When Workers Compensation Claim Adjusters have caseloads that exceed their capacity, experience, or training, the technical handling of the claim file can suffer greatly. The resulting claim cost can be minimal to astronomical.
An adjuster with a case load that exceeds their capacity, experience, or training can fail at the following:
- Missing diary dates and following through on plans of action.
- Allowing over payments of both benefits and medical bills.
- Missing excessive treatments and prolonged disability.
- Performing cursory investigations that allow the claim to be improperly processed to disposition.
- Missing subrogation potentials.
- Poorly documenting the file.
- Poor reserving practices.
- Allow subsequent involvement of underlying medical pathologies.
- Fail to prepare properly for disposition.
- Miss proper filings with the state that will incur fines and penalty.
- Missing exaggerated or fraudulent situations.
- Failing to establish professional rapport with the injured employee.
The list goes on…
Case Handling Guidelines:
Adjuster case load studies and independent claim audits generally reached similar conclusions as to what constitutes criteria for proper case work-loads.
They have found work should be distributed by level of claim needs, so the answer is not a one size fits all conclusion. Jurisdictional requirements, adjuster experience, and ancillary support play a large part in determining claim personnel needs.
Here are some general guidelines by claim type:
Most claims only require medical care for short periods of time. This ranges from 80% to 90% of the injuries sustained, and cases normally close within six months. With current medical fees, the total cost should not exceed a $25,000 value.
There cannot be any lost time from work past waiting periods. No permanent disability should be paid as a medical only.
In most jurisdictions, a medical adjuster can carry a monthly caseload as high as 250 to 300 claims. (New cases should be assigned against closures. Closures should be equal to or greater than new assignments. Monitoring of open files must be a regular task to avoid cases remaining open that should be closed.)
A few jurisdictions require state approval before payment is made. This may limit case count activity.
Active Lost Time Claims
Active lost time claims (indemnity cases) vary from a few days up to multiple years. The adjuster’s active handling tends to slow within three to nine months, and most settle with minimal or no permanent disabilities. The indemnity claims usually average between 5% and 8% of reported losses.
Depending on the jurisdiction, an experienced adjuster can handle a case load as high as 125 to 200 claims a month, and new cases should be assigned on the closure record. (Monitor that closures are current)
Fatalities, PTD, Catastrophic, Occupational Disease
The last category covers fatalities, permanent total disabilities (PTD), other catastrophic cases, and long term occupational disease that often require reinsurance intervention. This level of adjuster typically has 10-15 years experience and handles multiple jurisdictions. This adjuster will have a much lower case load because the claims are more complex. Once the claim has settled into routine maintenance it can be assigned to a lighter experienced adjuster.
The question of how many claims is too many claims for an adjuster does not have a one-size fits all answer.
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 compact. 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 quality of the claims and identifying the appropriate caseload for each adjuster handling your claims.
Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: firstname.lastname@example.org.
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