8 Ways to Grade Your Workers Compensation Claim Adjuster

Often it is assumed the designated adjuster(s) working on your workers compensation files is a good adjuster. But, you know what “they” say about “assuming.” Use these eight tips to judge your adjuster(s) overall ability and effectiveness.

Track how often the adjuster makes timely contacts. If your Best Practices say claimants, medical providers, and the employee’s supervisor must be contacted within 24 hours of the first report of an accident, expect your adjuster to be making timely contacts with all parties at least 90% of the time. The higher the percentage, the better. Timely initial contacts go a long ways toward establishing the future tone of your claims and establish the adjuster as the person in charge.

When you look at your loss run and compare what the claim settled for against the claim reserves you gain insight into the ability of the adjuster to evaluate the claim. If you see a lot of reserve changes right before the claim settles, then the adjuster is either inexperienced at evaluating the claim or is indifferent to the impact reserves have on your company. If you see the reserves on the claim were established since the adjuster obtained key medical information on the injured employee, you know the adjuster is looking out for your financial interests.

Does the adjuster always answer the phone when you call, or do you often have to leave messages and wait a few days to hear back? When you send e-mails, do you get a prompt response, or do you forget what the subject of the e-mail was by the time the adjuster responds? A good adjuster tries to keep you informed about your claims and takes the time to respond to your questions and needs. The quicker the response from the adjuster, the better the adjuster.

If your employee complains the TTD or TPD check did not arrive on time, then the adjuster is not organized (or may have too many claims to handle properly). You should expect never to hear from an employee about the indemnity check not arriving. If your employees are receiving dunning notices from their doctors on medical bills, then the adjuster is not processing the bills timely. While any adjuster may occasionally have a medical bill or other missed expense, you or your employees should not be constantly getting reminders on medical bills.

The good adjuster stays in contact with employees out on workers comp. The great adjuster builds rapport with the employees and the employees make an effort to keep their adjuster informed as to their medical progress and their ability to return to work. The poor adjuster has a higher percentage of employees represented by an attorney then the good adjuster. As the percentage of employees represented by attorneys is impacted by the legal climate in your locale, you must consider the results of your adjuster compared to other adjusters in the same locale.

6. Knowledge of Workers Compensation

When you have a question about workers comp in general, the good adjuster can answer it for you, (or at least get you the answer). If the adjuster does not know the answer, or tells you it would be better for you to talk to a workers comp attorney or the adjuster’s supervisor, the adjuster’s workers comp knowledge is weaker than it should be. The good adjuster knows all the ins and outs of state statutes and is willing to share that information with the employer.

Often claim offices do not want to talk about their claim quality audit scores. This often arises out of a concern that the employer may not understand that the 100% perfect claim file seldom happens. However, the good workers comp adjuster scores in the 90+ percentile. Ask the adjuster for a copy of the most recent audit score. The good adjuster is glad to share it with you. The weak adjuster probably has reasons why it cannot be shared.

Every adjuster knows the best file is the closed file. However, it is seldom a good idea to close a file prematurely. The good adjuster makes sure all aspects of the claim are resolved, all medical bill paid, all indemnity checks issued, and all expenses paid before closing the file. If you see more than a few reopened files on the loss run report, than the adjuster is closing claims prematurely.

None of these 8 criteria alone indicate a good or poor adjuster. When the adjuster is strong in all 8 areas, you have a great adjuster working your claims. If the adjuster is weak in most of these areas, it is time to consider requesting another adjuster to handle your workers comp claims. Having a strong adjuster on your claim files makes your life easier and saves money. A few select TPA’s DO actually “grade” their adjusters, giving monthly bonuses to those that excel, and get high grades – nearing 100.