Every adjuster has an individual style when it comes to handling claims. Just like snowflakes, no two adjusters are exactly the same. Yes – they may be similar in deciding if a claim is compensable, but how they arrive at that result that varies. It is safe to say claims supervisors must monitor each adjuster differently.
7 areas supervisors wish their adjusters would improve:
1. Document The Files
When it comes to documentation in the file, everyone is different. Notes should be succinct, and tell the story without droning on and on. Adjusters are very busy handling several different issues at once, and, at times, some information is overlooked. What a supervisor may think is important to document in the file notes the adjuster may not, and some facts can be overlooked. That does not mean the adjuster is not aware of these facts, it just means they are not in the actual file notes. It is all about documentation when it comes to handling files since you do not know who at the executive level is looking in the file. A happy medium needs to be reached when deciding what HAS to be in the file, versus what can be skipped.
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“How Do I Get My Adjusters To Follow My Account Handling Instructions?”
2. Research Medical Diagnoses
No matter how many years experience an adjuster has, the brutal truth is the adjuster is not a medical doctor. Diagnoses are becoming more and more complicated with several types of degenerative conditions complicating acute injuries. The job of the adjuster is to separate what is pre-existing from what is acute and possibly work-related. Sometimes when adjusters see the word “degenerative” or “arthritis” they automatically lean toward denial of the claim.
However, in the world of workers comp a common issue is exacerbation of pre-existing conditions — this is seen especially in back strains. Someone may have a pre-existing disc herniation. That does not mean when attempting to lift that box the back was not strained a little leading to a temporary exacerbation of the pre-existing condition. Adjusters can be quick to wrongfully deny a claim, and in the end it comes back to haunt them in litigation.
Adjusters need to know what type and duration of treatment is needed before they can correctly deny ongoing treatment or set up an Independent Medical Evaluation (IME) to terminate ongoing benefits. Using medical guidelines can help. Consulting with a board-certified M.D. is even better. Consider subcontracting with a physician review service so your adjusters have the services of M.D.s to review claims; these services can be purchased on an outsourced basis. Include senior nurse reviewers in the process. Let your clients know about these services.
3. Communicate with Insureds
With caseloads increasing for the average adjuster, it is hard to find the time to sit down and explain to the employer about a medical condition, or to discuss why a claim was denied, or to pick up the phone and update the employer on open files. Adjusters need to remember the employer is their client, and proper customer service is what can separate their insurance company from their competition. Giving adequate time to every employer, leads to a great relationship between all parties and, in turn, makes dealing with future issues much easier.
4. Communicate With Claimants
Many adjusters forget the average claimant knows little about the way the claims process works. Without proper communication, the claimant has no idea what is going on, why the claim was denied, why they cannot see their own doctor, or why it is taking so long to receive a check if the claim is deemed compensable. This can lead to litigation, and even worse bad faith claims made against the carrier, which can become a severe issue for the insurance company and the client employer.
If an injured worker comes back to work and complains about the way in which the claim was handled to the supervisor, you can bet that will result in a phone call to the claims manager, which can lead to discipline for the adjuster. It should be mandatory (but it is not) on every claim that the adjuster takes time to explain to the claimant what their rights are, what the insurance company’s rights are, and to address any questions or issues a claimant has in regard to the claim at any time.
5. Balance Aggressiveness
This varies by adjuster. Some are overly aggressive, whereas some are a bit more liberal in the way they interpret claims statutes. This can be both good and bad. If a claim is denied due to over-aggressiveness, it can lead to wrongful litigation and possibly penalties against the carrier for bad faith claims. In turn, some claims are accepted when they should be denied. Obviously, that is a serious issue as well and the financial leakage ensuing on a wrongfully accepted claim can be disastrous for the carrier. This can include embarrassment and possible discipline for the adjuster handling the claim as well as ramifications for that adjuster’s manager.
6. Background Checks and Investigation
An adjuster has several tools to do background checks on claimants, including the Insurance Service Office (ISO) database, the SIU (Special Investigating Unit) department background research, outside vendor surveillance, and court research. The ISO keeps a database on all personal injury claims by name, social security number, and address to help adjusters identify repeat claimants who have an auto bodily claim, a general liability slip, fall claim, and a workers comp claim all going at the same time, for example.
There are a lot of repeat offenders out there who make a living going from employer to employer, settlement to settlement. Due care needs to be taken on the part of the adjuster to put the time in when background checks are needed, since the results can lead to case denial.
7. Vendor Use
When vendor marketers come in to an insurance carrier’s office, they are typically very personable and offer a variety of services to make the adjuster’s life easier. Sometimes, adjusters use a certain vendor because they like that company or are personal friends with the marketer. Even though that particular vendor is ineffective or overly expensive, the adjuster continues to send them business for the sake of the personal relationship. Do not tolerate this scenario and include manager involvement to be sure vendor use is appropriate, effective, and performed at the time the services are needed.
Summary
Every adjuster is different. The manager’s role is to make sure claims are being handled ethically and properly within the practices set by the carrier. Typical adjusters wear several hats during the course of a day doing their job, and each one deserves proper attention and care. If adjusters fail at any of their tasks, it makes everyone look bad and costly penalties can be assessed when someone fails to take appropriate care of the situation at hand.
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. See www.LowerWC.com for more information. Contact:[email protected].
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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