Seven Ways Carriers and TPAs Ensure Quality Control

Quality control does not just apply to files, it can also apply to personnel handling files. When you make that choice for a carrier or third-party administrator (TPA), you want to be confident the adjusters and managers handling your claims are qualified to do so, and that they are representing your company in the best way possible. Below we discuss some general employee screening tactics along with some quality control tactics used on claim files.

1. Multi-level screening of adjuster candidates

Most carriers/TPAs actually prefer to hire entry-level candidates that have no experience. When you talk to your adjuster to see how they got started in this business, a good percentage of them will say they just “fell into the business.” This happens because of the way HR departments look for new candidates.

Carriers/TPAs will require their candidates to be college graduates. It also helps to have a degree in some area that applies to insurance. This could be economics, accounting, finance, human resources, criminal justice, etc. That is not to say someone with a different degree would not qualify, but it is probably not the carrier/TPA’s first choice for the perfect candidate upon first glance. The best carriers/TPAs provide career path training so trainees know what they must do to move to the next level. In addition to onsite training, virtual training may be offered so new adjusters can commute virtual to training.

As the adjusters move forward with their careers, they attain the AIC (Associate in Claims) designation from the AICPCU (The Institutes), which is a nationally recognized program. At each career path level the adjuster also has in-house and some external courses to complete to meet their educational requirements to be promotable. There is also annual compliance training, which includes insurance fraud awareness training.

The candidate will also have to pass a credit check, and a normal criminal background check. They also have to be verified to be eligible to be considered as a “fiduciary agent” since they will be making payments for your carrier/TPA on behalf of another party. So it makes sense that you have to be good with money, and have no blips on your personal history that could be construed as potentially negative to employment with said company.

2. Proper, extensive, continued training and education
   

   Going back to carrier/TPAslooking for candidates with little to no experience, this is because the carrier/TPA does not want anyone bringing bad habits into a company that they may have learned other places. Once hired, they will be sent to an extensive claims school, or formal training program – normally these are in-house training facilities. They will learn the skills from veterans of the insurance industry. They will handle fake claims to go through the motions, and the education on the medical aspect can be fairly thorough.

Once they are established adjusters, continued education is still required. An adjuster usually has to obtain a certain amount of extra training and education every year. This is obtained by attending legal/medical seminars, taking online courses, or obtaining an insurance designation such as an AIC (associate in claims). In most cases, it does not matter how many years of claims adjusting you have under your belt, carriers/TPAs still require you to stay current with legal changes, medical techniques, etc. The adjuster role is one that is constantly being improved and educated at all times.

3. Two-week manager brief review on new files
   

   When new filescome in, unless it is a very minor claim or a “report-only” claim with no medical treatment, the claims manager will review the file at or around the two-week mark. This way, the contacts have been made, a medical diagnosis is obtained, and it is fairly clear if a claim is lost time or not. The manager can then set another date for review depending on the future outlook and risk drivers on the claim, and go from there at the 60-day mark.

4. Sixty-day status report

A 60-day status report is the first formal report on a claim the adjuster makes to the file. This report will usually go in the file, and will be reviewed by the unit manager. This report summarizes the contacts made, the medical obtained, and the future outlook on the claim. It also will address the reserve amounts. Most carrier/TPAs will place a default reserve in the file once they get assigned to it, and they will address those amounts at this 60-day mark. The manager again will review the report, make recommendations on the file, and place another date to further review the file as needed.

5. Status report: 120-150 days in
   

   This report willassign the current and future exposure on the claim. By 150 days, It will be fairly clear if this will be a long-term large exposure claim or not. By this time, an injured worker may have had surgery, or has surgery pending. Or, using the flip side, at the 150-day mark the worker may be released from medical care and the file will be set to close.

Reserves will also be placed in the file for the long-term exposure. This is when the large reserve increases will be made depending on the file exposure based on risk drivers. Again, by this time in the file, it will be known what the future should hold.

6. Roundtable of higher-exposure files
   

   For a complex file, around the 150-day mark, a roundtable may be set to discuss the claim with senior adjusters, managers, and probably the employer. If several parties are involved, they will be brought together to discuss the future of this claim. If the exposure is there, the file may be assigned to a senior-level adjuster. The roundtable is used to brainstorm the file and come up with ways to limit exposure. This could be by assigning a nurse case manager, review by legal counsel, or creation of a light duty job to reduce wage loss exposure. Whatever the reason for the roundtable, it is a common tool used to the carrier/TPA to come up with ways to move the file onward towards the common goal which could be return to work, release from medical care, or overall redemption of the claim through a settlement.

The best TPAs include medical professionals on the roundtable teams such as mental health professionals to determine if there is a mental health component to the claim and, if so, RNs with mental health expertise may be assigned to the claim.

7. Following up with involved parties
   

   Whatever the claimmay be, quality control is best assessed by proper communication with all parties. Adjusters should be talking to employers to keep them up to date. Adjusters should be talking with their on-site nurses or with their vocational counselors. Adjusters should be talking with plaintiff counsel or defense counsel to keep the file moving towards resolution. Carrier/TPAs always preach trying to keep all parties current and up to date with the activity of the file. Lack of communication is a recipe for disaster, no matter what the exposure is on the claim.

In summary, carriers or TPAs have several tools they use to maintain that the work product they put out is of top-notch quality, no matter what the exposure. We have touched upon a few here, and these will vary slightly from carrier to carrier and from TPA to TPA. You should ask your adjusters and managers at your carrier/TPA what they do to maintain quality, and let them take you through the process. The more you know, and the more involved you can be, the better outcome your claims will have.

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 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].

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