If you ask an adjuster candidate if s/he knows how to handle a work comp file, you will get an obvious answer like “I handled an open inventory of  approximately 125 claims at any one time during my 5 years at XYZ Company.” The answer by the adjuster candidate assumes s/he was doing the job correctly, but is that true?

Before you interview adjuster candidates, take time to create a fictional test claim customized to the statutes within your state, with a partial investigation completed. The purpose of a “test claim” is to test the candidates’ technical competence and real knowledge of file handling.

Include in the fictional test claim information:

• facts of the accident, with the supervisor’s name and the names of witnesses
• information on the injury (make it a burn or a fractured limb with the need for surgical repair, or another complicated injury)
• Employer’s First Report of an Accident form for your state (with wage information but no mention of the employee’s second part-time job)
• have facts (like horseplay or intoxication) that create questions regarding compensability
• have facts (like sub-contractor or seasonal worker) that create questions regarding coverage,
• employee treating at an unapproved medical provider

Following a review of the fictional claim by the candidate, ask the person:

• opinion as to coverage for the claim
• opinion as to compensability for the claim,
• to outline the investigation steps to take (interview the employee, the supervisor, and witnesses? contact the medical provider?)
• provide a reserve calculation sheet showing how reserves will be set for the claim,
• show his/her calculations of the average weekly wage
• list the state forms needing to be filed, and when
• handle the medical treatment at the unapproved medical provider

In your review of the adjuster candidate’s answers to the questions on the “test claim” determine if s/he missed any key points like coverage and compensability. Verify the investigative steps are correct, that s/he know how to establish the average weekly wage properly and to set reserves. Be sure the appropriate state forms would be filed and s/he knows and understands all state-specific statutes. [If you are unsure as to the quality of the adjuster’s answers your claims manager or defense attorney can review the answers].

PERSONAL CHARACTERISTICS

The personal characteristics of the workers’ comp adjuster candidate are very important. Being a workers’ comp adjuster is not easy. It takes a person with many personal characteristics beyond the job skills.

Personal characteristics include:

• Self-stress management as the workers’ comp adjuster position can involve difficult people, deadlines, conflicting demands, pressure from both outside and inside the organization, and frequent change.
• Reasoning to understand relationships between facts, information from various sources and to data.
• Creative thinking as the facts and issues vary from one claim to the next.
• Problem-solving ability to analyze the facts and use proper reasoning to solve the problem when confronted with both relevant and irrelevant facts.
• Oral communication ability to obtain information from various sources and to convey information in a clear and precise manner.
• Written communication skills to convey information in a well-organized manner
• Interpersonal skills to deal with people who are injured, difficult, or even hostile.
• Self-motivation to set personal goals and to take the initiative to accomplish personal objectives and company goals.
• Honesty and integrity in all aspects of her interactions with everyone.
• People skills including tactfulness, empathy, understanding, and concern.
• Planning ability to set priorities, organize work, to achieve short-term and long-term goals.
• Customer service skills to maintain rapport with employers and provide guidance and assistance to them.
• Self-esteem to maintain a positive image of self and the company and to display it professionally.
• Mathematical ability in establishing indemnity benefits and reserves.
• Conscientious about the details of the work.
• Plays well with others and encourage cooperation, commitment, and company loyalty.

If you are unsure how to measure or evaluate the personal characteristics of the adjuster job candidate, there are various personality testing services and forms available.

The list of technical job skills and personal characteristics could be extended several more pages for the selection of the best adjuster candidate for your self-administered claims program. The skills and characteristics outlined here will assist you in weeding out unqualified or inappropriate adjuster job candidates. While testing of the technical competency and personal characteristics of the adjuster candidates takes more time and expense, it is well worth the investment of your goal in hiring the best-qualified adjuster.

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: RShafer@ReduceYourWorkersComp.com.

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

©2018 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.

It seemed like a simple enough claim. The employee, a truck driver, was driving along when a car pulled in front of him from a stop sign. The big Mack knocked the car out of its path, while the truck driver brought the truck to a stop. The truck driver jumped out of the cab and ran over to check on the woman and her children in the car. The ambulance arrived and took the family away. When the police interviewed the truck driver and asked if he was hurt, he said, “No.” The next morning the truck driver awoke with a very sore neck and aching back.

It was three weeks to Christmas and the truck driver, having a family to care for, continued to work each day taking heavy doses of Tylenol. By Christmas, he was in constant agony and with his wife’s encouragement, went to the local emergency room. The doctor diagnosed both back and neck strain and told him he could not work. The employee reported the claim to the trucking company. The trucking company clerk, whose job it was to report all workers comp claims to the third party administrator (TPA), noted the accident occurred three weeks prior to being reported. The trucking company’s policy with its employees was for all injuries to be reported within five days of the date of injury. When the clerk reported the accident to the TPA, she told the adjuster the claim should be denied, as the police report showed the truck driver was not hurt and failed to report the claim within the employer’s five-day reporting period. (WCxKit)

Adjuster Said “Okay, if that is what you want”

The adjuster said, “Okay, if that is what you want,” and promptly sent the truck driver a denial of benefits letter. Unfortunately, the state law where the claim occurred, allows the employee one year from the date of the accident to report the claim. When the truck driver received a denial of benefits letter he immediately hired a lawyer.

The adjuster knew what the law was, but made a wrong decision, by allowing the employer’s reporting policy to prevail over state law. The adjuster should have immediately advised the reporting clerk that the state statutes give the employee a year to report the injury. The adjuster abandoned decision-making on the claim to the employer, even though the adjuster’s knowledge of workers comp statutes was greater than the clerk reporting the claim.

Since the adjuster denied the claim based on the employer’s wishes (or the WC clerk), no further action was taken.

Ten things the adjuster failed to do:

1. Make 24-hour three-point contact with the employee, employer, and medical provider.
2. Obtain a recorded statement from the employee regarding the details of the accident and the nature and extent of the employee’s injuries.
3. Obtain documentation on the damage to the truck (to reflect the force of the impact suffered by the driver).
4. Obtain information on the woman who caused the accident for the purpose of subrogation.
5. Put the insurance carrier for the other party on notice of the intent to subrogate.
6. Obtain the doctor’s diagnosis and prognosis.
7. Obtain wage documentation and in order to calculate the indemnity benefit rate.
8. Establish appropriate reserves for the indemnity and medical cost.
9. Arrange for the employee to return to work on light/modified duty.
10. Provide any type of medical management on the claim.

Now, since employee hired an attorney who expects to earn a fee, when the employee was released to light duty following his first doctor’s visit, the attorney failed to convey that information to the adjuster. The attorney arranged for the employee to see a doctor he referred his client to. This new doctor kept the employee off work until the employee, ignoring the doctor’s advice, returned to work on his own.

The attorney waited until the employee was released back to full duty before sending his letter of representation. The attorney-selected doctor gave the employee a small impairment rating from which the attorney would take his fee, plus his percentage of the employee’s PPD, for the time the employee was kept off work.

When the defense attorney strongly recommended the claim be settled, the adjuster had nothing to mitigate the damages. As a part of the settlement agreement, the TPA gave up the right to subrogate against the woman who caused the accident, allowing the employee and his attorney to bring a lawsuit for the traffic accident.

Employer Did Not Know Consequences of Denying Legitimate Claim

The employer and/or the clerk did not know the law or understand the consequences of denying compensation on a legitimate claim, even when reported late. What should have been either a medical-only claim or a very minor indemnity claim became a PPD claim, costing at least five times what it should have, because the adjuster abandon her (or his) responsibilities and allowed the employer to make the decision on compensability. The TPA also had to negotiate away the right of subrogation to get the claim settled. With subrogation rights, the entire amount paid by the TPA on the claim could have been recovered.

If, as an employer, you do not know all the aspects of the workers’ compensation statutes in your state, trust the adjuster to make the correct decision. If you question the adjuster’s decisions on claims, discuss why they are proceeding in the way they are. Create a partnership with the adjuster in the handling of your claims, but trust the adjuster judgment and knowledge of the law. It is usually a wrong move to handle workers comp claims by what you want rather than by what state statutes require. And, it might be a good idea to train all employees involved in processing workers comp claims to not make suggestions on how a claim ought to be handled.

Author 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: https://blog.reduceyourworkerscomp.com/

©2018 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.

Workers Compensation Adjusters get new claims every day. Most days they receive many claims, depending on the type of adjuster they are. For the most part, medical-only adjusters and lost-time adjusters receive the most new claims per day.

Good adjusters can tell if a claim is going to be trouble right away. They base this on several criteria, including the type of injury, if the worker is still working or off-work, date of birth, hire date for that employer, the city the worker lives in, and additional comments made by the insured submitting the claim.

Type of Injury:

This is the most obvious. Of course, an adjuster is going to scan right to the injury comments to see how bad the claim is going to be. This also determines how much attention the claim will get. If an adjuster gets the claim and the injury is a simple laceration or contusion, it is probably not going to get a super-thorough investigation. These claims are normally compensable since lacerations and contusions are generally sustained in the course and scope of employment. They usually do not include any lost time away from work, and bills are simple to read through and process.

At the other end of the spectrum are pending surgeries and subjective strain-like soft tissue injuries. The adjuster knows if the word “surgery” is included in the injury description, a lot of work is going to lie ahead. This is especially true if the word “surgery” is paired up with a strain injury to the low back, shoulder, or knee. This means the injury sustained was bad enough to warrant the need for a surgical procedure, and that will include lost time from work and a thorough investigation to see if the claim will be compensable.

Still Working or Off Work:

If the worker is still working, either on restrictions or not, the adjuster will breathe a sigh of relief because that roadblock has already passed. Getting a worker to remain working is half the battle. If the injured employee is working, it means the adjuster can focus on gathering statements from all parties and securing medical records first and then determine if the claim is compensable or not.

If the worker is off work, the adjuster knows she has to hurry, since every day is another day of accrued lost-time wages. Many jurisdictions have a time limit for the investigation of the claim, so the adjuster must hurry to gather all the information needed to figure out if the claim will be accepted.

Date of Birth:

After looking at the injury, the adjuster will then peer toward the date of birth. This will also hold a lot of clues if the claim is going to be a problem. A rule of thumb is the higher the age, the longer it will take to get back to full duty because it takes an older body longer to heal when an injury occurs. If a 25-year-old worker sustains a strain injury, they will typically be able to rehab faster than a claimant who is 75-years-old. The younger worker will also have fewer prior medical problems to have to overcome, including arthritis, prior surgeries, scar tissue, diabetes, etc. All of those issues will lead to longer rehab time, which stretches out the life of the claim.

Age also plays in factor in recovery post-surgery. If a 70-year-old worker falls on his arm and fractures his wrist, you automatically know it is going to cost more medically than if the same injury occurred to a worker who is 23-years-old.

Date of Hire:

This factor will come in to play more often with subjective injuries. If a new hire sustains a back strain, the adjuster will perhaps raise an eyebrow, wondering if this new hire is trying to pull off a fake injury. But, you can also look at it the other way. Newer hires are less experienced, and they may be trying to do too much at once to impress their employer, leading to the injury. Newer hires also may not have the experience operating machinery, leading to lacerations or contusion-type injuries.

City Employee Lives:

This factor will tell the adjuster what doctors are around the area where the employee lives. If it is a rural area, maybe the town does not have an occupational clinic, which leads the worker to seek out treatment with their primary care physician. This can cause an issue gathering documentation, medical records, and medical restrictions for work, etc. The primary care docs are not that familiar with work comp, so they do not document as well as occupational clinics. This leads to delays in getting the correct info to the adjuster to review for claim compensability.

Workers living in more urban areas also have a benefit because there are more specialty doctors. It will not take a claimant a month to see an orthopedic doctor or a hand specialist. This will speed the claim up, because the worker is being directed to the right physician who can treat appropriately, without delay. Medical care is generally less accessible in rural versus urban areas.

Additional Comments:

The last thing the adjuster glances at is to see if the person that submitted the claim has anything else to add. This is where the employer can help an adjuster out. If the employer knows there are some outside issues potentially making a claim not compensable, it will give the adjuster a running start that the claim just does not add up. Plus the adjuster can raise the red flag that there needs to be a proper, detailed investigation right off the bat. The adjuster can also file the paperwork with the State for an extension to their investigation, so penalties do not get handed out to the carrier for delays. Or the claim can be “paid without prejudice.”

The employer can also indicate other items that will help the adjuster. Examples are the claim was filed to process bills, or the injury was not questionable and the worker is ok. This helps the adjuster know the claim is not questionable, and they can set it up, make their contacts, process the claim, and close the claim down without keeping it open longer than it needs to be.

When an adjuster gets a new claim, he or she looks at the above criteria before picking up the phone or sending an email. The employer can greatly help the adjuster by completing all the information on the First Report of Injury and adding any comments that would be helpful to the adjuster in their investigation. This will help steer the adjuster in the initial phase of the file, leading to the desired outcome.

Author 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: https://blog.reduceyourworkerscomp.com/

©2018 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.

Having a great claims adjuster can be invaluable. Claims are processed smoothly, timely, and satisfactorily.

But getting the ideal adjuster is not always possible, and employers often blame adjusters when things don’t go as efficiently as they could. Should you seek a different adjuster, or just accept that you’re stuck with a dud? Actually, you may be able to avoid both. By taking a step back to gain some insight into the adjuster’s world and using a few simple strategies, you may be able to turn things around.

Set Realistic Expectations

The adjuster’s role is the fair and reasonable settlement of claims. First step is to figure out what that means to you and how it fits in with your company’s claims handling plan. Setting up expectations is important. If there are no clear directions or goals, you really can’t blame the adjuster for failing to meet your expectations.

For example, do you want the adjuster to be in constant contact with you, or do you want communication only when absolutely necessary? You need to determine that and let the adjuster know.

If you expect the adjuster to resolve claims within a certain period of time, are you doing all you can to facilitate that? How soon are injuries reported? Is that on a consistent basis? Do you have a timeframe for when and how investigations are performed?

Other factors can also affect the resolution of claims. Not having a return-to-work program or light duty/transitional work can make more work for the adjuster, along with the lack of a fraud prevention program. Make sure your actions and goals are in line with your expectations of your adjuster.

Understand the Adjuster

It can be upsetting when the adjuster doesn’t get back to you when you think he should, or denies treatment on a claim with no explanation or approves a questionable claim. But seeing things from the adjuster’s standpoint can help.

Instead of lambasting the adjuster, consider what is happening on his end. Being an adjuster can be a thankless job;

• There are constant questions, emails and phone calls, often from disgruntled employees, employers or others.
• His caseload may be overwhelming.
• There are constant deadlines that may or may not be achievable.
• The turnover for the profession is such that his office may be understaffed at any given time.
• While you might be easy to work with, others may not be.

You can find out what’s going on by talking with the adjuster.

Build a Relationship

Developing a bond with the adjuster can go a long way toward having a better connection with him. Working better with the adjuster can involve a few simple steps:

1. Pay him a visit. A ‘chairside visit’ is a great way to establish a good relationship with an adjuster. For this informal meeting, you literally sit at his desk to understand the demands of his day. You can also take the opportunity to learn how he handles claims; the intake process, medical-only and lost-time claims, and catastrophic claims.

2. Get to know him on a personal level. While you don’t need to be best friends, you can find out a little about him — his home life, kids, hobbies, etc.

3. Realize he is the expert. Even if you don’t like the way he’s handling a claim show him respect. That said, find out his expertise level. If he’s new to the profession, he’s probably not the right person to handle complex claims. On the other hand, a highly experienced adjuster might be bored handling simple, medical only claims.

4. Ask questions. There may be good reasons for the way he’s handled certain aspects of a claim. Don’t just get angry, find out why. Ask open-ended questions that are not accusatory. Putting him on the defensive won’t help your relationship, and it likely won’t get you answers.

5. Give praise when warranted. If the adjuster does a particularly good job with a claim, tell him so. He’s probably much more used to hearing negative comments than true appreciation. Doing so will make things much easier when you later have concerns about a claim.
6. Listen to what he says. You may have ideas to solve some of the challenges he’s facing.

7. Offer to help. There may be things you can do that would help him expedite the claims process.

Conclusion

If you’re having problems with your adjuster, first look at your own program. Having an organized plan for claims handling and relaying that sets up realistic expectations.

Then, work with the adjuster. Develop a bond so you can easily find out the reasons for any problems and set up strategies to avoid future challenges.

Author Michael Stack, Principal, 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 & lead trainer of Amaxx Workers’ Comp Training Center. .

Contact: mstack@reduceyourworkerscomp.com.

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

©2017 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.

Despite your best efforts to get medical restrictions from all treating physicians and evaluate your employee on a weekly basis, there are times when the medical provider says the injured employee can do more than s/he thinks s/he can.

• For example, a bus driver injured his right arm in a work-related accident. The doctor finds the muscles and bones have mostly healed and the patient should no longer be feeling pain and may return to work for four, rather than an eight-hour day.
• But in your weekly reviews, the employee complains that opening the bus door is still so painful he cannot drive home at the end of the day.

In this situation, write an email from the injury coordinator to the adjustor asking if a functional capacity evaluation (FCE) may be needed. Also, consider options for alternate work for a while longer.

8 Part Email To Send When Transitional Duty Doesn’t Work

1. Be sure to include claim number and all relevant addresses and contact information on the letter.
2. Include the supervisor in any discussions.
3. Clearly explain the situation: who is injured, what the injury is, what the current complaint is and what the physician says the worker should be able to do
4. Explain the company’s medical advisor reviewed the reports and the employee’s complaints do not mesh with the current medical diagnosis.
5. Acknowledge the pain could be imagined (but without judgment) or the result of the employee being fearful of additional injury. Be aware that the pain might be very real also, and don’t minimize the likelihood of this possibility. Anyone who has ever had repetitive arm injury knows how painful it can be and often even a small amount of use can trigger painful symptoms.
6. Ask your adjustor if an (FCE) is needed and, depending on results, perhaps an off-site work hardening program is in order.  In work-hardening the employee is allowed to build up to his regular job capacity in a supervised setting, removing the fear of re-injury.
7. Ask the adjustor for suggestions of work-hardening centers in the area.
8. Acknowledge the difficulty of this claim and ask the adjustor for a timely response.

Real or imagined, pain while doing one’s job benefits neither the company nor the employee. There are programs designed to help your employee work through these issues.

Vigilant attention to the employee will ease this process.

Author Michael Stack, Principal, 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 & lead trainer of Amaxx Workers’ Comp Training Center. .

Contact: mstack@reduceyourworkerscomp.com.

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

©2017 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.

The old adage “Time is Money” definitely applies to the handling of workers’ compensation claims.   Experienced claim professionals know the longer a work comp claim remains open, the higher the overall cost to conclude the claim. Every delay along the path from the start of the work comp claim to its conclusion costs your self-insured program or your insurer money (eventually coming back to your company as higher work comp insurance premiums).

Here are some tips and suggestions on ways that you, the employer, can speed up the processing of your workers’ comp claims.

Pre-Accident Training

Every employee needs to know what to do in the case of a work comp injury. Your company needs to set the stage for your involvement in the work comp claim process from the very beginning.

Your new hire package must include instructions on the proper and timely reporting of the work comp injury. The accident reporting instructions must specify that the injury must be reported immediately, to whom the employee reports an injury, who are the approved medical treatment providers (in the jurisdictions where this is permitted) and information informing the employee of the return-to-work program your company uses.

Display, where all employees can see them, posters and/or billboards clearly showing these requirements, including the importance of immediately reporting the work comp injury. Be sure to post these materials in the employees’ prime languages in addition to English.

Remind supervisors and managers on a regular basis that all work comp injuries are to be immediately reported to your work comp claims coordinator. The supervisors and managers should be familiar with the information required to complete the First Report of Injury form required in their state.

Prompt Reporting

When the work comp claims coordinator receives the information about the new work comp injury, the claims coordinator immediately reports it to the claims handling office. If for any reason the claims coordinator does not have all the information necessary, the claim is still reported to the claims office with a note indicating the rest of the information will be forthcoming as soon as it is available. This allows the work comp claims adjuster to go ahead and get started on the claim.

Claim Service Standards

When your company starts an insurance program, the insurer or third party administrator (TPA) should provide you with information on their claim handling service standards. Those service standards usually specify within how many hours the adjuster will contact the employee once the claim is reported to the claims office. Great service standards specify the employee will be contacted within 2 (or 4) hours, while good service standards specify the employee will be contacted within 24 hours. If the service standards are silent on how fast the work comp adjuster will be in contact with the employee, ask them to make the 2-hour contact with the employee a claim-handling requirement on your files. If the insurer or TPA is reluctant to require prompt contact with the injured employee, it is time to get another insurer or TPA.

Employee Follow-up

When employees are injured, they are concerned about their future with your company, their future income and their ability to care for their families. When the employee’s supervisor or your company’s work comp claims coordinator contacts the employee shortly after the accident, the employee knows and feels s/he is valuable to the company.

When the employee initially reports the claim to the employer, the employee is instructed to keep the employer informed of medical treatment and medical progress. Emphasize the employee can expect to hear from the employer if the employee does not provide timely updates to your company.

Keeping in contact with injured employees lets the employees know the employer cares about them and their well-being. Employees who feel valued by their company are less likely to malinger off work when they could return to work, or hire an attorney.

For employees who are off work for an extended period of time, the claims coordinator should be contacting them on at least a monthly basis to inquire about their condition, their treatment and their expected return-to-work date.

Medical Follow-Up

In the majority of states the employer is allowed to contact medical providers in regards to when the employee is medically able to return to work. Regular follow up with medical providers reinforces the importance of the employee returning to work.

Return to Work Program

Employees should know the expectation is they will return to work as soon as medically able. Often an employee is willing to return to work, but the treating physician is concerned that the employee may be re-injure by attempting to return to work before full recovery from the accident.   Or, the employee is afraid to return to work because of concerns for his/her own safety. To protect themselves from malpractice claims, doctors often keep employees off work longer than is necessary.

The best way to alleviate both the fears of the employee and the fears of the doctor is to have a modified duty return-to-work program available to accommodate the employee. A modified program allows them to return to work before they are 100% recovered from their injury. The return-to-work program is structured to remove from the employee’s regular routine the activities the doctor feels could possibly cause the employee to be re-injures, whether it is a lifting restriction, standing restriction, bending restriction, etc.

The sooner the employee is back on the job, the sooner the employee fully recovers from the injury. A modified duty program provides the employee with physical reconditioning for the work they will be doing when the job restrictions are lifted by the treating physician.

The return-to-work program has a major impact on the amount of temporary total indemnity benefits are paid to the employee, reducing your overall work comp cost. Plus, when the treating physician states the employee has reached the maximum medical improvement, the employee who is back to work will normally receive a lower permanency rating then the employee who is still off work. The lower permanency rating also translates into lower work comp cost for your company.

Summary

Follow the proper steps throughout the work comp claim process from before the accident occurs, to when the employee returns to work. The time saved translates into savings for the employer through lower workers’ compensation cost and improved productivity by the employee being back on the job sooner.

Author Michael Stack, Principal, 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 & lead trainer of Amaxx Workers’ Comp Training Center. .

Contact: mstack@reduceyourworkerscomp.com.

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

©2017 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.

The experience and expertise of your adjuster will have a significant impact on the cost and life of a workers’ compensation claim.  Every employer must be absolutely certain the adjuster handling claims knows what, how, and when to do everything from the first report of injury to the final disposition.

Claim supervisors and managers need to be the most experienced, as well as have sufficient time to monitor staff and claim handling.  They also must teach, critique, and discipline all claim handling.

An adjuster needs to be part detective, part doctor, part lawyer, part father confessor, part director, and part politician.  Investigating facts and activities requires an inquisitive mind with questioning capacity.

Additional Adjuster Tasks & Responsibilities:

• Adjusters must know medical facets of traumatic injury, healing periods and usual complications.
• Proper medical care must be achieved.
• Adjusters must direct and control the claim.
• Complying with the law’s requirements and duties requires legal knowledge.
• Listening, being empathetic, and addressing injured worker needs, is paramount to successful resolution.
• Adjusters must be good communicators in spoken and written format.
• Adjusters must have convincing gravitas to have people accept their proposals.
• Adjusters deal with all walks of life. They must be comfortable in public dealings.
• A college degree might be preferred, but it is not always necessary.

There are two schools of thought for selecting adjusters.  First, hire only experienced people.  Second, train your own.  Both have pros and cons. Each has had successes and failures.  Selection is a matter of choice.

Various Adjusters:

Medical Only Technician:

Medical-only adjusters, an entry level position, are trainees with little to no experience. They handle minor medical claims involving simple lacerations and minor strains/sprains not involving any lost wages or complicated medical injuries/conditions. When an employee has a few clinic visits the employer sends the claim in with the bills and the adjuster sets up the claim, processes the bills, and closes the claim.

Some issues a medical technician faces are:

1. The history of the injury occurrence may only be addressed in the first reporting and billing.
2. Aggravations for underlying pathologies may be casually addressed or not commented on.
3. Often a treatment number is the only clue that the employee is being treated for more than the original injury.
4. Treatment time and expense exceeds normalcy or claim unit authorities.
5. Treatment may be going on that was not authorized.
6. Missing permanent partial disabilities. Or paying permanent partial disabilities as a med case instead of an indemnity case.

Lost time/indemnity adjuster

Lost-time/indemnity adjusters are more experienced, with knowledge of local legal statutes and a high degree of medical training in handling occupational claims. Their expertise is with claims running past 90 days involving more severe injuries such as a complicated lacerations, level 2/3 sprain/strains, surgical repairs, or pending surgeries. When employers question claim compensability, the claim is immediately assigned to the lost time/indemnity adjuster.

Some issues that could hamper performance are:

1. Assigned case overload impeding ability do a proper job
2. Performing tasks that are better served clerically
3. Failure to be analytical and innovative
4. Have attitude issues that can cause cases to explode
5. Failure to explore the worst case scenario
6. Lack of empathy for the injured employee
7. Lack of effort to resolve cases promptly and expeditiously

Litigation Technician:

Litigation adjusters handle claims involving lawsuits. These adjusters share the same level of experience as the lost-time adjuster. However, they have advanced training in legal issues and in investigating the compensability of occupational claims.

When a compensable claim is disputed, and the claimant retains counsel and files a Notice for a Hearing, the claim goes from the lost-time adjuster to the litigation adjuster. The litigation adjuster works with in-house or outside counsel gathering details on the injury, and appears for hearings and mediations to quickly resolve the claim at minimum legal expense.

Catastrophic adjuster

This level of adjuster is the most complex, handling very difficult claims, usually ones where the claimant has a severe injury requiring multiple surgeries, amputations, loss of sight, hearing loss, or internal medical issues such as asbestosis or chronic joint degeneration due to occupational exposure, etc.

General/catastrophic adjusters have many years of experience in the Insurance industry, combined with advanced medical and litigation training and experience. They also have advanced claim investigation training, and may possess a law degree or are licensed attorneys.

Summary:

It is vitally important for adjusters to have the proper intelligence, personality, and training to obtain maximum resolution of their claims.  Cases should be assigned  at proper levels of adjuster competence.  Supervisors, managers, and employers need to monitor adjuster activities to maintain maximum benefit for the claim.

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.

The foundation of workers’ compensation is the employer-employee relationship.  Depending on the injury and the relationship, this can mean an awkward scenario if your favorite employee’s workers compensation claim is being denied. Your employee is coming to you for help, but you are essentially powerless. Or, you are the agent and your client is upset that the carrier you recommended will not cover this particular comp claim.

1. Get both sides of the story.

If you are only listening to what your employee is saying, you are only getting one side of the story. This will show how involved you are with your claims. If you do not talk to your adjuster a lot, or if you do not know who your adjuster is, chances are you will be confused as well. But you cannot take the side of your employee without also hearing the facts from your adjuster — especially if this is a questionable, subjective claim to begin with. You may want to protect your employees, but both of you cannot team up against your carrier, who, by the way, is working hard to investigate all claims and make the proper decisions, which affect your overall premium.

Take the time and call the adjuster and get their side of the story. If there is something you do not understand, ask them to explain it. Make sure you really understand what the issue is and why it is there. This way you will understand what is going on, and you can explain it to your disgruntled employee. Carriers do not create the laws, they only abide by them. Each adjuster has different styles as well, so if a worker had a similar claim six years ago and it was accepted, and now the same thing happened and it is denied — find out why. Make sure the adjuster has legal evidence to back up the denial.

It is possible the claim has not been denied; it could be suspended pending results of investigation or upon receipt of medical records. Whatever the case, call your adjuster and talk to them about it before you start choosing sides on who is right and who is wrong.

2. Meet and discuss in person with all parties and counsel.

The best way to decide who is right and who is wrong is to meet up. The employee can come as well, but it is probably best they do not — at least not at this point. But you, as the employer, should go discuss the case in person and roundtable it with all of the involved players.

If the case has potential for litigation, get local counsel or the house counsel the carrier uses involved. This way you can all discuss the file in a global aspect, and also plan for the ramifications should certain decisions be made. Going over pros/cons, future exposures, and the costs involved with all of those decisions helps not only you as the employer, but the adjuster as well. This forces him to get deep into the file, discuss monetary values, develop plans of action, etc.

3. Find a middle ground for plans of action, if possible.

Just talking about the file and meeting up in person does not mean you will all agree on what to do.  If you are not satisfied with what you are hearing, see if there is a middle ground, or a non-aggressive approach to everyone agrees.  Considers options such as an independent medical examinations (IMEs), nurse case management, or a vocational assessment.

After you have compiled all the options, go over the pros, cons and monetary values of each one, then work to choose a strategy. Explore your options, and come out of the meeting with an agreed-upon plan. Not just agreeing to disagree.

4. The adjuster knows best.

The adjuster has had medical and legal training, negotiation training, and is up to date with the current law changes and trends. Adjusters also have experience to know which doctors’ opinions are questionable or strong.

When push comes to shove, the adjuster and legal counsel likely know best about what option you should be taking. Thorough discussion should bring you to this point, but be sure to understand why they are taking a certain course of action.

5. Leave your personal feelings behind.

The hardest part from the employer perspective is not to drag personal feelings into a decision. Whether the injured worker is your favorite employee or your worst hire, you cannot bring personal feelings into your overall decision on the file. You can alert the adjuster to these feelings, but you cannot let it influence your decision.

In the end, the decision must be fair, and backed by legal precedence. The carrier requires good reason to deny or accept a particular claim.  They understand that the worker may be your friend and you want to do what is best for them, but you cannot force the issue.

No matter who is injured, when they are injured, or what they were doing when they were injured, personal feelings often develop about why a claim should be accepted or denied. The best way to feel comfortable with the final decision is to understand all of the information through effective communication.

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.

Adjuster Objectives:

Some objectives of every workers compensation claim adjuster should be to:

• Promptly investigate.

• Monitor medical care.

• Process the workers compensation claim to a timely full disposition.

• Maintain constant dialogue with employee, employer, and all other entities directly connected to the loss.

• Secure any potential recoveries.

• Develop the loss for the best outcome possible.

• Be adequately educated, trained and continually self-educated for continued professional growth.

Additional adjuster objectives:

• Clearly compensable claims should be paid promptly at the proper benefit rate, medical care should be the best available, and prompt return to work should be a priority.

• The adjuster should be available to assist the injured employee as needed.

• Good claim work results in minimal disability, good employee relations, and lower claim cost.

• Conversely, claims that are questionable, malingered, fraudulent, or suspect for any reason, require the claim adjuster to be extra determined so that a good investigation and claim preparation can sustain declination and litigation.

• Workers Compensation Claims are always under time guideline and handling pressure. Decisions and actions must be made or done quickly.

Employer Injury Coordinator & Assisting The Adjuster

The adjuster has primary responsibility for successful claim disposition.  However, the adjuster can only be as effective as the information gathered during investigation.  Therefore, every employer should strive to get the full facts, and supporting documentation to the adjuster as soon as possible after the loss occurs.

Every employer should have at least one person assigned to establish policy and procedures to implement when an injury occurs.  The person should know and understand all requirements of the workers compensation management program, including the employer and employee responsibilities.

One of the biggest responsibilities of the employer injury coordinator is communication with the claim adjuster.  This should be done as necessary, and during acute stages of a claim it may be daily.   As time passes on this claim this should continue on a regular weekly schedule.

Conclusion:

Worker’s Compensation Adjusters need to have good education, training, and the highest objective standards in order to reach proper handling and resolution of claims.  However, they cannot achieve this without proper employer support and interface.

Employers who designate an employee to be the workers’ comp injury coordinator to assist the claim adjuster will reap the benefits of better claim handling and cost.

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.

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.

Problem:

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:

Medical Only

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.

Summary:

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 comp act.  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 claims quality 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: 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.