If you are the risk manager or workers’ compensation claims coordinator for a large company where you report new work comp claims on a regular basis, you need to select your adjuster. Whether your workers’ compensation claims are handled by the insurance company or a third-party administrator (TPA), your claims handling agreement should specify that your company has the right to select, from their staff, the adjuster(s), who will handle your claims. If the insurance company or TPA balks at your company having input into who handles your claims, it is time to get another insurance company or another TPA.
Someone in your company must have an in-depth knowledge of the adjuster handling your claims – NOT just the adjuster’s name and phone number. If you want to maximize the effectiveness of your adjuster, you need to know the adjuster’s claim handling style. You also need to know when to step in if the adjuster is not achieving your expected results.
#1- Dedicated or Designated
If you have multiple workers’ comp adjusters in the same claims office handling your claims – ASK — “How many of our claims are you handling?”
The problem with having multiple adjusters in the same office each handling only a few claims for your company is:
- They do not know what your preferences are.
- They do not know your return-to-work program.
- And, they do not know the claim handling philosophy of your company.
Depending upon the jurisdiction and the statutes involved, the experienced workers’ comp adjuster can handle from 125 to 150 claims at a time. If you have less than 125 claims in the claims office, it would be in your company’s best interest to have only one adjuster, a designated or dedicated adjuster, working on your claims.
A “designated” adjuster handles all your claims plus claims for other employers. On the other hand, a “dedicated” adjuster handles only claims for your company. If, for example, you have 280 open workers’ comp claims in the same claims office, you want two dedicated adjusters who working exclusively on your claims.
If your insurance company or TPA is using multiple adjusters on your claims, you need to have a serious chat with them about having a designated adjuster or dedicated adjuster(s) for your program.
#2- Adjuster Experience – Why It Is Important
The level of experience and training the adjuster(s) bring to your program makes a major difference in the outcome of your workers’ compensation claims. While every adjuster has to go through the training stage, do you want the adjuster-trainee making mistakes on your claim files? Let the adjuster trainee learn how to handle claims on the workers’ comp files of the employers who not attuned to their workers’ comp program.
Request an experienced adjuster who knows:
- the statutes and case law within the jurisdiction,
- the plaintiff attorneys who settle fast and cheap
- the attorneys who drag the employees’ claims out trying to maximize them,
- the medical providers and their treatment style
- the medical providers who are liberal with their permanency ratings and the medical providers who are conservative
- the best defense attorneys, and
- the tendencies of the industrial commission/workers’ comp board/court
#3- Investigator or Record Taker
You do not want the experienced dedicated adjuster who is a record taker. A “record taker” copies what is on the Employer’s First Report of Work Injury form to obtain the description of the accident that injured the employee.
An “investigator” reads the Employer’s First Report then contacts the employer’s workers’ comp coordinator, the employee’s supervisor, the employee, and any witnesses to the accident. The investigator obtains detailed information from each party about how the accident occurred before accepting compensability.
The investigator does not stop being quizzical when compensability is accepted. The investigator reads every medical report thoroughly to have a complete understanding of the medical status and medical issues. The investigator then uses that knowledge to move the claim toward resolution. The record taker just makes a note of what the medical report stated.
#4- Combatant or Complacent
When the employee’s attorney makes an unreasonable demand, you want an adjuster who will stand up and say NO. Your company does not need an adjuster who takes the easy way out and accepts whatever the employee or the employee’s attorney wants. Your adjuster should not always be in a combatant mode but should know when to take a stand on statutes, principles, or common sense. The complacent adjuster who does not stand up for the employer’s rights will cost your company a lot of money. When selecting your adjuster ask questions about how aggressive the adjuster will be in defending your workers’ comp claim.
#5- Up to Date or Behind the Times
The workers’ comp statutes and the case law in every jurisdiction are constantly being challenged and changing. The adjuster (and the adjuster’s company) you select for your workers’ comp program should be staying current on all legislative changes and recent case law. When selecting your adjuster, ask what sources the adjuster uses to know about changes in the workers’ comp statutes. The best adjusters have several sources of new information including defense firm newsletters, workers’ comp websites (like this one), and workers’ comp groups on LinkedIn and other social networks.
The adjusters for your company’s workers’ comp claims should be current in their state required continuing education courses. It is also a good sign if the adjuster has obtained their AIC, ARM, AIM or CPCU designation, as it shows the adjuster has continued to learn and improve his/her skill set.
#6- Supervised or Unsupervised
As a part of your claims handling agreement with your insurance company or TPA, you need access to their on-line claim file notes. While you expect to see your adjuster notes frequently, how often do you see the supervisor’s file notes? Does the adjuster’s supervisor offer suggestions or recommendations on your claims, or, do you never see a file note by the supervisor? Even if you have the claims office’s best adjuster, every adjuster can benefit from a second set of eyes on the file. The supervisor should be reviewing the file and making comments on the progress of the file every 60 to 90 days. If not, you need to get the supervisor involved.
#7- Historian or All in Adjuster’s Head
A good adjuster is a historian, meaning everything the adjuster has done on the claim file is documented completely in the file notes. If your adjuster is on vacation or off work sick, you should be able to read the files notes on any of your workers’ comp claims and know exactly where the claims stand. If the adjuster does not keep good files notes, but has it “all in his head,” what happens if the adjuster quits, transfers, gets promoted, or dies? The next adjuster will spend considerable time not working on your claims, but recreating what should already be noted in the file. When you are selecting your adjuster, be sure to state your expectation that activities on the file are to be documented in the file notes.
Once you have experienced dedicated adjuster(s) working on your workers’ comp claims, don’t stop there. You must benchmark your results each year to verify that the adjuster(s) working on your claims are exceeding the benchmarks for your industry. If your adjuster’s results are not adequate, do not hesitate about asking your insurance company or TPA for the selection of another adjuster(s) for your workers’ comp program.
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 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 co-author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:.
Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/
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