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.

Communication From Adjuster When Denying Claim Is Critical

Communication has always been the key aspect in dealing the claims.  There is a direct correlation between lack of communication and a claim outcome.  The less the communication and involvement the injured worker has, the worse and more expensive a claim is to resolve.

 

For the adjuster, this can be a tricky part of the claim.  Especially if the claim early on is looking like it is not going to be compensable.  Should this be the case, what do you share with the injured worker?  After all, you do not want to give them a blueprint of exactly how and why their claim was denied, so once they return to work they claim another injury but instead this time they listened to your advice and now you are backed in to a corner that you created.

 

 

Use Clarity and Facts When Discussing Claim With Claimant

 

In my opinion, the answer is to use clarity.  Adjusters are not here to trick anyone; the case is what it is.  However, the adjuster must also take the time to explain how and why said claim is not compensable.  You accomplish this with medical and legal evidence.  Take the time to go over the claim with the claimant. 

 

For the most part, 90% of claims are compensable.  However the 10% that are not need to be handled with care.  Failure to do so increases the likelihood of costly litigation, and that could result in a claim being around for many months to years.

 

I have seen many claims result in unnecessary litigation due to a breakdown of communication, and I blame some of this on the adjuster.  Once the denial is filed and mailed to the employee, it is like the claim never existed in the first place.  Of course the claimant will call to inquire why their claim was denied.  This uncomfortable conversation is part of the job.  The adjuster has to answer the call, be patient, and explain themselves and the basis behind the denial.  I believe some adjusters forget that the injured worker typically knows nothing about claims, nothing about the jurisdictional statutes, and even less about medical evidence. 

 

 

Communication Critical When Claim Denied By “Insurance Company’s Doctor”

 

Even worse is when a claim has been accepted, and then denied by an Independent Medical Exam (IME).  For all the worker knows, all was going fine and they were failing to get better.  Then the claimant went to the “insurance company’s doctor” and all of the sudden the brakes were put on and now they are faced with an unknown future.  Again, if the adjuster failed to communicate with the claimant, you can expect some litigation to be coming in the near future.  I notice in some files it appears that the IME was never even sent to the employee!  Why would the adjuster hide the IME report from the patient it was completed on?  This makes no sense at all.

 

To be a really great claims adjuster, you have to put yourself in the shoe of the injured worker.  The adjuster has several interactions with the injured party, and they can tell right off the bat how “savvy” this worker could be.  With the wonders of the internet, injured workers are becoming more and more involved in the research and treatment options for their injury.  Of course, this is a good and a bad thing.  Their simple back strain all of the sudden morphs into a disaster because they are Googling “Back pain” and are confronted with surgical pictures and the complications of recovering after a lumbar fusion surgery.

 

The adjuster has to remember that this worker does not have their same training and expertise. The claimant has not handled hundreds of back strain claims, and this may be the first work comp claim they have ever had.  Some compassion goes a long way in this industry, and empathy for the injured worker can really make the difference.

 

 

Involve The Injured Worker In The Process

 

Involve the injured worker in the process.  Take the time to explain to them what the medical reports are showing, why an IME is needed, and what options the future could hold.  Explain to them the role of the nurse case manager, and why they are on the case.  Explain to the claimant why you need past medical records, why the surgery is not being approved, and what options the worker has in case their claim is denied. 

 

The claims adjuster has to consider the injured worker, what their issues and concerns are, and they have to communicate properly and effectively.  Sure, some injured workers are going to require a lot more effort and a lot more phone calls than others, but this is part of the job.  Each claimant has to be treated fairly, ethically, and with the utmost respect.  If your adjuster that handles your files fails to do so, then it may be time to get someone new on your cases. 

 

Imagine if that were your wife or husband with the claim and the injury, not knowing what is going on or what the future holds.  The adjuster is not returning your phone calls, or answering your questions.  Would you consider that acceptable and proper treatment?

 

 

Author Michael B. Stack, Principal, COMPClub, Amaxx Work Comp Solutions. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  He is co-author of the #1 selling book on cost containment, Your Ultimate Guide To Mastering Workers Comp Costs www.reduceyourworkerscomp.com, and Founder of the interactive Workers’ Comp Training platform COMPClub. Contact: mstack@reduceyourworkerscomp.com

 

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

 

SALES TO PAY FOR ACCIDENTS CALCULATOR:  http://reduceyourworkerscomp.com/sales-to-pay-for-accidents-calculator/

MODIFIED DUTY CALCULATOR:   http://reduceyourworkerscomp.com/transitional-duty-cost-calculators/

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

WORKERS’ COMP TRAINING: https://workerscompclub.com

 

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

 

Read Adjuster’s File Notes To Understand Your Work Comp Claim

To know what is occurring on your company’s workers’ compensation claims, read the adjuster’s file.  Self-insured employers should include in their claims handling contract with the third party administrator the right to full on-line access to the adjusters’ files on a read-only basis.  Employers who have insurance with a standard workers’ compensation insurer can ask for read-only access to the adjuster’s files.  Some insurers will oblige while other insurers who are less confident about their adjuster’s work product will decline (they will give you a different reason for declining).  Both third party administrators and insurers will limit your claim file reading to the claims of your employees only.

 

 

Adjuster’s File Notes Contains Key to Understanding Claim

 

While the medical reports and lawyer reports can make for interesting reading, to maximize the value obtained from reading the adjuster’s file, focus your attention on the adjuster’s file notes.  Properly documented file notes will contain a synopsis of each phone call, each email and all correspondence received.  The standard method of entering this information is in the chronological order it was received.  The objective of the file notes is to give anyone who reads the file notes an understanding of the claim development and claim status.

 

The better claim management systems also require the adjuster to categorize any file note.  The most common categories will be employee contact, employer contact, medical provider contact, lawyer contact, reserves, medical reports and lawyer reports.  There are many other categories that will be used less frequently like subrogation, surveillance, state report filings and drug screen results.  The best claim management systems allow you to search the file notes by category, for instance: documentation of each employee contact.

 

When you read the adjuster’s file notes, you will find them to be a journal-style record of contacts, document reviews and future claim handling plans.  The adjuster file notes will also contain files notes entered by the adjuster’s supervisor and claims manager, claim support staff and nurse case managers (if the nurses are employees of the third party administrator or insurer).  The file notes entered by other employees benefit you as a reader of the file notes by giving you a more complete picture of what is going on, on the claim.

 

 

Adjuster Diary Documents Future Follow Up

 

In addition to file notes, the adjuster file should contain documentation of their diary system.  (“Diary” is simply placing an activity on their computer calendar for future follow up).   The diary should include a brief note with the date of follow-up.  The diary note will usually read something like:  “Call employee after doctor’s appointment” or “Confirm medical report received” or “Verify employee RTW (returned to work)”.  Normally diary length is set in 15 day, 30 day and 60 day increments, but precise date diary (for example: date of hearing) can be used.

 

The first group of file notes (remember they are in chronological order) will document the adjuster’s initial investigation of the claim.  This includes a discussion of the initial contact with the injured employee, the initial contact with the employer and the initial contact with the medical provider.  The adjuster should be documenting any issues relating to the claim including questions of compensability, subrogation, fraud, prior medical conditions and return to work capability.

 

 

Understand Compensability, Subrogation, Reserves, & Action Plan

 

The file note in regards to compensability should provide a reason the claim is compensable or a reason the claim is not compensable.  Examples:  “Claim compensable as the employee was performing standard work duties when the incident occurred”, or “drug screening showed employee was intoxicated at time of the injury and the injury occurred due to the employee’s intoxication”.

 

File notes for each note category should be precise and address the subject of the file note category.   Examples:  Subrogation – “No subrogation as no third party involvement in injury”;  Surveillance – “Assigned to PI Investigators to confirm employee’s physical capabilities”;  Return to Work:  “Employer unable to accommodate employee’s 5 pound lifting restriction, but will be able to provide light duty work when lifting restriction is raised to 20 pounds”.

 

The file notes for reserving are often limited to “See reserve worksheet”.  However, if the reasoning for a reserve change is simple, the reserve change should be explained in the file notes.

 

Action Plan file notes are often combined with the adjuster’s diary.  The action plan file note should include adjuster’s goals on the claim file and the steps the adjuster is going to take to advance the claim forward.  The action plan file note should explained the plan course of action and what the adjuster is going to do to accomplish the claim handling plan.  [This is an excellent place to look to see if the adjuster is really on top of the claim, or is just going through the motions.  When an adjuster is top of the claim, the adjuster’s action plan files notes will be specific as to what is needed.  The vaguer the action plan file notes, the less the adjuster understand the claim he/she is handling.]

 

 

Review Select Files On a Regular Basis

 

Reality is employers do not have the time to read every file note on every workers’ compensation claim.  We would recommend selective reading of the claims where the injuries are severe; where there are concerns about fraud; where there are return to work issues; and any other claims you have questions about.

 

 

Author Michael B. Stack, Principal, COMPClub, Amaxx Work Comp Solutions. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  He is co-author of the #1 selling book on cost containment, Your Ultimate Guide To Mastering Workers Comp Costs www.reduceyourworkerscomp.com, and Founder of the interactive Workers’ Comp Training platform COMPClub. Contact: mstack@reduceyourworkerscomp.com

 

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

 

SALES TO PAY FOR ACCIDENTS CALCULATOR:  http://reduceyourworkerscomp.com/sales-to-pay-for-accidents-calculator/

MODIFIED DUTY CALCULATOR:   http://reduceyourworkerscomp.com/transitional-duty-cost-calculators/

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

WORKERS’ COMP TRAINING: https://workerscompclub.com

 

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

 

Have All The Right Information Before Changing Your TPA

Rash decisions in the business world can be a significant expense. Not only can it be an expensive decision when changing out an insurer or third-party administrator (TPA), but it can lead to questions from both employees and clients.

 

So, how do you best go about building a firm, long-term relationship between your business and your present claims administrator?

 

The simple way to go about that is by:

 

  • Hiring a competent TPA to begin with
  • Making sure all necessary information is provided to the TPA when asked for
  • Asking questions of your TPA and keeping an open line of communication

 

In order to best decrease your workers compensation expenses, make sure you put together a formidable relationship from day one.

 

As an example, a risk manager we worked with was ready to fire their TPA as he felt they were over-utilizing Nurse Case Management and it was too costly.  We encouraged him to visit the TPA to get a better understanding of how claims were handled.  After visiting with the adjusters, he learned he was receiving nurse expertise on nearly every claim for no charge, and when nurse case management was used it was saving him a great deal of money. There is no substitute for first-hand knowledge of your claims handling process.

 

 

Building a Constructive Relationship

 

  • Begin by building a better relationship in becoming more informed regarding the services your claims administrator offers. Host a Vendor Day, and invite your TPA in with every one of their services – miss out on none. Ask for samples of reports and deliverables so you can better appreciate the product and will know when to request services. Have them provide brochures before Vendor Day, and read the brochures so you can ask worthwhile questions during about the services;
  • Visit one or two claims offices and take in the process. Educate yourself on the categories of desks at your carrier, for example, what is the level of adjusters? Do adjusters have backup and clerical assistance to retrieve medical files or close files? Sit at the intake desk, and then join the lost time and medical adjusters for a short time at their desks. Look to see what takes place with medical bills when they enter the system until the time they are paid and filed. This will help you better appreciate how you can interact more effectively, what information adjusters need from you and what information you can offer regarding your workplace and employees;
  • Lastly, invite your adjusters to come to your workplace, thereby letting them see what your business does, the kinds of jobs and skills necessary of the employees. They can then see exactly how an injury occurred better than if they’d never been to your work place. They can also view the possible transitional duty tasks, and maybe come up with a few more.

 

 

Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  He is co-author of the #1 selling book on cost containment, Your Ultimate Guide To Mastering Workers Comp Costs www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.

 

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

 

SALES TO PAY FOR ACCIDENTS CALCULATOR:  http://reduceyourworkerscomp.com/sales-to-pay-for-accidents-calculator/

MODIFIED DUTY CALCULATOR:   http://reduceyourworkerscomp.com/transitional-duty-cost-calculators/

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

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

 

 

Employers Critical Role In Work Comp Claims Handling

More and more employers are developing workers compensation claim handling instructions to claim units and adjusters.  This is especially true where adjusters and claim departments have fallen short in following best practices of claim handling.

 

High profile or serious injury cases are usually investigated and documented very well.  On the other hand, day to day claims are often left lacking in some form or step of the claim handling process.  As a result, when the everyday claim develops into a major issue, it is often too late to gather information that might have prevented the higher value from occurring.

 

 

Example for Need of Employer Intervention:

 

A classic example is:  Employee has onset of back pain while lifting an object at work.  The employee continues to work a few days.  Several days later lost time begins.  Initial diagnosis is strain of lumbar area.  The doctor attributes it to the lifting at work.  The employer confirms the pain started on the job because that is what the employee presented as fact. The doctor gives a sprain diagnosis.   On the surface for the routine handling claim technician, all these items appear to point to a compensable injury that should be of short duration.  The case is accepted.  Benefits and treatment are started.

 

As soon as the lost time was reported, the adjuster failed the first duty by not taking a statement from the employee.  The statement should have clarified the mechanics of the incident.  There was no employee interview for past injuries, underlying pathologies, possible subrogation or even fraud. (Especially if this was an early Monday Morning history).

 

No independent medical examination was arranged to determine causal relationship, future course of medical care and expected disabilities.   Meanwhile the attending doctor continues with conservative office visits and medications.  A Medical Authorization was not obtained and no medical background investigation was done.

 

All of the above handling generally takes place within the first five to six weeks after the injury.

 

About the seventh or eighth week the attending Doctor asks for permission to do an MRI.  Several more weeks may go by until the results reach the adjuster.  It is discovered that there were prior back problems with ruptured discs and maybe even surgery.  Future disabilities and extended treatment are now paramount.

 

The adjuster scrambles to obtain an Independent Medical Examination.  It returns an opinion that the problem was not caused by the lifting incident alone.  A petition is filed by the adjuster raising the issue of causal relationship.  However, the compensation judge, having no other facts or evidence to weigh, continues the case as compensable and the employer is now forced to accept full responsibility for the case.

 

Reserves are increased, medical and vocational management may be required, and a permanent disability rating will be made.

 

 

 

Employer Input:

 

Most claim technicians want to, and do, serve their employer clients very well.  However, day to day job pressures, workloads, and unexpected situations can allow even the most dedicated adjuster to fail in some steps of claim processing.    The burden of proof is always on the employer when a claim controversy develops.  Any innocuous step overlooked today may be tomorrow’s catastrophe.

 

It is suggested that employers develop basic procedures and protocols for how they want all their claims to be processed.  These protocols should be reasonable, in keeping with best claim handling practices, spell out authority levels, and legally acceptable.  They need to become a written part of the Third Party Authority contract, or policy between employer and insurer.

 

A check list needs to be developed and made a part of every claim created by the claim unit. Since more and more claim files are now handled electronically, some type of flag or block should be on each item listed so that the adjuster cannot proceed to further handling without documenting that the item has been properly addressed.

 

 

A partial sample listing:

 

The following list is just a few of the items that should be developed.

  1. All lost time claims must have an employee statement or interview confirming fact and developing proper health and background information.
  2. Obtain a signed all-encompassing a medical authorization.
  3. Advise employee of o benefits and responsibilities.
  4. Settlement or disposition inputs where the employer needs to be involved.
  5. Needs for Independent Medical Examinations, Medical Management, and Vocational Management.
  6. Reporting Procedures to the Employer.
  7. All cases should have professional medical triage as soon as the claim is presented.

 

 

Summary:

 

In the everyday handling of workers compensation claims, it is extremely easy for the claim technician to overlook vital investigative steps during the early stages of what might appear to be a routine case.  The employer needs to develop a program that places checks and balances to limit this potential.

 

 

 

Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  He is co-author of the #1 selling book on cost containment, Your Ultimate Guide To Mastering Workers Comp Costs www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.

 

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

 

SALES TO PAY FOR ACCIDENTS CALCULATOR:  http://reduceyourworkerscomp.com/sales-to-pay-for-accidents-calculator/

MODIFIED DUTY CALCULATOR:   http://reduceyourworkerscomp.com/transitional-duty-cost-calculators/

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

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

 

Top 10 Employer Complaints About Their Adjuster / Carrier

Over the years I have fielded several complaints from employers about their work comp adjuster or carrier in general.  I think at one point or another we have all heard of the same complaints about how a work comp program is run from the carrier side.

 

What I always find amusing is the fact that these employers just sit back and take it.  The reasoning behind this is usually that the employers accept that this is the way they think work comp is supposed to be.  They always hear the same pitch from each carrier:  Said carrier is different, they are aggressive, they are more hands-on, etc.  But in the end, the employer arrives at the same dissatisfaction, and they jump from carrier to carrier and arrive at the same issue time and time again.

 

But this is not the way it has to be.  The agent/broker is supposed to be fielding these issues for the employer, but maybe that does not happen.  I have compiled the most common complaints below.  Remember, if you are dissatisfied with your results, you have the power to correct this issue.  If you complain, and nothing changes, you must continue your search to find the right fit for your work comp program.

 

1. The adjuster does not act fast enough. 

The main complaint here is that if/when an MRI is ordered, there is no reason it should take 2-3 weeks to complete the testing, start the therapy, see a physician, and so on.  I imagine the reason this takes so long is because the adjuster has 200 files to work, and you are low priority on the list.

 

2. The adjuster does not communicate quickly enough, if ever. 

Again same result as above.  The reality is that the adjuster does not have the time to properly work the file.

 

3. The adjuster does not see the red flags about compensability. 

See above again.  Chances are the adjuster takes the easy way out, because they did not properly investigate the claim properly.

 

4. I talk to a different adjuster every time I have an issue. 

Unless you are a large account, it is unlikely you will have a dedicated adjuster assigned to your account.  This means you have to chase down who your adjuster is, understand their style of handling claims, and take the results as they are.  This should not be accepted.

 

5. Billing issues never get resolved. 

This is due to a breakdown in communication between the adjuster and their bill payer vendor.  The backload in billing is because the adjuster is not approving payment of their bills timely, and this leads to rebilling issues and credit report problems for the claimant.  One of the most important things an adjuster will hear is that they have to work their mail every day.  Failure to complete this task will lead to mail and bills piling up for weeks at a time.

 

6. The adjuster is not aggressive enough. 

This comes again from the adjuster not working the file.  If a claim is questionable, the adjuster should know that right away from their investigation.  Sadly, most adjusters will take the easy way out.  A typical excuse is “The medical report says the injury is work related, so it must be work related.”  We all know that the medical aspect of the claim is only one facet of claim investigation.  Is what the claimant told the doctor correct?  Did the mechanism of injury remain consistent?  Did all of the facts line up with the way the employer reported the injury? 

 

7. I am not updated on claims activity.

This is due to adjuster workload again.  Periodic claim reviews will help to alleviate this problem.  But if you demand to be kept up to speed on your most active claims, chances are the adjuster assigned to your account just does not have the time to complete this task.  Ways around this are to ask for weekly updates, but I imagine what you will get will be very concise, and probably not what you are looking for.

 

8. My claim concerns are not being addressed. 

No matter what your issue with a claim, your adjuster should be listening to your take on where the claim is and what should be happening going forward.  If this is not happening, that is a major issue.  I would think this is also due to adjuster workload, but that should not be an excuse.

 

9. We had light duty available but the adjuster did not work to get light duty restrictions. 

This is a very costly error for the adjuster.  If a worker is labeled to be off work, that should mean total bed rest, usually post-operative.  Outside of that, if a worker can work sedentary jobs and the employer has this option open, the adjuster has to do the legwork to get take care this.  This puts the employee back to work, lessens wage loss, and contributes to overall decreased claim expenses.

 

10. I do not like a lot of the vendors being used, but the adjuster told me that I do not have the choice to pick. 

This is true and not true, depending on your program.  In a guaranteed cost program, there is almost never a choice of services, and in a self-insured and self-administered arrangement, you will have full autonomy in who you select. As the size of your deductible increases to $100,000, $250,000, or $500,000, so does your ability to negotiate and choose your vendors.

 

These are 10 examples of common issues I hear between the employer and their carrier or adjuster.  I think the employer has the wrong view with comp programs in general—this is not how it has to be as there are a lot of options.  These issues need to be addressed by the broker.  If your broker is not presenting you with options to correct your issues then maybe it is time to find a new broker.

 

 

 

Author Michael Stack, Principal of Amaxx Risk Solutions, Inc. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  As the senior editor of Amaxx’s publishing division, Michael is on the cutting edge of innovation and thought leadership in workers compensation cost containment. http://reduceyourworkerscomp.com/about/.  Contact: mstack@reduceyourworkerscomp.com.

 

©2015 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

SALES TO PAY FOR ACCIDENTS CALCULATOR:  http://reduceyourworkerscomp.com/sales-to-pay-for-accidents-calculator/

MODIFIED DUTY CALCULATOR:   http://reduceyourworkerscomp.com/transitional-duty-cost-calculators/

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

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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