Key Questions to Ask When Selecting An Insurance Broker

January 20, 2016 by 2 Comments

Selecting an insurance broker is an important decision for a company. Usually, smaller companies just use their insurance agents. However, most large companies have brokers rather than agents because they have many coverage lines that are obtained from many different insurance companies.

 

The insurance broker acts in a fiduciary role for your company. Your company trusts the broker with protecting your financial assets through selecting and obtaining your insurance. While the broker acts on your behalf, their actions are subject to your control and consent.

 

This fiduciary responsibility of the broker goes beyond just finding the best price for your company’s insurance. They also have the fiduciary obligation to recommend the best financial protection of your assets for both the short and long term. The insurance broker’s duties and obligations are to put your company’s best interests first. A good broker will take the initiative to act to provide benefits to your company without the company having requested it.

 

To make sure your company selects the best insurance broker for its needs, it is important to interview any prospective brokers before finally selecting a broker. You need to make sure that the broker you choose is the one that best suits your company’s needs, which isn’t necessarily the biggest firm or the one with the most advertising.

 

 

Key Questions to Ask

 

Cost Effectiveness

 

First, you want to know how the insurance broker will make your program more cost effective. Some brokers have cost containment experts to provide suggestions and support. Ask the broker how they will:

 

  • Review and analyze your existing coverage?
  • Structure your company’s program?
  • Market your company to insurance carriers?
  • Enhance your company’s insurance coverage and reduce costs to make your program more cost effective?
  • Do they have incentive-based options for their fees?

 

 

Customer Service

 

Second, you will want to know what type of customer service your company will receive from the broker. As the broker:

 

  • Who is the team that will service your account? Are they willing to meet with your team to brainstorm and implement ideas?
  • How easy is it to reach their team by phone?
  • Are they easily accessible via email?
  • Is the broker tied into the internet? Is their website user friendly? Do they have lots of educational resources available for clients?
  • What experience they have in your industry? Do they have industry groups for your industry?
  • Do they have RIMS (Risk Management Information Systems) capabilities?
  • If your company has operations outside the United States do they have experience in those parts of the world?
  • What is their timeline for all the activities they propose?
  • How will they ease the transition from your present to any new carriers? Do they have experience with your existing carriers?

 

 

Capabilities

 

Next, you will want to know what the broker’s capabilities are in the following areas:

 

  • Claim Advocacy: Do they have claim specialists to help in difficult situations?
  • Claim Reviews: What are their procedures for claim closure and best practice reviews?
  • Loss Control: Do they have specialists to help develop strategic plans in areas such as:

o Ergonomics

o Repetitive motion injuries

o Loss trend analysis

o Slip and fall prevention

o Air quality programs,

o Lock-out/ tag-out expertise,

o Safety consulting on OSHA requirements and safety cultures

  • Post-Loss Cost Containment: What systems and procedures do they have to reduce workers’ comp costs after an employee is injured?

 

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: mstack@reduceyourworkerscomp.com.

 

 

©2016 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.

 

Filed Under: Broker Issues & Relationships

Unethical Carrier Behavior? When To Run For The Hills…

January 14, 2015 by Leave a Comment

Over the course of several years and numerous files I have reviewed, I would say that most of the time an adjuster does their job very well.  Files that should be compensable are compensable.  Benefits are paid out on a timely basis.  Reasonable and necessary medical treatment is authorized and covered under the claim.  Providers are paid in a timely basis, and so on.

 

From time to time, I do see claims where I question the motivation of a certain denial.  For example, it is not a claim where it is a flat out denial due to clear non-occupational circumstances.  Those claims are easy to see a non-occupational correlation between a diagnosis and the alleged claim details.  Perhaps there is a lack of witnesses, or the physical exam showed clear signs of secondary gain or malingering, or the objective medical evidence is not there to support compensability.

 

I have come across claims where I see a clear causal relation, and the medical seems to support the mechanism of injury.  Why are these claims denied, and steered towards potential litigation rather than just accepting the claim?  Is this clearly the fault of the adjuster or manager?  Is it a lack of claim investigation?  Is the adjuster maybe giving in to the manager and their motivations of hitting a certain benchmark for denials?

 

Maybe it is all of the above, but I do wonder about motivations from time to time.  I would hope that the adjuster or manager or carrier in general has the best interests of claim ethics on their side.  However, I lack faith that this is held true 100% of the time.  So why would a claim that appears on the surface to be compensable be denied on purpose?

 

 

The employer does not want the claim accepted for whatever reason

The employer does not have the right, nor the authority, to force a claim to be denied for any reason.  However the pressures the employer can create for the carrier/adjuster/manager are always going to be there, especially when they strongly feel a claim should be denied for whatever reason.  In this scenario, the adjuster/carrier/manager needs to discuss this with the employer/client and explain to them the rationale behind the claim and its acceptance.  To blindly look the other way and just deny the claim is not only doing so in bad faith, but it is totally unethical, unacceptable, and that type of behavior should never be tolerated at any time.

 

 

The claims manager thinks the claim should be denied but the adjuster has good rationale for claim acceptance

The claim manager should be there to help with these decisions in the first place.  But the adjuster is the one that completed the claim investigation.  Does the manager know the whole story?  Are the claim notes complete and updated with the current information at the time the manager reviewed the file?  Disagreements between the adjuster and their manager on the outcome of the investigation of the file should then be round-tabled with other claim staff.  This meeting should include the adjuster, the manager, the employer contact, and the manager’s supervisor.  Somewhere along the way some fact is being misinterpreted by one of the parties, and everyone needs to be on the same page before moving forward.  Quite often the adjuster left out a note, or piece of medical, or some other fact that can be the missing piece of the puzzle the manager is not seeing which can swing the claim from being denied to being accepted.

 

 

Or the other way around—the adjuster wants to deny and the manager thinks the claim should be accepted  

This is due to a lack or breakdown in communication between the adjuster and the manager.  Before moving forward, the file needs to be broken down and reassembled so everyone is on the same page.  Perhaps the adjuster did not complete a thorough investigation, and is trying to deny the claim without completion of the investigation.  A claim denial can lead to significant future exposure.  Before a denial should take place, everyone has to agree to the decision to protect the insured and the carrier.

 

 

The claim involves high exposure and the adjuster/manager/carrier wants to control the claim by steering it in to litigation rather than voluntarily paying it 

Should a claim involve a serious injury, that should not mean that you dodge responsibility by pushing it towards litigation in order to control costs.  It all comes back to proper and complete claim investigation.  Denials should be based on the investigation of the claim and the supporting case law.  It should not be based on the fact that the carrier does not want to complete the proper investigation and they just want to “rubber-stamp” the denial on the case in order to make the claimant escalate the issues in litigation.

 

 

Renewal time is approaching and the carrier wants to look aggressive to the broker and insured

Perhaps the most severe behavior of all, this type of issue is more common than you would think.  When you review a loss run, it is not uncommon to see a bunch of denials starting a few months before policy end.  This is because the insured wants to put on a face of aggressiveness for the broker and for this account, to show how they are fighting to protect the employer/client.  I would love to say that this does not happen, but sadly it does.  Not at every carrier, and not all of the time.  But this fact is out there, and if anything it should thrust that red-flag to the tallest flagpole in the land.  If your carrier is exhibiting this type of behavior near policy-end, it should reveal the weakest attempt at showing their worth.  If I were the broker/insured and I see this happening, I would run for the hills as fast as possible.  This type of behavior should show the insured the obvious—that their current carrier does not have their best interests at heart.

 

I have probably only scratched the surface here, and I wish I did not have to mention this happening anywhere.  Let me clearly state that this type of behavior is not rampant, but it can be out there, and it is something to watch for.  If a broker or insured even thinks that the carrier is not acting in their best interest, then they need to get out of that carrier as soon as possible.  Denying claims is not the stamp of approval for a proper carrier/insured relationship.  Every single claim needs to be properly investigated and handled according to Jurisdictional case law and Statute.  Blind denials and unethical behavior should never be tolerated on any claim, even the most insignificant.

 

 

 

Author Michael Stack, Principal of Amaxx Risk Solutions, Inc. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  As the senior editor of Amaxx’s publishing division, Michael is on the cutting edge of innovation and thought leadership in workers compensation cost containment. http://reduceyourworkerscomp.com/about/.  Contact: mstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

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

 

Filed Under: Broker Issues & Relationships

The Workers Comp Insurance Broker – Employer Relationship

January 28, 2013 by Leave a Comment

 

The relationship between the insurance broker and the employer is often overlooked in the management of a workers’ compensation program.  (Employer as used in this article is any business that has employees subject to the workers’ compensation statutes of their state).  An understanding of the role and responsibilities of your insurance broker will make your interactions more productive and will strengthen your workers’ compensation insurance program.

 

The insurance broker acts in a fiduciary role for the employer.  The employer is entrusting the broker with protection of the financial assets of the employer, through the selection and obtainment of the workers’ compensation insurance.  While the broker is acting on the behalf of the employer, the broker’s actions are subject to the control and consent of the employer.

 

The broker is acting as an agent of the employer.  [The technical differences between an insurance broker and an insurance agent would be a separate blog, but for simplicity of this blog, an insurance broker is an insurance agent, but also performs a broader range of services for the clients than an insurance agent only would provide].  The agency relationship of the insurance broker from a textbook analysis includes:

 

  • Acting on behalf of the employer
  • Acting with the consent of the employer
  • Acting under the guidance and control of the employer
  • Acting as the fiduciary of the employer

 

 

Acting on Behalf of the Employer:

 

The insurance broker’s primary duty is acting in the best interest of the employer.  In most situations the broker’s and the employer’s interest align and this is simple for the broker to do.  However, there are situations where what is in the best interest of the employer does not benefit the broker as much as a conflicting interest.  For example, Insurance Company A has lower insurance rates but also pay only a 10% commission to the insurance broker.  Insurance Company B has insurance rates that are only 5% higher than Insurance Company A, but Insurance Company pays a 15% commission to the insurance broker.  The ethical broker will act on what is in the best interest of the employer, even if it is not the most beneficial approach for the broker.

 

 

Acting with the Consent of the Employer:

 

The insurance broker’s primary purpose is to represent the employer to the insurer(s).  In order to do this, the broker must have the consent and authority given by the employer.  Without the employer’s consent to act on the employer’s behalf, the broker is powerless to provide any services or benefits to the employer.  In several jurisdictions, insurance brokers require a written authorization from the employer to act as their agent/insurance broker.

 

 

Acting Under the Guidance and Control of the Employer:

 

The employer is responsible for guiding and controlling the actions of the insurance broker.  By this, we mean the employer instructs the insurance broker on the type of coverage (workers’ compensation) that is needed, the date the insurance coverage is needed, the type and number of employees to be insured, and the amount of payroll on which to base the workers’ compensation premium.  The broker has the duty to obey the instructions of the employer in obtaining insurance within the perimeters of the instructions provided by the employer.

 

The professional insurance broker will carefully follow the instructions of the employer, but will also provide assistance and guidance to the employer when the employer’s directions to the broker are not in the employer’s best interest.

 

 

Acting as the Fiduciary of the Employer:

 

The broker, acting as a fiduciary of the employer, is responsible for protecting the financial well-being of the employer.  Often employers think this means only finding the best price for insurance coverage.  This can be short sighted.  The fiduciary responsibility of the broker is to recommend the best financial protection of the employer assets both for the short term and for the long term.

 

If Insurance Company X has a lower initial price, but the broker knows Company X provides horrible claim service which results in employees being off work longer than necessary, causing more administrative headaches for the employer, and resulting in higher than normal claim cost, Insurance Company X would be a bad recommendation by the broker.  If Insurance Company Y has a slightly higher price, but provides excellent service and lower than average claim cost, the insurance broker would be violating his/her fiduciary responsibility to the employer if he/she recommends Insurance Company X without fully explaining and discussing his/her knowledge of both Company X and Y.

 

 

A Degree of Care:

 

The insurance broker has the duty and obligation to put the best interest of the employer first and should demonstrate a standard of care that shows the employer that the broker puts the customer first.  This does not mean the broker should do what is impractical or impossible.  If the broker sees that an instruction of the employer cannot be met, the broker should advise the employer of the reason(s) the instruction is not followed.

 

It should be noted that the broker often will act in what he/she believes is in the employer’s best interest in areas that have not been discussed with the employer.  When an employer finds a broker who takes the initiative to act and provide a benefit to the employer without the employer having requested it, the employer should recognize the broker is a good bet for a long-term relationship.

 

 

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 author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com.

 

Editor 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: mstack@reduceyourworkerscomp.com.

 

©2012 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

Filed Under: Broker Issues & Relationships Tagged With: , , , , , ,

Three Areas to Review for 2013 Workers Comp Preparation

November 16, 2012 by Leave a Comment

With the New Year approaching, it is always a good idea to reflect on the last year and think of new ways to do business.  Whether this is in a claims aspect, or relevant to your business in general, change is always a good thing.

 

Oftentimes we become too comfortable and familiar with the normal relationships we have day in and day out, and at certain points it is a good idea to take a peek at your business as a whole and come up with new ways to do things more efficiently.  Below are some points of interest that may be applicable to your business:

 

 

  1. Outside vendor relationships

 

Let’s say that your pal Bill’s company is the company that provides all of your work laundry, carpets, and other industrial items.  Bill has done business with your company for years, and there have never been any complaints.  His prices seem to be in touch with the industry averages, and the products he supplies you with work just fine. Overall you are satisfied with his work and when there has been an issue in the past he has been able to resolve it with little conflict.

 

This is an example of a good working relationship.  But, your lack of research has maybe let you down.  Bill’s company may have many competitors and those others in the market may have something that is of benefit to you and your company. Bill’s biggest competition is Dave’s company.  Perhaps Dave has better work shirts, made of better materials that are lighter to wear and more breathable for your employees.  Maybe Dave’s company has better wear resistant carpets with the latest technology that can further reduce slips and falls for your workers and customers.  Despite what Bill has told you, maybe Dave’s prices are very close to Bill’s prices, but the technology is better.  This better technology leads to fewer trips out to your workplace for repair and replacement.  The less service calls you have, the cheaper the cost is on an annual basis.

 

This may be a small aspect of your yearly costs, but there is an important lesson here: To always be aware of the latest companies out there and what they can offer you. If you never reach out to them, you may never know what they can offer you.  This doesn’t mean that Bill does a bad job, but healthy competition can keep Bill on his toes so that he is offering you the latest and greatest thing out there, which can only benefit you and your company in the end.

 

 

  1. Your Current Carrier/TPA/Broker

 

The same can be said with your carrier that is handling your insurance claims. XYZ Company does a great job with your claims.  You have never had any major blowups with any of your claims, but again this doesn’t mean that they are on the cutting edge of claim technology.  A lot of carriers out there are now fiercely competitive, both in price and with their claim technology.  Carriers want you to be interactive with them, allowing you access to their systems in an ease to create that “teamwork” atmosphere.  The more you are involved, the more proactive you will be—at least that is their hope.  Even though you may have never had an issue, again you do not know what is out there unless you go look for it.

 

The same can be said with the current Broker that handles your business.  You may think you have adequate service, but how can you know until you see what else is out there?  You may find other brokers that are quicker, better, and more efficient with your issues that you need addressed.  So take a look around, and maybe talk with some other Brokers to see what they have to offer.  If nothing in particular tickles your fancy, then by all means remain with the current relationship that you have.  But at least you looked in to it, and can be satisfied with the service you have when compared to what else is being offered.

 

 

  1. The Current Claim Team that Handles Your Insurance Issues

 

Sticking with XYZ Company, you think they do a good job and you are satisfied with the current team that handles your claims.  Despite the fact that you may have never met them face to face, they are personable and professional, and seem to know what they are talking about.

 

But what about everyone else that is in that office?  Who else works there, and what do they have to offer your company?  Insurance people are known to go from place to place, and you may never know that Frank, who is new at XYZ but has years of claim experience, lived in the city where you do business and has handled claims there for a number of years.  He knows the city, the type of people that reside there, and more importantly he knows of a lot of physician groups and vendors that may be overlooked at XYZ for whatever reason.  Frank could be a great asset to the team that handles your claims.

 

Most carriers will keep a profile on their adjusters.  This will have their educational achievements, professional licenses, and claim experience levels to best match up insured clients to their own staff in order to create the best team possible for said client. But if you never ask, they will rarely change anything, since the squeaky wheel will be the only one that gets the grease.

 

To see what you have to choose from, you can ask the claims supervisor if they can send you a current roster with profiles. You may be able to find a new addition to your team that can turn out to be a great asset for 2013 and beyond.  If Nancy handles your claims, and all of the sudden Frank gets moved in and Nancy goes on to handle another insured account, trust me Nancy is not going to lose any sleep over it.

 

Adjusters can handle several clients at once, and getting swapped out for another adjuster is not going to generate any ill will.  The worst that could happen is that Frank is not as awesome as you thought he could be, and you can always swap them back out again.  Bear in mind there may be a bit of a learning curve for Frank in the beginning, but give him a chance because you may find a great resource just by “trading” the staff of adjusters that addresses your claim needs every day.

 

 

Summary

 

Change can be good, and competition can be healthy.  It is hard to adapt to change in the beginning, but you have to be patient and let it run its course. It is only when you do not change that you can never be evolving into something greater.

 
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: mstack@reduceyourworkerscomp.com.

 

©2012 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

Filed Under: Broker Issues & Relationships Tagged With: , , , , ,

Industry Leaders Discuss Challenges at Broadspires First Pharmacy Summit

April 5, 2012 by Leave a Comment

 

pictu1Medications and drugs continue to play an increasingly important role in the overall of medical costs in workers compensation claims. In addition to the increases in costs, the potential claim risks have also increased surrounding the growing use of narcotics in the treatment of pain. These issues impact all involved parties in the claim administration process – from injured worker, to employer, to carrier or payer. How to manage these issues has now become a critical issue.
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On March 22, 2012, Broadspire, a Crawford Company and leading third party administrator (TPA) and medical management services provider, brought together representatives from a number of key industry organizations to discuss the challenges in prescription drug management for workers compensation claims during its first pharmacy summit.

 

 

 

pictu2

The intention of the summit was to focus on global industry issues, trends and developments in the future. In bringing together resources from all aspects of the pharmacy management process, the group was able to have an all encompassing discussion of the issue, and examine the challenges from all perspectives and vantage points. Throughout the day, the group discussed the common threads that tie together claimant, payer, employer and carrier interests. The group also shared ideas that could be put into practice to improve outcomes for everyone concerned.

 

 

 

 

More than 50 brokers, practice leaders, clinicians and others from major insurers, insurance brokerage firms and pharmacy benefit management (PBM) organizations attended the summit, which was held at Broadspire’s Sunrise, Fla., medical management headquarters. The panels were divided into four key areas of focus

 

  1. Pharmacy program design
  2. Opioids and controlled substances
  3. Physician dispensing
  4. Key legislative updates.

 

 

 

pictu3The first session focused on the overall design of an effective pharmacy program. Panelists in the discussion included Eileen Ramallo, Executive Vice President of Healthcare Solutions; Lori Daugherty, President of PMSI/Tmesys; Atermis Emslie, President of MyMatrixx; and Kathy Tiemeier, Clinical Program Manager of Express Scripts.

 

 

 

 

 

 

pictu4Candy Raphan, RN, BSN, ARNP, MAOM Candy joined Broadspire in 1989.  For over 20 years, she has held various management roles within the Broadspire organization in a variety of functional areas, including Occupational and Non-occupational Disability Management, Utilization Management, Medical Bill Review, Quality, and Medical Management Strategic Outcomes.  In her current role as Director of Medical Services, Candy is a Practice Leader for Broadspire’s Comprehensive Pain Management Solution and responsible for the clinical components of the pharmacy program, medical analytics, reporting and other clinical program development.

 

 


In addition to her experience at Broadspire, Candy brings a varied background of clinical, managed care and health industry related experience.  She is a certified advanced registered nurse practitioner with a specialty in family practice, Candy holds a bachelor’s degree and advanced practice certificates in nursing from the University of Miami and a master’s degree in organizational management from the University of Phoenix.  Candy is also a member of the National Association of Professional Women and the American College of Healthcare Executives.

End Article
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WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com 
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
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Understanding Key Differences Between Insurance Agents and Insurance Brokers

March 24, 2012 by Leave a Comment

Employers often wonder does the workers compensation agent or broker work for them or does the agent/broker work for the insurance company?  If an issue develops with the workers compensation insurance company, will the agent/broker be there to assist you, the employer in resolving the issue, or will the agent/broker repeat what the insurance company says?

 

 

As both insurance agents and insurance brokers sell insurance to the public, many people use the terms “agent” and “broker” interchangeably.  They think of them as one and the same. There are some subtle, but important differences between an agent and a broker. [WCx]

 

 

The insurance broker is an independent business that sells insurance products for various companies. The insurance agent can be either an independent agent or a company agent.  The independent agent, like the broker, will sell insurance policies for multiple companies. While the company agent, also referred to as a captive agent, sells insurance policies for a single insurance company.

 

 

Both the agent and the broker act as intermediaries between the client (the employer) and the insurance company.  They are both responsible for the proper processing of the application for insurance, the various forms and collecting, and submitting the premium to the insurance company. Large domestic and multi-national companies use insurance brokers to handle their insurance needs which are complex, with multiple types of insurance.

 

 

The difference between an independent agent and a broker is a matter of degree.  A pure agent will sell the insurance policy and perform the administrative functions.  The broker in some states will have a different license than the insurance agent, representing more experience, more education or both.  Brokers often offer a wider variety of insurance products.  Brokers will often have the expertise to analyze employer business needs and make recommendations on how to provide the coverage needed.  Brokers cover the cost of the higher level of expertise by adding an administrative fee to the workers compensation policy in the form of a higher premium. If they place sufficient volume with an insurance company, the commission they receive is higher from the insurance company. In all states, insurance agents and brokers need to be licensed.

 

 

A good agent or a good broker will educate the client ( the employer) any time there is a question or a concern about what  insurance coverage is needed. By providing you with information, they will guide in making the best decision for your company. The good agent or broker will never make the decisions for you, but give the information to make the best decision for your company.

 

 

The independent agent and the broker will place your insurance business with the insurance company(s) that can best provide your company the workers compensation or other insurance products that are right for the company. The insurance contract is arranged by the agent or broker or between your company and the insurance company.  The agent or broker is not a party to the contract.

 

 

Often the greatest difference between an agent and a broker can be seen when a dispute arises between the employer and the insurance company.  The captive agent is an employee or agent of the insurance company and will toe the company line.  The independent agent and the broker represent the client, the employer. In all situations the insurance policy language will prevail.  When the insurance policy is ambiguous and does not clearly address the situation between the employer and the insurer, the independent agent and the broker have the responsibility and the obligation to represent the interest of the employer.

 

 

Brokers and independent agents run into trouble when they allow loyalties to shift to the insurance company because of concern for maintaining business relationships with the insurer.  Brokers and agents should work in the best interest of the client, the employer, even when it could be to their own detriment.

 

 

Whether a captive agent, independent agent or broker, they each have a duty of due diligence and attention to the suitability of the insurance policy they are arranging for you.  Each should be looking out for the employer interest and using their expertise to provide your company with the workers compensation insurance coverage that is right.

 

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 website 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 author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20% to 50% www.WCManual.com. Contact: RShafer@ReduceYourWorkersComp.com.

 

 

Our WORKERS COMP BOOK:  www.WCManual.com

WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact info@reduceyourworkerscomp.com.
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Know These 5 Ways to Keep the TPA Relationship Running on all Cylinders

February 16, 2012 by Leave a Comment
Whether your carrier/TPA is a small firm in your state, or a larger nationwide facility located on the opposite coast of the US, you will always have to have some sort of interaction with them. 

Claims will never be avoided, and since you are the employer, risk manager, claims coordinator, whatever your title may be, you need to know who to reach out to with questions. If the only source of contact with your carrier/TPA is a 1-800 number to call with questions, you probably will not get very far. You may eventually get to the right person, but it could take you all morning. 

 
 
To avoid such a scenario, you need to know who is handling your claim, where they are located, and how they can help you. The more you personalize your relationship with them, the better they will work for you, and the quicker your questions will be responded to.   Even if you only have a handful of claims per year, adjusters will respond to those employers they have a good interpersonal relationship with. Let’s discuss 5 ways to improve your relationship with your adjusting team: (WCxKit)
 

1.    Know your adjuster and their team

If you do not have a lot of claims per year, or you are a smaller shop with limited exposure, you may not really know which carrier/TPA office location will be handling your claims. Maybe they start off in one city, such as Boston, then end up in Philly. Or maybe they start off and end in Milwaukee. Do you really know who has your claims, where they are, and who to contact with questions?
 
 
If you call your agent/broker, they may have the answer to this question. But with insurance carrier/TPA offices becoming more and more consolidated, even your Agent may not be 100% sure. So reach out to your carrier/TPA and find out if a dedicated local office will be handling your claims. Or, maybe they will start out at their Home Office in Boston, and then be transferred out to a local office in your state if it is a lost time claim, a claim that needs special investigation, or a claim that has issues with compensability. If you know who to call or email with questions, it will make filing claims and getting answers to your questions that much easier and quicker.
 
 
2.    Communication is key
The main reason a claim derails from running smoothly is a lack of communication. Whether it is from the employee not talking to the adjuster, or a miscommunication between the employer and the adjuster, communication is extremely important when dealing with any aspect of claim handling. Be sure to check with your adjuster on all your open claims, and get an update on what is going on, and what their plan is to resolve the claim.  
 
 
Even if you only have a handful of claims per year, your input is valued more than any other. After all, you as the employer are their client, and the carrier/TPA wants to make you happy. Adjusters will appreciate someone out there that cares about what they are doing to move these claims along. Scheduling regular claim updates is also a great way to prevent a claim from slipping through the cracks. Plus the more you as the employer are involved, the more the adjuster knows they have to keep an eye on your claims since you will be checking up on them. The more you are involved, and the more you communicate, the better your claim will be handled.
 
 
3.    Answer all questions the adjuster asks
If an adjuster has a question about something, no matter how insignificant it may seem to you, it is probably really important to the adjuster. Several states require reporting to the State Bureaus of Work Comp, and missing information will hold an adjuster up from completing their filings. Even minor missing info such as a date of hire is important to the adjuster. They need complete info as part of their job for their state filings, so if they have questions about personal info, phone numbers, hire dates, wage history, etc. do what you can to get that info for them so they can move on with the claim. 
 
 
Details such as the hire date could also key them in on certain aspects of the claim. If it is a new hire, maybe that explains why a worker cut their hand, or strained their back. Wage info is always needed when there is lost time. If the adjuster needs the wages, they probably can’t pay your worker until they get that info. A date of birth is needed for state filings, but it is another key to the claim, since an older worker may mean that this particular claim won’t resolve as easily as it would with a younger worker. The examples here are endless, and the bottom line is to get any requested info to your adjuster on a timely basis. You don’t have to stop what you are doing to look that info up, but try to get it for them within a few business days. The sooner you do, the quicker it is off your desk and the less chance you have of forgetting about it.
 
 
4.    Bring your adjuster and their team out for a tour of your facility
If you are a large enough employer to churn out 50 claims per year, you probably will know who your adjuster is by name. You may even know who their manager is by name. But do you actually know who they are, other than just by name? Employers that have a lot of claims may know a little about their adjusters through casual conversation, such as if they are married and have kids, if they are sports fans, etc. 
 
 
A way to strengthen the relationship is to have them come out to your facility for a tour. Not only can you put a face to a name, but it greatly helps your adjusters by seeing the premises. Adjusters can look at the machines, observe the workers doing their jobs, and get a better idea and understanding of what you guys do day in and day out. This helps them mentally process the claim by knowing what your injured workers are talking about when they are describing what they were doing when they were injured. If you describe a machine injury to 10 people, you could get 10 different ideas of what happened. But if you show your claims team the machines and how your operators run them, and then they know exactly what a worker is talking about when they were injured.
 
 
5.    A “Thank you” goes a long way
As we have said time and time again, the work of a claims adjuster is often a very thankless job. Sure, it is the adjuster’s job to handle these claims, but often it is a stressful, high demand profession. Taking the time to thank your adjuster for their hard work will mean a lot to them, and they will take that compliment and use it to handle any of your issues right away. Your adjuster certainly will not forget your praise, and you can get them to work that much harder for you now and in the future. (WCxKit)

 

Summary:  
Even if you only have a few claims per year, you will want those claims to be handled as if you are the only client that adjuster works for. Unfortunately, this is not the case. Adjusters usually have 150+ claims they are keeping an eye on, and a good way to get yours handled effectively is by implementing what we have described above. Get to know your team, take the time to meet them in person and show them around, and hand out praise when it is deserved. Your adjusting team will not forget it, and it will only make your life that much easier when it comes to getting claims resolved.
 

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website 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 author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com. Contact: RShafer@ReduceYourWorkersComp.com.
 
 
Our WORKERS COMP BOOK:  www.WCManual.com
 
WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php

 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact: Info@ReduceYourWorkersComp.com

Filed Under: Broker Issues & Relationships, Claim Management, Communication with Employees, TPA and Claims Administration, WC 101 Tagged With: , , ,

What Insurance Agents Need to Know about Workers Compensation

January 29, 2012 by Leave a Comment
 If you are going to sell business insurance  to the business community, you need a strong basic understanding of workers compensation insurance. While companies will be concerned about having insurance for their buildings, inventory, and vehicles, and will understand the need for various types of property insurance, the same companies will look at work comp insurance as a governmental mandated cost of doing business.
 
 
As their agent, you need to be able to explain to your client business the importance of workers compensation and how it works.
 
 
While your clients, the companies, will think about their property insurance exposures, they will have a far higher frequency of workers compensation claims then property claims. Therefore, selling and servicing workers compensation insurance can be challenging for any agent, even experienced ones. The successful insurance agent will be the agent who can explain the advantages of all types of business insurance including workers compensation.(WCxKit)
 
 
A major part of the challenge of workers compensation insurance is the way it is different from the other various business lines. With property insurance, the cost of the claim can normally be ascertained fairly quickly and easily. The longer life of some work comp claims, along with the variables of medical treatment, income replacement, and a third party (the employee) who has a different perspective and different motivation, makes the evaluation of the cost of the work comp claim much more complex.
 
 
The complexity of work comp is what often keeps insurance agents from being as educated in workers comp as they are in the other insurance products they sell and service. However, learning the parameters of work comp is not nearly as difficult as you might think. To assist you in becoming more proficient in work comp, we have put together a guide that has become quite popular both with agents/brokers and with risk managers/corporate financial control management.
 
 
Our guide will assist agents in better understanding the entire work comp process which will assist you, the agent, in providing a higher level of service to your clients when they have a claim or even when they just want a better understanding of workers compensation. The chapters of the guide that will be of special interest to insurance agents include:

1. How an employer should assess their work comp program.

2. How the employer should structure their work comp team.

3. The forms and documents the employer will need to process/submit their work comp claims.

4. The training the employer will need in their work comp program.

5. The management and monitoring of the employer’s work comp program.

 
Additionally, as the agent, you will want to understand what is going on with the client’s work comp claims. Learning more about the claim progress will allow you to answer the questions your clients have about their claims. Knowing the differences between the way property and work comp claims are handled will allow you to better service your clients. Some of the topics that benefit insurance agents and allow for a better understanding of workers compensation include:
 
1. The role of the third party administrator in the work comp claim.
2. The differences between bundled and unbundled services.
3. The importance of proper account handling instructions.
4. The role of medical management in the claim.
5. The best practices of work comp claim handling.
6. The ability of the employer to control the selection of the medical providers.
7. The importance of a return to work program at the client.
8. The importance of a solid safety program.
9. How to fight fraudulent claims.  WCxKit
 
It is important that the agent can answer all of their client’s insurance questions including the questions on workers compensation. We encourage you to learn work comp to the point that you can answers all your client’s questions. If you want to know more about cost containment, learn more about our book Workers Compensation Management Program: Reduce Costs 20% to 50%.
 
 
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 website 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 author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com. Contact: RShafer@ReduceYourWorkersComp.com.
 

NEW 2012 WORKERS COMP BOOK:  www.WCManual.com
 
WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php

 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Filed Under: Assessment & Diagnostics, Broker Issues & Relationships, Insurance Issues, Rates, Premiums Tagged With: ,

Five Signals Your TPA is Doing a Great Job

September 19, 2011 by Leave a Comment

pic7In the world of insurance, it is hard to tell if your carrier or third-party administrator (TPA) is doing a good job if you do not interact with them often. Of course, the goal is to have as little interaction with them as possible — if you do not have to file any claims that is a good thing.

 

 

But, accidents will eventually happen. Property damage happens. Workers get injured. Customers get injured. So how can you tell if your carrier or TPA is doing a great job and looking out for your bottom line?  (WCxKit)

 

 

5 Ways to Tell Your TPA Is Looking Out for Your Bottom Line:

  1. Ask your injured workers when they return to work how their interaction went.

Your injured worker should have had plenty of interaction with their adjuster during the course of the file. The amount of interaction depends on the severity of the injury, but they should at least be able to name their adjuster and give some feedback on how the claim went.

 

 

If your injured employee’s claim was denied, you may not get a truthful answer. But, for a normal, routine claim that was accepted and uncomplicated, the worker’s responses should be a good indicator of how their claims process went.

 

 

A sample of questions you might ask a recently returned worker:

Was the adjuster helpful?

Did he or she explain you worker’s rights as defined by the Comp Act?

Did he or she explain your medical condition to you?

Did the adjuster return phone calls promptly?

Did the adjuster listen to your questions and answer them to your satisfaction?

 

 

Any negative responses to these questions is usually a good indicator of how your carrier is doing while handling your claims. A lot of negative responses from your workers could indicate it is time to explore using another carrier or TPA.

 

 

  1. Ask your agent what they hear about your carrier or TPA within the industry.

If you have a good-sized agency, or broker, that handles your insurance needs, it should be more than familiar with their clients’ companies. If you ask for an unedited opinion, chances are they will give it to you. Agents hear a lot about the pros and cons of certain carriers and TPAs from other clients. Issues an agent speaks of may or may not be of importance to you, but, the more information you have the better.

 

 

Ask your agent about these factors to learn about your carrier or TPA:

What is the carrier’s reputation with other agents?

What does your agent hear about the carrier or TPA’s litigation response; do they deny and fight every claim, or accept and pay out on every claim? (either is bad – there should be a balanced approach)

How are their reserving practices? Do they constantly bump or stair-step reserves? Do they inflate reserves in an effort to raise premiums?

How are their adjusters? Do they return calls and help agents with questions or are they impossible to reach?

How is the carrier’s local management? Are they knowledgeable and experienced?

Does your carrier/TPA write a lot of businesses like yours, similar in size?

Does this carrier/TPA only like to write very large national accounts or do they prefer lower-level, local markets?

How are your TPA’s underwriters? Are they usually accurate or do they have to do a lot of work when submitting a premium estimate?

 

 

All of these questions will give you a feeling about how your business fits in with the other businesses your carrier/TPA writes for. A smaller company that uses a carrier/TPA that prefers large national accounts may find their business needs are not tended to when you need them.

 

 

  1. Ask for a meeting with your carrier/TPA management and the team of adjusters assigned to your account.

The best option is a team handling your account within your immediate community. If it is a major road trip to meet with your insurance team, question if they are the right fit for you; if it’s a flight, question it even further. Some businesses want that local presence so they can physically meet with them when issues arise. Some businesses do not really care about the location, as long as their needs are met immediately. It is your choice. Consider TPAs that will provide a dedicated unit ON SITE at your location if you wish; yes, there is a price for such a high level of service, but the overall value may have an excellent ROI. Short-sighted companies concerned only with today’s price rather than total price might want to reconsider the price-first approach.

 

 

Every Carrier/TPA knows who would be handling your claims if any were to happen, so meet with this person. Get to know him or her and find out about their industry experience. Find out if you mesh with them or not. If you get a good vibe, then there should not be a lot to worry about. But, if you walk away feeling less than confident, you already know you should start shopping around before it is too late. Check their “grades” — the best TPAs score their adjusters.

 

 

  1. Ask for your business peers thoughts.

This will not apply to everyone, but typically if you are a niche business and know your competition, ask your peers about their experiences. Ask how their claims were handled and if they were satisfied. All business competition aside, most managers run into the same people from their competition at certain events, trade shows, etc. If you are amicable with any of them, it will not hurt to ask. It is almost like a test drive. If your competitors had bad experiences with certain carriers/TPAs, chances are you would as well. This can save a when it is your turn to file a claim with your Carrier/TPA.

 

 

  1. Do your research.

Most Carriers/TPAs will have websites that show their capabilities, office locations, new technology, agent relationships, etc. Do some searching around to see who you like.

 

 

Some things to look for include:

Who has cutting-edge technology for claim handling?

Who has invested time and effort into research and hiring practices to ensure they have the best of the best in staffing adjusters and counsel?

Who has local offices in your area?

Which agents are partnered up with your carriers/TPAs of choice?

Is your carrier/TPA involved in local charities and in giving back to their community?

 

 

Not all of these items may play a factor in learning if you have the right carrier/TPA for your business needs, but it cannot hurt to find out the answer to some of these questions. (WCxKit)

 

 

The goal is to not ever have to file an insurance claim. But, as we all know, that is unlikely. You will have to cross paths with your carrier/TPA at some point. Making sure you have the right one who will take care of your needs when you need it the most is worth the effort. Ask around; do your research, and take time to meet with your prospective team of insurance professionals. This will help you know you made the right choice, and not a choice you will regret when you need help or have questions about your insurance needs.

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 website 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. Rebecca is the author of Manage Your Workers Compensation Program. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

 

Our WC Book: www.WCManual.com

WORK COMP CALCULATOR: http://www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:  http://www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP: http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

 

Filed Under: Assessment & Diagnostics, Broker Issues & Relationships, Claim Management, TPA and Claims Administration Tagged With: , ,

Fiduciary Responsibilities of the TPA

August 23, 2011 by Leave a Comment

pic8Nothing in this article is intended as legal advice. Seek the assistance of an attorney in drafting your next TPA contract. This article is based on hypothetical situations.


The self-insured employer was livid. In the self-insured employer’s eyes, the third-party administrator (TPA), who had handled their workers compensation claim files for three years, had not lived up to promises made when discussing the claims handling contract. The self-insured employer remembered the TPA had promised “excellent claim service” and “cost control,” but the self-insured employer had to deal with inquiries from the Workers Compensation Board, complaints from unpaid medical providers, and their average claim cost was up almost 50 percent in just three years.

 

 

The self-insured employer wanted to sue the TPA for breach of contract. The attorney the self-insured employer consulted with had a different idea. Instead of suing for a breach of contract, the attorney recommended a lawsuit for the TPA’s breach of their fiduciary responsibilities.(WCxKit)

 

 

Why? The relationship between a self-insured employer and a TPA of claims is one of trust and faith. The self-insured employer relies on the TPA to act in every instance in a manner that is in the best interest of the self-insured employer. In this case, the self-insured employer was relying on and trusting the TPA to handle their workers compensation claims with the same due diligence and professionalism they would expect from a workers compensation insurance company. As the self-insured employer was paying the TPA to handle the self-insured employer’s financial obligations (the payment of workers compensation claims) and trusting the TPA to handle their assets (their money) in a prudent and careful manner, a fiduciary relationship was established between the self-insured employer and the TPA.

 

 

The self-insured employer relied on the TPA’s superior workers compensation claims knowledge and claims handling skills in the management of the self-insured employer’s workers compensation claims program. The self-insured employer relied on the TPA to put the interest of the self-insured employer ahead of the TPA own interest in every claims handling decision made.

 

 

The TPA is in the business of adjusting insurance claims. The self-insured employer is in the business of manufacturing plastics. Therefore, the TPA’s knowledge and understanding of workers compensation claims is far superior to that of the self-insure employer. The TPA was being compensated to provide the self-insured employer with claims handling, guidance, counseling and advice on their workers compensation claims. At any point where the TPA saw the self-insured employer making an incorrect decision on a workers compensation claim, the TPA had both a duty and the responsibility of a fiduciary to explain both the ramifications and the probable outcome of an incorrect claims handling decision. The self-insured employer was of the opinion the TPA had repeatedly failed to provide proper guidance.

 

 

The self-insured employer was trusting the TPA to handle the self-insured employer’s workers compensation claims in accordance with generally accepted standards (commonly known as best practices) within the insurance industry. The original contract between the self-insured employer and the TPA was silent on the subject of claim quality. Best practices for claims handling had not been incorporated into the contract. The purpose of best practices is to control claim costs while providing the insured/self insured with a quality claims product. Each time the TPA adjuster, claims supervisor or claims manager failed to follow the generally accepted claims handling standards, they were breaching their fiduciary responsibility to the self-insured employer, but not their contractual requirements.

 

 

The original contract between the self-insured employer and the TPA also had not specified the number of claim files each adjuster would be assigned. The adjusters at the TPA were handling an average of 180 workers compensation files each. This number of claims is far above what a claims adjuster can properly handle. The TPA knew or definitely should have known a claims inventory/workload of this size was unrealistic and generally accepted claims handling standards could not be met. Each time the claims supervisor or claims manager assigned a new workers compensation claim to the claims adjuster with a claims inventory of 180 files, the TPA was intentionally breaching their fiduciary responsibility to the self-insured employer.

 

 

Any time a self-insured employer and a TPA enter into a claims handling agreement, the self-insured employer should be sure the contract specifies it is a fiduciary agreement. The contract should incorporate the best practices in claims handling. The contract should specify the number of claims files that can be assigned to any one adjuster. The contract should also specify how any damages the self-insured employer incurs due to the TPA’s breach of fiduciary responsibilities will be resolved.(WCxKit)

 

 

 


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 website 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. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

 

 
Our WC Book:  http://www.wcmanual.com

WORK COMP CALCULATOR: http://www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:  http://www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP: http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

 

Filed Under: Broker Issues & Relationships, Legal Doctrines, TPA and Claims Administration Tagged With: , , ,
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