Ensuring TPA Quality Control of Adjusters

Ensuring Quality Control Quality control does not just apply to files; it can also apply to the personnel handling files. When you make that choice for an insurance carrier or third-party administrator (TPA), you want to be confident the claim handlers and other members of the team working your claims are qualified.  During the selection process, there are items interested stakeholders should consider before finalizing a decision.  This includes a review of screening tactics an insurance carrier or TPA uses when building their claim teams.



Multi-level Screening and Training Requirements


Most insurance carriers/TPAs prefer to hire entry-level candidates with little to no experience. This happens because HR departments look for new candidates to enter their company.  While it is generally a requirement a claim handler has a college degree, important considerations should include:


  • Requiring a candidate to have a degree in an area that applies to insurance. Examples of this include economics, accounting, finance, human resources, and criminal justice.


  • Training for new members of a claim management team is essential. The best insurance carriers/TPAs provide career path training so trainees know what they must do to move to the next level. Training can also include training that is onsite so they will know and understand the company culture.


  • Forms of advanced training are key to a claim handlers’ success. Proactive stakeholders should require new claim handlers to take steps to receive their AIC (Associate in Claims) designation from the AICPCU (The Institutes).  Other training should include annual compliance training, which includes insurance fraud awareness training.



Other Quality Control Requirements


Interested stakeholders need to go beyond the basics when hiring members for a claim management team.  To ensure the best people are selected, other criteria need to be taken into consideration.  Items to consider may include:


  • Reviewing a candidate’s credit history;


  • Criminal background check; and


  • Be verified to be considered a “fiduciary agent” since they will be making payments for your carrier/TPA on behalf of another party.


State and federal laws may apply to this process.



Commitment to Continuing Education Required


All members of a claim management team are required by state law to complete continuing education in some form.  Once hired, a claim handler will be sent to an extensive claims school, or formal training program – normally these are in-house training facilities.  They will learn the skills from veterans of the insurance industry.  They will handle fake claims to go through the motions


What happens after this initial training is key.  A claim handler is required to obtain a certain amount of extra training and education every year. This is obtained by attending legal/medical seminars, taking online courses, or obtaining an insurance designation.


The management of individual claim handlers is also essential to the success of a workers’ compensation program.  Unless it is a minor claim or a “report-only” claim with no medical treatment, the claim manager will review the file at or around the two-week mark. This will ensure contacts have been made, and a medical diagnosis obtained.  Additional status reporting will also take place at various points in the future:


  • 60-Day Status Report: This is the first formal report on a claim. It summarizes the contacts made, the medical records obtained, and provide an outlook on the claim. It also will address the reserve amounts.


  • 120-150 Day Status Report: This report will assign the current and future exposure on the claim. By 150 days, it will be clear if this will be a long-term large exposure claim. By this time, an injured worker may have had surgery, or has surgery pending. The injured employee may also be released from medical care and the file will be set to close.






Insurance carriers or TPAs have several tools they use to maintain that the work product they put out is of top-notch quality, no matter what the exposure.  There are many items to consider when selecting a team to handle workers’ compensation claims.  Making the right selection includes examining who will be working a claim, and what that company does to prepare their team.  The more you know, and the more involved you can be, the better outcome your claims will have.




Michael Stack - AmaxxAuthor Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a 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 & lead trainer of Amaxx Workers’ Comp Training Center .


Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/


©2019 Amaxx LLC. All rights reserved under International Copyright Law.


Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

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