A work comp injury can change a person. It can change the way they think about their daily functionality. It changes their attitudes. It can change their motivation in life, and it can change their overall demeanor.
These are just some of the things the claims adjuster has to deal with. For example, an employer files a new claim and they tell the adjuster that Joe Blow is a great guy, there are no concerns on the claim, and they expect him back to work in no time. Jane Adjuster thinks she has this one in the bag—finally a straightforward claim with a person that is amicable to talk to and motivated to return to work.
Then right from the get-go, this is not how it unfolds. Joe Blow is rude, dodges answering questions about his medical history, and comes off as overall suspicious. But the employer said this was a good guy? What the heck happened?
The encompassing spectrum of work comp is what happened. Adjusters play many roles in this profession. They are trained to spot trends, look for inconsistencies, dig for the truth, and so on. But investigating claims is not the only role the adjuster plays. The overall work comp system is filled with trap-doors, outside financial incentives, improper billings, internal financial leakage, and the list goes on. The following are a few other things that the adjuster feels pressure from throughout the course of a normal day:
Medical Provider/Legal Provider/Client Financial Incentives
Every occupational clinic or doctor out there that treats work comp cases does so because it is a good way to stabilize a practice. Work comp is an issue that will never go away, so it makes good business sense to see these patients and bill the insurance company since you can make a lot of money treating patients in this realm.
The same can be said for Legal Counsel. Providing insurance defense is profitable for a law firm. It provides a lot of business, which looks good for your fiscal books. Attorneys will bill hours, time spent on the phone, time composing emails, preparing cases for mediation, etc. All of these things mean big bucks, and becoming a large law firm that is well known in the insurance defense business means you have a huge profit margin!
Employers/clients of the insurance company also have financial incentive, but this comes in a different manner. They are potentially hiding evidence, not reporting claims, or providing incorrect evidence in order to prevent their premium from increasing, or to prevent another hit on the loss run books.
The adjuster has to look at each of these three relationships in just about every claim. Insurance doctors love to treat, and they love to keep patients coming back for more until the adjuster finally cuts the treatment off. The clinics will refer the patient for unneeded physical therapy, prescribe strong addicting opiates, and will refer patients to their peers in orthopedics or neurosurgery to further the “kickback” they could later receive. The attorneys love to bill hours, and that’s how they make money. Legal bill auditing software is constantly finding billing errors in time where attorneys (whether they did it intentionally or not) incorrectly billed extra time while preparing or reviewing a case. The common adjuster (or the overloaded one) may miss all of these points, which results in financial leakage for the carrier, which in turn is passed to the clients in the form of increased premiums.
Adjusters are Investigators, Mediators, and Conflict Resolution Specialists
The life of a claims adjuster does not end with just reviewing claims. As part of the process, adjusters must also be effective in many other fields other than adjusting claims. They must be effective in resolving conflicts between all involved parties. This can include conflict between the injured employee and their employer, from insurance carrier and medical provider, or even conflict from the adjuster and their own supervisor.
Many parties are involved in a claim. There are the claimant, the employer, the adjuster, the insurance carrier they work for, the doctor, the occupational clinic, the defense counsel, the plaintiff counsel, IME doctors, SIU people, nurse case managers, vocational professionals, and the list can go on and on. But one thing remains constant—and that is that the adjuster is steering all of these parties, and trying to resolve all of the conflicts between all opinions of the parties, at all times. Rarely does a claim sail along smoothly like a boat on a sunny day out at the Cape. The adjuster has to piece the puzzle together, and the pieces of that puzzle are ever-changing by the day. If you cannot multitask and be a chameleon of sorts in juggling all of these issues, then you wouldn’t last an hour at the desk of a claims adjuster.
Achieving Excellence Through Communication
Simplicity is vital to the work comp system. But, it is a farce to think the system is cut and dry. New laws, regulations, and processes are constantly being implemented or changed, then changed again, then later changed back. The key to the system is communication, and the communication has to be directly with the adjusters.
For example, it is easy to theorize that someone that is obese is going to take longer to heal than someone who is more fit. But what is obese, using a BMI measurement? When was the last time you saw a Body Mass Index reading in the clinic notes at an occupational clinic? I’ve seen the doc label someone “obese”, but this person is a 5’10” 200lb male that does heavy work lifting day in and day out. Is this person really “obese?” I don’t think so. If this is the case then how can you justify setting a reserve on a claim for an “obese male” when you don’t think he is obese to begin with?
Communication between the doctor and adjuster are pivotal in any claim. But it doesn’t end there, the doctor and adjuster also have to communicate effectively with the injured worker. This will mean that a long phone call or conversation has to take place since the injured worker most likely doesn’t know how this affects his case.
Treat Every Claimant as a Friend or Family
I tell newer adjusters to pretend that every claimant is a friend of theirs, the dad of a friend, or your sister/brother. If a claim happens in your family, you will take the time to explain to your relative or sibling what their rights are, what the process is, other doctors they could see, etc. So why would your claimant deserve any less attention than the best attention you can give a person?
Unfortunately the answer to that is that you (the adjuster) can’t spend an hour on the phone with every claimant, because you have 200 active claims in addition to the new ones coming in every day. You also have reports that are due, reserves to set, meetings to go to, forms to file, and phone calls to answer.
Just remember as you go through your day—your claimant is someone’s brother, dad, son, daughter, cousin, sister, uncle, aunt, neighbor, etc. They deserve to get their questions answered to their satisfaction just as much as if the shoe were on the other foot, and you were the injured worker with questions and concerns on your mind, having no idea what is going on or what to do next.
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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