigilant attention to the employee will ease this process.

 

 

 

Author Michael Stack, Principal, 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 & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

 

©2017 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 Elements To Review In Your Adjuster’s Action Plan

Workers' comp Plan of ActionThe old adage “Time is Money” definitely applies to the handling of workers’ compensation claims.   Experienced claim professionals know the longer a work comp claim remains open, the higher the overall cost to conclude the claim. Every delay along the path from the start of the work comp claim to its conclusion costs your self-insured program or your insurer money (eventually coming back to your company as higher work comp insurance premiums).

 

Here are some tips and suggestions on ways that you, the employer, can speed up the processing of your workers’ comp claims.

 

 

Pre-Accident Training

 

Every employee needs to know what to do in the case of a work comp injury. Your company needs to set the stage for your involvement in the work comp claim process from the very beginning.

 

Your new hire package must include instructions on the proper and timely reporting of the work comp injury. The accident reporting instructions must specify that the injury must be reported immediately, to whom the employee reports an injury, who are the approved medical treatment providers (in the jurisdictions where this is permitted) and information informing the employee of the return-to-work program your company uses.

 

Display, where all employees can see them, posters and/or billboards clearly showing these requirements, including the importance of immediately reporting the work comp injury. Be sure to post these materials in the employees’ prime languages in addition to English.

 

Remind supervisors and managers on a regular basis that all work comp injuries are to be immediately reported to your work comp claims coordinator. The supervisors and managers should be familiar with the information required to complete the First Report of Injury form required in their state.

 

 

Prompt Reporting

 

When the work comp claims coordinator receives the information about the new work comp injury, the claims coordinator immediately reports it to the claims handling office. If for any reason the claims coordinator does not have all the information necessary, the claim is still reported to the claims office with a note indicating the rest of the information will be forthcoming as soon as it is available. This allows the work comp claims adjuster to go ahead and get started on the claim.

 

 

Claim Service Standards

 

When your company starts an insurance program, the insurer or third party administrator (TPA) should provide you with information on their claim handling service standards. Those service standards usually specify within how many hours the adjuster will contact the employee once the claim is reported to the claims office. Great service standards specify the employee will be contacted within 2 (or 4) hours, while good service standards specify the employee will be contacted within 24 hours. If the service standards are silent on how fast the work comp adjuster will be in contact with the employee, ask them to make the 2-hour contact with the employee a claim-handling requirement on your files. If the insurer or TPA is reluctant to require prompt contact with the injured employee, it is time to get another insurer or TPA.

 

 

Employee Follow-up

 

When employees are injured, they are concerned about their future with your company, their future income and their ability to care for their families. When the employee’s supervisor or your company’s work comp claims coordinator contacts the employee shortly after the accident, the employee knows and feels s/he is valuable to the company.

 

When the employee initially reports the claim to the employer, the employee is instructed to keep the employer informed of medical treatment and medical progress. Emphasize the employee can expect to hear from the employer if the employee does not provide timely updates to your company.

 

Keeping in contact with injured employees lets the employees know the employer cares about them and their well-being. Employees who feel valued by their company are less likely to malinger off work when they could return to work, or hire an attorney.

 

For employees who are off work for an extended period of time, the claims coordinator should be contacting them on at least a monthly basis to inquire about their condition, their treatment and their expected return-to-work date.

 

 

Medical Follow-Up

 

In the majority of states the employer is allowed to contact medical providers in regards to when the employee is medically able to return to work. Regular follow up with medical providers reinforces the importance of the employee returning to work.

 

 

Return to Work Program

 

Employees should know the expectation is they will return to work as soon as medically able. Often an employee is willing to return to work, but the treating physician is concerned that the employee may be re-injure by attempting to return to work before full recovery from the accident.   Or, the employee is afraid to return to work because of concerns for his/her own safety. To protect themselves from malpractice claims, doctors often keep employees off work longer than is necessary.

 

The best way to alleviate both the fears of the employee and the fears of the doctor is to have a modified duty return-to-work program available to accommodate the employee. A modified program allows them to return to work before they are 100% recovered from their injury. The return-to-work program is structured to remove from the employee’s regular routine the activities the doctor feels could possibly cause the employee to be re-injures, whether it is a lifting restriction, standing restriction, bending restriction, etc.

 

The sooner the employee is back on the job, the sooner the employee fully recovers from the injury. A modified duty program provides the employee with physical reconditioning for the work they will be doing when the job restrictions are lifted by the treating physician.

 

The return-to-work program has a major impact on the amount of temporary total indemnity benefits are paid to the employee, reducing your overall work comp cost. Plus, when the treating physician states the employee has reached the maximum medical improvement, the employee who is back to work will normally receive a lower permanency rating then the employee who is still off work. The lower permanency rating also translates into lower work comp cost for your company.

 

 

Summary

 

Follow the proper steps throughout the work comp claim process from before the accident occurs, to when the employee returns to work. The time saved translates into savings for the employer through lower workers’ compensation cost and improved productivity by the employee being back on the job sooner.

 

 

Author Michael Stack, Principal, 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 & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

 

©2017 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.

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.

 

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