The risk manager is perplexed. The workers compensation adjusters on the self-insured program always seem to be behind in the work. Very little is getting accomplished on time. Investigation on new claims took longer than they should, vendors are calling about missed payments, the employer’s workers comp coordinator seems to be doing half of the adjusters’ jobs for them and the cost of the workers comp program keep creeping higher.
A discussion with the claims manager for the third party administrator (TPA) does not provide many answers. The claims manager is reassuring, verifying the 3 dedicated lost time adjusters worked only on the self-insured program and do no work for anyone else. The adjusters know the Best Practices and are striving to meet them, even though they often fall short. The risk manager knows the adjusters are working long hours from the various e-mails and phone messages being sent at night or even on the weekends.
While the risk manager is reviewing the lost run at the end of the month to see how much the workers compensation cost has increased, he notes the 3 adjusters are handling a combined 513 lost time files, an average of 171 files each. Is that too heavy a caseload? What is a reasonable number of lost time files for each adjuster to handle?
Any discussion of caseloads has to be tempered with consideration of where and what the claims are. An adjuster in California handling construction workers could handle maybe half the claims of an adjuster in Mississippi handling office workers. With that caveat in mind, a TPA caseload of 100-125 is normal without full ancillary support, which is something most adjusters do not have. Most TPAs provide only partial ancillary support, if any.
Best-in-class TPAs provide administrative support for adjusters. This allows them to focus on return to work strategy, communications with employer/employee/medical providers, and making judgments and decisions on the files. Adjuster administrative assistants perform tasks such as paying medical bills, sending requests for medical records, and filing and copying as needed. A lower case loan will be necessary for adjusters without administrative assistance.
In our risk manager example above, depending on the state, a caseload of 171 would be doable if each adjuster had their own personal assistant. The cost of service, however, would be proportionally impacted. State laws, state mandated forms, the level of litigation and the nature/extent of the injuries all impact caseloads.
TPAs have a built-in conflict of interest. The higher the caseload, the more adjusters and support staff the TPA must provide. If the TPA raises the cost per claim to pay for the additional adjusters and support staff, they drive away customers and lower their market share. It is therefore in the interest of the TPA owners to handle as many claims with as few adjusters as possible. When the caseload gets too heavy for the adjuster, mistakes are made, oversights occur, and errors & omissions increase.
Caseloads are a constant balancing act between what is in the best interest of the self-insured employer and what is in the best interest of the TPA owners. When the caseloads get too heavy, the TPA owners profit at the expense of the clients. When the caseloads are full, but not over burdensome, the conflict of interest between the TPA and the clients is kept in check. When the caseloads are too light, which is rare, the TPA loses money, but there is little impact on the clients. When caseloads go up, and all else remains the same, the adjuster’s quality will decline.
Unethical TPAs who intentionally look for clients shopping TPA services by price only, will provide a low price per claim, but then load the adjusters with 200 – 250 files knowing the adjusters will provide mediocre service at best, The clients of these TPAs pay for it with higher indemnity costs and have an overall higher cost of work comp. It is better for the TPA clients to pay more for the TPA services and negotiate into the client instructions and claims handling contract the maximum number of files the designated or dedicated adjusters will be assigned
The employer’s level and nature of involvement in the claims will impact the caseload the adjuster can handle. If the employer is reporting all claims timely, maintaining regular contact with the employee, and providing a transitional duty program, the adjuster can handle a higher caseload. If the employer does not report the claims until a letter of representation arrives from an attorney, the amount of work per claim is increased and the number of claims the adjuster can properly handle decreases proportionally.
To evaluate whether or not your TPA has assigned too many claims to the adjusters is often a difficult task as the TPA will be reluctant to admit the adjusters have too many files. You can obtain a general idea as to whether the caseload is too high by reviewing the nature and type of claims, as well as the requirements of your states work comp act. To know more precisely what the caseload should be, hire an outside, independent claims auditor to complete a Best Practices Audit of the TPA files. The outside expert can assist you in identifying the issues impacting the claims quality and identifying the appropriate caseload for each adjuster handling your claims.
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. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com. Contact: RShafer@ReduceYourWorkersComp.com.
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: Mstack@ReduceYourWorkersComp.com.
Our WORKERS COMP BOOK: www.WCManual.com