The Daily Battle Facing Your Work Comp Claim Adjuster

Workers compensation claim adjusters handle a loss from initial reporting through final disposition.  The cost of each claim cost has a direct financial impact on the employer. This makes it imperative that proper claim disposition reaches the most cost effective level possible. The adjuster must accomplish this despite statutory time constraints, state compensation department interface, maintaining employee control, reporting to the employer, controlling medical and disability benefits, filing required claim forms, controlling possible litigation, and constantly documenting the claim file activity.



Adjuster Duties:


Most claim adjuster job descriptions have fifteen to twenty basic duties.  Two examples are to perform a three point investigation 24 hours after the case is assigned, and establish liability for compensability and benefit payments. (Liability Determination and Benefits are usually due 14 days after the claim is reported to the adjuster.)


A vital duty is to set the claims reserves. Under estimating the reserve value, stair stepping of reserves in order to meet payments, and late posting of reserves are areas where the employer is often caught with unexpected exposure. Conversely, excess reserving may impose unnecessary dollar charges for renewal of the insurance contract, or employer set asides.


The adjuster is required to audit and make appropriate payment of benefits, medical bills, and expense costs in keeping with the workers compensation law, rules, medical fee schedules, and regulations. (Benefits are due bi-weekly, medical bills usually have to be paid in 30 days, and expenses should be paid in 30 days)



Adjuster Education and Experience:


It is preferable for the adjuster to have a college degree.  However, many persons with proper intelligence and formal claim training might do just as well. States that require adjuster licensing make the adjuster pass State examinations. This assures that the adjuster is technically knowledgeable. States may also require the adjuster to maintain a current level of claim education in order to renew their licenses.


Adjusters must have excellent written commutative language, highly developed oral communication, as well as ability to gather facts and control difficult situations.


Strong interpretive analysis capacity is a must. Self-organization of workloads, priorities, and time are necessary for efficiency.  The adjuster must be able to work with a team, as well as be self-motivated to work independently. All of these requirements depend on strong interpersonal skills.





The adjuster must record everything that happens during the life of the claim. All claim activity and happenings need to be posted in the file’s notes or adjuster’s record of claim handling.


These should include statements, medical reports, investigations, telephone calls, legal reports, letters, and opinions, plans of action, reserve changes, all payments, and any supervisory input.



State Mandates:


All states have reporting and handling procedures that utilizes forms.  These may be paper or electronic, and can be overwhelming by their number. There may be time frames for use, and penalties for late or improper use may include fines or inability to contest issues. The onus is on the adjuster to know when, where, and how to use them.


High volume form states may impede the adjuster’s ability in the number of claims that can be handled.


If possible, a well-trained clerical person might be able to process the routine forms such as listing all payments, the starting and stopping of benefits, filing wage data, and notifying of date, time, and place for independent medical examinations.  A full review of all forms is necessary to determine how many can be clerically processed.


All states have some precedents or presumptions for what claims can and cannot be contested. The adjuster must be knowledgeable of them and be able to advise the employer when applicable. Strong documentary evidence and testimony from reliable sources are the only tools to overcome the state interpretations.



Work Loads:


Review of adjuster case workloads needs to be done monthly. If the case workloads are too high, claim processing can fall into disastrous situations from lack of handling.  A few problems are overpayments, unchecked disability, excessive medical treatment, late payment of benefits and medical bills, delayed form reporting and filing and many more troubled areas.


A claim requires the most attention during the first thirty to ninety days. Changes can occur on a daily bases that require the adjuster’s attention and processing.  Incoming reports, medical bills, telephone calls, investigations, medical explorations, state form handling, and payments of bills and benefits are just a few items that occur.


Should the claim be contested, investigations coverage issues, later reporting, medical relationship, and many other aspects need constant attention to prepare for litigation. In such situations an adjuster may only get to handle and document 6 to 10 files in a working day.


Coverage issues must be addressed in 10 days for reservations of rights and declination. Most adjusters can handle 12 to 20 files daily during the 90 day period.


Prompt closing of claims will help keep adjuster workloads in balance.  Long term claims like permanent total, death, and lifetime medical can be placed on diaries up to 3 months for routine review.  Subrogation claims waiting for recovery and long term cases might be able to be reassigned to a superior clerical person for routine review as long as they are trained to bring unusual situations to the experienced adjusters.



Medical Only Claims:


The information cited above applies primarily to the claim adjuster handling contested, lost time, claims with some form of bodily restriction, or serious disability cases.


Normally 50 to 60 percent of claims should be for medical care only.  They are short lived being closed within 60 to 90 days. They should close for minimal dollar value and have no medical disability residuals.



Medical Claim Adjuster:


The Medical Only Adjuster need not be as technically expertise as the Disability Adjuster. But they need to be more knowledgeable than a clerk. Working with computers and telephone requires communication skills.  There is need for education and intelligence.


The medical adjuster will have a working knowledge of traumatic injury, causally related disability, normal treatment and healing time limits.  They follow and implement medical fee schedules.  A general working knowledge of the compensation system is needed. Medical Only Adjuster’s need to recognize situations that require more technical handling and expertise.



Claim Assignments:


Daily screening of all newly reported claims should be done by a claim supervisor who will then classify the claim as either Medical Only or Indemnity.  The supervisor makes adjuster assignments accordingly.


Once a month, the claim supervisor should review the medical only claim files with the Medical Only Adjuster to determine if the medical only classification is still appropriate.





Learn your adjuster’s education, training, strengths and weaknesses.  Know adjuster workloads, state mandates, and all areas that might bog down the adjuster’s claim handling.  Be sure to supply the adjuster with necessary documents, witnesses, and any information that will assist in the claim resolution.  The better you can work together as a team, the more successful your claims handling.




Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  Contact:


©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.





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.


A Delicate Dance With Your Work Comp Claims Adjuster

From time to time I review files. For the most part they are fairly benign and normal insurance claims. I do have the pleasure of finding a hidden gem every now and then–a file where nothing makes sense. By nothing, I mean it’s clear an injury occurred somewhere. There are a ton of notes in the file from the adjuster and the account contact going back and forth over something (usually compensability or some Statute clarifications) but it is all worthless information. Why are these notes even in the file?




Crazy Promises Can Put Adjusters At Disadvantage


I know why, and this is the part of the adjuster’s job that does not get the attention they deserve. From the very start, account executives and salespeople promise the moon to new and prospective accounts. Promises such as “Your adjuster will drop everything and put your account first” to “We want to make sure you have every question answered within one hour of sending that email to us.”


Not only does this put the adjuster at the disadvantage, but it usually blindsides them because the salesperson forgot to mention this to the adjuster on the account. Crazy promises also allow an insured contact to think they have the control over whether a claim is accepted or denied based on whatever reasons they have to justify the action. Sadly, this is far from the truth.




Employers Need to Understand Their Important Role


Let me show you a good example that always sticks in my mind. This guy delivers stuff to stores. He was delivering product and as he moved his dolly and turned his foot he felt a pop in his ankle. He kept working. The next morning he mentioned it to his boss, who allegedly told him he couldn’t go to the clinic because they were already short staffed and he had to wait at least 2-3 weeks before treating because this employer needed all off the drivers they had (Employers—this is a very, very, very, very bad idea and please do not ever do this to your employees unless you want to be punished by your Jurisdiction should they ever find out about this).


So worker kept working another week or so but couldn’t wait any longer, so he went to his doctor. The doctor sent for an MRI which was negative. All in all this was an ankle sprain.


Now shift gears to the claims adjuster. The adjuster looks at the claim, and determines this is fairly objective. This worker had a specific incident, reported the claim and was denied treatment by his employer, attempted to keep working then went to his doctor which is allowed in this jurisdiction. The injury is no big deal; little bit of TTD and some therapy and this claim should be on the way to close.


When I looked at this file, the amount of documentation would fill boxes. This barely medium-level claim was viewed as a catastrophic claim by the employer. The employer peppered the adjuster with easily 40 questions about compensability, about how they could get around owing him TTD, about how this injured worker is lazy and has a bad reputation with his superiors, etc.


Everyone talks about why adjusters are not productive and why they cannot move and handle files. This employer can often be the reason why. The employer plays a significant role in managing their workers compensation costs, but understanding this role is extremely important. Your job is to ensure the incident is reported and documented, that your employee gets the medical attention required, that they feel cared for, and that they are back to work quickly in a modified duty capacity.




Compliment The Work Of Your Adjuster, Don’t Make Their Job More Difficult


You should be a compliment to the efforts of your adjuster, not a hindrance. A best practice is to establish a good working relationship and understanding of how your claims are handled by your carrier or TPA. Sitting at the desk of your adjuster for a chair-side visit will allow you a clear understanding and open your eyes to the claims process.


Let your claims adjuster handle the claim files on a daily basis, and schedule a review of open claims regularly. This allows the adjuster to block off the time, adequately prepare, and be ready to address any concerns you have, as well as get valuable feedback from you on the injured workers status. It is not fair to regularly bombard your adjuster with unreasonable requests for information just because you have their email address.




Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  Contact:


©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.





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.


Does Your Adjuster’s Opinion Flip-Flop Like A Bad Politician?

It has been said time and time again that successful adjusters and claims professionals will have to be good multi-taskers.


There is simply no way around this. If you are terrible at doing a lot of things at once, across multiple mediums, then you will fail at this job. But don’t feel bad because a lot of people that fail at this job still end up working in it. They work in this field for decades and the sad truth is that they are terrible at their job. But they are there, and it is a body at a desk, and sometimes that is all a carrier is looking for. Someone to put out whatever the “Fire of the day” may be.


Time for my disclaimer, not all claims personnel are awful at their job. In fact, only a small percentage is terrible and still somehow gainfully employed. Most adjusters care about their jobs and produce a quality work product.


So now that I got that out of the way, I am going to hyper-focus on the terrible claims personnel out there. There are a group of you that are at every carrier, in every state, and you have been doing this type of work for a long time.


The first handful of years if you are awful at this job you either:


1. Quit because you have been audited down to nothing and you just cannot take it anymore




2. Slowly migrated your way from the mailroom up to a medium-exposure adjuster and you are learning as you go.


But, the person I am talking to that is terrible at their job, you have been doing this for over 10-15 years. Sometimes over 20 years. You have been the proverbial thing that has survived it all. You survived field adjusting, changes in technology, changes in management, downsizing, outsourcing, mergers, etc. You survived it all!


You may not know why you are awful at your job, but I do. I have solved the rubix cube of the terrible adjuster!! The answer is……… allow yourself and your opinions to be influenced by someone that has limited to zero involvement in the claim. This alone has warped you from being a great adjuster and one that sticks to their guns, to a ho-hum fence jumper that really has looked to everyone else to make the decision for them. Then when the palace comes crumbling down and you point the finger at the 13 people you consulted on this claim.


Those 25 people or however many people you talk to about work–those are the ones that are doing your job. Sound confusing? Let me break it down:



Forces Influencing Adjuster Opinion


There are two types of forces:


1. Outside forces

2. Inside forces


Outside forces are vendors and your spider web of professionals in the business that you use for your claims. These consist of outside Legal Counsel, IME marketers, former claims people turned salespeople for any type of DME-IME-SIU-TCM-NCM-VOC-MSA whatever service that just tell you what you want to hear in order to get some business from you. This includes former bosses demoted to adjusters at other carriers, former coworkers out of the business, the Internet, and so on. Anything or anyone else you can come up with that doesn’t work for your employer is considered an outside force.


Inside forces come about a different way. You, the awful adjuster, become jaded on your own claims due to internal and external claim issues. For example, this can come from a poor audit scoring. Your manager calls you in the office to go over your last audit, and big surprise the results are terrible. These claims were questionable and maybe accepted too early, so you are told to do a better investigation. Awful Adjuster takes this as meaning you should start filing some denials on claims, in order to make it look like you are trying to be more aggressive (Don’t laugh—these people are out there and probably handling YOUR claims).


Example #2 of inside forces are your own inside vendors swaying compensability on a questionable case. These usually consist of in-house attorneys, nurse case managers, SIU staff, and maybe a vocational person.


Let me give you an example. Let’s say you have a questionable claim on your hands. Protocol says to send it to all of these people so they can “Assess” whether they need to be involved or not. This takes time. Plus another big surprise they all say they need to be involved in your claim! Why? If they are not involved in any claims, they are not working.


So, inside vendors start to flex a case as being compensable. The attorney says it could be a tough defense to deny this case, but they are willing to do it if you want. But for now they need more investigation, they have to send out subpoenas, etc. The nurse says the medical is subjective but the injury sounds legit, and if this person has surgery they will need nurse case management on the file to help with the recovery. The SIU guy didn’t find anything out but they need more time. Your voc person says that the worker can work but probably not in their regular job; hence they will need some major vocational workup once they are nearing MMI.



Adjuster Needs To Determine If Injury Happened In Course & Scope of Employment


This questionable case is not sounding good. You are using the opinions of your peers to steer your boat. But you forgot the most important thing–to do your job, which is to determine if the injury occurred in the course and scope of employment!!!! Because if it did not, and you know why it did not, and you have proof of why it did not, then all the rest of that crap everyone else is telling you is total garbage!


Awful Adjuster forgets about that though, because they are already envisioning the inevitable which is that no matter if the claim is denied or accepted, they do not want to be the one that made the call. There is no way they are going to fall on the sword. So they farm it out to all of these internal/external people for opinions. Now Awful Adjuster has people to point the finger to should this file be a disaster down the road.


I want you to think about that file example. I know this exists out there, and I have witnessed it with my own eyes. I have seen it time and time again. Everywhere.



CYA (Cover Your Butt) Protocol


Do you know why this happens? Because everyone is protecting themselves from everyone else. This is CYA (Cover Your Butt) protocol. The biggest CYA out there is the awful adjuster. But it is not just their fault. Look at those other “Forces.” Everyone had an angle in order to try and get adjuster to push the file their way in order to secure a sale or a commission, or some job security. This is what it is all about today. Every involved party is either protecting themselves, protecting their employment, or trying to secure a commission or sale. You can bet that they do not care about Joe Worker at all. Joe is just a speed bump on the road that is about to be put through the gauntlet of having to deal with 13 people at once ranging from their 3rd different adjuster on the file to a voc person to their DME contact and whomever else.


Why did Awful Adjuster get this way? If they were around for 20+ years, they must like the work in some aspects right?


Yes that’s right. And I know why they don’t care. They don’t care because they themselves have no authority, no accountability, and no real involvement in what goes in on the claim. Once this happened, it was over. Awful Adjuster is just another face working from 8-4pm and they figured out a way to tweak the system.


This is sad, but unfortunately this is reality. Sure the entire system needs to be overhauled, and the way claims are handled need to be addressed, and adjusters need to go back to having more authority and more accountability on files. Someday this may happen, but until then it is the client and their injured worker that is the one being harmed the most.




Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  Contact:


©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.





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 about workers comp issues.

Adjuster Selection Attributes That Will Save Workers Comp Costs

Self-insured employers with successful workers’ compensation claim management programs know one key fact – the better the adjuster, the lower the claim cost. Whether the self-insured employer has dedicated and/or designated adjusters at the third party administrator, or utilize their own in-house adjusters, the selection of the best adjusters can be tricky. 
Too often self-insured employers make the mistake of judging adjuster quality based solely on the ability of the adjuster to maintain rapport with the employer. While rapport is important, there are several other key traits the self-insured employer needs in each adjuster handling their workers’ compensation claims. Successful adjusters have many attributes. Four primary attributes the self-insured employer should look for in the adjuster selection process are:
  • Communication
  • Documentation
  • Proactive
  • Courteous
Few things are more dangerous to the self-insured employer than the workers’ compensation adjuster who does not communicate openly and often. Major claim developments that are unknown to the self-insured employer can wreak havoc. With open communications between the adjuster and the employer, the employer is kept informed of each claim’s progress. Open communications allows for the exchange of information about the claim and ideas on how to assist the injured employee while moving the claim forward. Open communications with the adjuster is not for the employer to micro manage the claims, but to facilitate collaboration and claim progress.
The best workers’ compensation adjusters thoroughly document their files. Each phone call, e-mail, medical bill, medical report, attorney letter, state filing, etc., should be documented either in the file notes, the documents section of the file, or both. If the adjuster accepts employment elsewhere, takes ill, or for some other reason is unable to continue the handling of the claim, the next workers’ compensation adjuster who picks up the handling of the claim should be able to review the file and know immediately both the former course of the claim and the current status of the claim. 
The adjuster who allows the workers’ compensation claims to take their own course, rather than directing and influencing the claims, provides little benefit to the self-insured employer. The adjuster who takes charge and actively manages each aspect of each claim keeps the number of unpleasant surprises to the minimum. Ordinary claims that are not actively managed by the adjuster frequently take a wrong turn and become more complex (and more costly). The proactive adjuster will coordinate and manage the medical care either directly or through a nurse case manager. The proactive adjuster will arrange for the employee to return to work light duty. And, the proactive adjuster will coordinate all other aspects of the claim before there is a need for action.
When a workers’ compensation adjuster is not courteous to everyone in every facet of their claim handling, the resolution of the claim becomes more difficult to achieve. Courtesy is much more than the adjuster being polite on the telephone. Each missed telephone call should be returned as soon as possible, preferably the same day. Each email that needs a response should be promptly replied to.   Each paper correspondence that requires an answer should be addressed right away. 
Courtesy is especially important with injured employees. While a non-injured employee would over-look any unintentional slight, an injured employee who is already anxious about his/her future health and employment, will often take any bluntness or perceived lack of courtesy as the employer and the work comp adjuster not caring about their well-being. A lack of courtesy by the adjuster frequently results in the injured employee obtaining an attorney, which delays the claim resolution while increasing the claim cost.
Other Attributes of an Excellent Adjuster:
While the four attributes listed above are key to the successfulness of an adjuster, there are several other traits the self-insured employer should look for in the selection of an adjuster. The following attributes are also important, and should be evaluated in the adjuster selection (and retention) process. 
  • Negotiation skills
  • Organizational skills
  • Time management skills
  • Customer service skills (customer being both the self-insured employer and the injured employee)
  • Work ethic
  • Ability to prioritize competing demands
  • Compliance with Best Practices
  • Technical expertise
If you find all of these attributes in one adjuster, it is definitely an adjuster you want to handle your workers’ compensation claims. While few adjusters will be strong in all of these areas, the greater the number of positive attributes the adjuster candidate has, the better his/her selection will be for your company.

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%.
Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. Contact:
©2013 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

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