How Would You Attempt to Resolve a Problem with a TPA or Insurance Company

Q.   Assume you are asked to mediate in a situation where the employer expresses serious frustration with claims handling, and where the tensions are very high, possibly leading to non-renewal. How would you go about your assignment? Here are 5 ideas:

1 – Benchmark
the Cost per FTE and Cost per Claim to see privately, prior to any meetings whether the insured is more than, less than or at national average to put the situation in perspective as far as whether or not the alleged poor practices are causing financial consequences to the insured.

2 – Have and MD review files
to make sure the claims are valid and determine quality of handling by adjusters and vendors. Files should be given numeric scores so improvement can be measured against a baseline.

3 – Tour
the claims operation and sit with the adjusters to speak with them about the claims. They often have great ideas, but no forum to offer those ideas.

4 – Set up weekly
conference calls with client, TPA, Claims VP at Broker, and me (I work on behalf of the broker normally). All parties should tour the client operations. MD, etc. can be included.

5 – If there are things
the insured needs to do (cost allocation, return to work programs, training, etc.) I would use the RIMS Benchmark Surveys”(2009 and 2010) to show that a high percentage of other companies utilize the techniques we are recommending, e.g. 86% of companies have RTW programs at all or some of their divisions, etc.

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website 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. Contact:

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
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