Claim adjusters come in a number of varieties. They can be young, old, male, female, experienced, non-experienced, and so on. However, the most important difference is two basic types: proactive and reactive.
Every employer that has insurance issues would always choose the proactive adjuster rather than the reactive adjuster. But this is not always the case. Sometimes, your company gets assigned to an adjuster or team of adjusters, and if you do not speak up or are not involved then you get whomever to handle your claims.
This is why it is important to be involved in your overall claims process. There is no rule that states that you have to accept whoever gets assigned to handle your files. Below we discuss a few of the attributes of the proactive adjuster, and why it is important to have this person handle your claims.
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“How Do I Get My Adjusters To Follow My Account Handling Instructions?”
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Proactive adjusters respond to emails within a few hours, if not sooner
Claims professionals spend the majority of their time at their desk, handling their files. Some files are more important than others, but the proactive adjuster can differentiate between what needs to be handled now, and what can wait a few days. Part of the delegation process is prompt response to any communication the adjuster receives from an employer, their client. Insurance management will tell adjusters time and time again that the employer comes first, and any issues or questions that they may have need to be responded to right away. Even if the adjuster does not have the answer to the question, a response needs to be sent back to the employer ASAP that acknowledges receipt of the email and that the adjuster will get back to them right away with the answers that are needed to address the issue, or the person they need to talk to that can handle the problem.
Reactive adjusters sometimes do not put the employer first, because they are handling other claim issues that they feel are more important than a 10 second email back to the employer saying that they will work on solving their problem. Sometimes, an email won’t even be sent at all until the following day. This should not be acceptable customer service by any means. The employer is the customer, and the customer is king. If you notice an adjuster not responding your questions within whatever timeframe you deem acceptable, then you need to raise the issue to the claims supervisor.
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Proactive adjusters return phone calls and voicemails within 24 hours
Another sign of the proactive adjuster will be returning phone calls within the same business day, if not the first thing the following morning. If someone is calling about their claim, or about a medical issue, the adjuster has to return the call to keep the claim moving forward. Again, an adjuster spends most of their time at their desk, and they do have to do a lot of work on the phone. If your adjuster is not comfortable on the phone, then they need to find a new line of work.
Reactive adjusters will only return the phone calls that are the most important that day, if they return them at all. I have heard of claimants that call their adjuster 3-4 times with the same question, waiting for a response. This should not be tolerated.
Adjusters forget that the claimant has no idea what is going on. They do not know about claims, the legal process, and so on. It is not fair to them that their claim questions are not addressed and explained to them. Imagine if the claimant is your sister, or mother. How would you like it if that is the way they are being treated? Even worse, if you are the employer/client and you have sent emails and left voicemails with no response, that behavior cannot be tolerated, period.
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Proactive adjusters will handle the medical needs of the file promptly
To keep a claim moving forward, authorizations have to be given for physical therapy, diagnostic testing, surgery, injections, medications, etc. This means a phone call has to be made from the provider to the adjuster. A good proactive adjuster knows that the sooner you get that authorization to the provider, the sooner the claimant can move forward with getting the treatment they need. The sooner they get the treatment they need, the sooner they return to work. Proactive adjusters keep that medical train chugging forward with little to no delay.
Reactive adjusters fail to do this. Providers will make multiple calls for authorization or billing information, with no response. Then when the claimant calls to schedule their appointment, they find out that the medical office is still trying to get a hold of the adjuster. This will prompt the claimant to call the adjuster, to find out what the delay is. Failure to respond to those calls will lead the claimant to contact their employer, complaining about why they cannot get the medication or treatment they need so they can get back to work. Before the reactive adjuster knows it, they have 3 separate parties making numerous calls and emails to them on the same issue. This is just not proper behavior. Had the adjuster returned that one phone call to the provider back in the beginning, the rest of the issues and voicemails would have been avoided. Employers have more important things to do than babysit the adjuster that handles their insurance claims.
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Proactive adjusters take the time to explain claim issues to the involved parties
Claims professionals sometimes forget that not everyone knows what they are talking about. People do not have the same training within the claims realm, so they have no idea what is going on. A proactive adjuster will take the time needed to explain the issue to whoever is calling, whether it is the claimant, employer, or the medical provider. If a medical provider is calling to authorize a surgery, and this surgery is not approved because it has been deemed not related to the work injury, unless the adjuster tells the provider that the procedure is not approved and why, then the provider will keep on calling. Good adjusters will take the 2 minutes to tell the provider that the surgery is not authorized under work comp because of an IME, or because of legal issues, or whatever the case may be. Then at least the provider knows and can note their files as well so they do not keep calling the adjuster looking for an answer.
Reactive adjusters will usually fail to respond to the call at all, which starts the circle of phone calls again. The provider calls looking for authorization and gets no response. The claimant calls the provider to find out when their surgery is, and the provider tells them that they cannot reach their adjuster. The claimant then calls the adjuster, and gets nowhere. So they again go to their employer, who then has to place a call to the adjuster to find out what is going on. This can be avoided again in the beginning, by taking the time to explain to the party seeking authorization the status of the claim.
Summary
Since there are good and bad adjusters out there, it is that much more important as an employer to become involved in the handling of your claims. Each day an injured worker is out of work it costs you money, and it costs the carrier money in the form of paying out wage loss benefits. Good adjusters step up to the plate to run a claim as efficiently as possible, to streamline the claims process. Not just on the severe claims, but on all of their claims. It comes down to accountability—each adjuster has to be held accountable for the claims that they handle. They should be able to explain any issue relating to the claim, and to whichever party is requesting the information.
There is no rule that states that the adjuster cannot tell the treating doctor that they claim is denied because of an IME. There is no rule stating that just because a claim is denied that the adjuster cannot take the time to explain to the claimant what options they have for rebuttal, or how they can mediate the process if they want to fight the denial. There is no reason why an email cannot be addressed within a short time frame if the adjuster is in the office, no matter how busy the adjuster is or how many claims they are handling.
The customer is king, and the employer is the customer of the carrier/TPA. There is a lot of competition out there bidding for your insurance business. Make sure you have a proactive adjuster, and if not, then it is time to make a change.
Author 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. www.reduceyourworkerscomp.com. Contact: [email protected].
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