How To Ensure Your Adjuster Is Being All They Can Be

Workers comp adjusterIf you have ever felt an adjuster assigned to one of your workers’ compensation claims was not making a proper effort to investigate a questionable injury claim, you are not alone. Every large claims office has some really good adjusters, some acceptable adjusters and some unmotivated adjusters who are just going through the motions to make it to the next weekend.

 

If you contact an unmotivated adjuster about the status of their claims handling, the adjuster will tell you, that she is doing everything she can on the claim. The reason the adjuster will say that is because the adjuster knows that the employer most often does not know what can be done on the claim. If you want to really shake up the unmotivated adjuster and to get the adjuster moving forward full speed on the investigation of the claim, review the following list of investigation suggestions with the adjuster.

 

Check List of Investigation Tools:

 

  • Employer’s First Report of Injury form
  • Employee’s written report of claim form (in states where it is required)
  • Insurance Services Office filing (formerly known as the Central Index Bureau)
  • Contact with claim adjuster(s) on claimant’s prior work comp claims
  • Contact with prior employer(s) on claimant’s prior work comp claims
  • Medical records from claim files of prior work comp claims
  • Contact with work comp board/industrial commission for their records on prior claims (some states will not cooperate, other states do cooperate)
  • Employee’s detailed recorded statement
  • Recorded statement of any witnesses to the accident
  • Supervisor’s recorded statement
  • Police report on vehicle accidents
  • OSHA reports, whether federal OSHA or a state OSHA
  • Any other government agency records
  • Discussion of the claim with the employee’s attorney, if the employee is represented
  • Contact with any third party involved in the claim – driver of other vehicle in auto accidents, manufacturer of machinery that injured employee, manufacturer of defective product that caused employee’s injury, etc
  • Telephone contact with each medical provider to have the most recent medical report(s) faxed to the adjuster
  • Medical records for all medical appointments
  • Photographs of the accident scene
  • Diagram of the accident scene
  • Having the claimant call the adjuster after each doctor’s appointment to report on medical progress
  • Nurse case manager’s input on serious injury claims
  • Field case manager to meet with the employee and doctor, and to attend medical appointments with the employee
  • Review of claimant’s social media sites – Facebook, Twitter, LinkedIn, etc.
  • Employer’s personnel file on the employee, including job application, new employee forms, disciplinary records, etc.
  • Employer’s safety records for the accident location
  • Employer’s public notice of plant location closing, lay-offs, union issues, etc.
  • Referral of the claim to the Special Investigation Unit (the unmotivated adjuster may be quick to do this, as this passes the buck to someone else to do a complete investigation).
  • Outside Vendor Services (Investigation steps that can be taken, but not normally performed by the adjuster, but overseen by the adjuster).
  • Surveillance
  • Activity check
  • Neighborhood canvass
  • Background check
  • Credit check
  • Public records review / civil records searched
  • Criminal records check
  • Skip tracing
  • Clinic records sweep (checking for medical treatment at all clinics in the area of the employee’s address)
  • Hospital records sweep (checking for medical treatment at all hospitals in the area of the employee’s address)
  • Pharmacy records sweep (checking for prescriptions filled at all drug stores in the area of the employee’s address)
  • Video re-enactments of the accident
  • Examination under oath

 

Unfortunately, there is no central system where an adjuster can check to see if the employee is currently working another job. The use of a private investigator for surveillance can fill this void, but without knowing where an employee might be working, this is often a hit-and/or-miss approach.

 

It would be a very rare claim where it is necessary for the adjuster to take all of the investigation steps listed above. The key to an investigation is for the adjuster to take as many of the investigative steps as needed to verify the validity of the claim, or to disprove the claim.

 

We realize this checklist of the investigation steps your adjuster can take is incomplete. We welcome our readers to contact us with additional investigation techniques they would add to our investigation checklist.

 

 

 

Rebecca ShaferAuthor 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:.

Contact: RShafer@ReduceYourWorkersComp.com.

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

 

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

 

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

An Adjusters Wish List To Santa

 

Dear Santa,

 

I have been a very good adjuster this year.  As you know, I have endured yet another year handling claims.  I have dealt with leadership changes, protocol adjustments, reporting layout changes, staffing issues, and so on. I worked so much I barely was able to use my vacation time, per usual.  It seems like this year was more stressful than others, with the constant law changes, and a lot of employee turnover, but I weathered the storm and did the best that I could.

 

You know what time of year it is.  Every year I ask you to help me out, and honestly sometimes you do.  It’s not that I am ungrateful!  Trust me, with this economy I am happy to be working.  I’m only asking for a few little things to make the days less stressful.  Please do what you can, and I promise to be a good adjuster all of 2013. My wish list is below; please call me if you have any questions.

 

 

  1. Easy to Use, Efficient Claims Technology

 

Santa, I would love to have some software that is less cumbersome to use day in and day out.  I know advancements have been made since the days of DOS operated systems, and these have been great.  But it seems like with every new technology that gets rolled out, it means that I have to input more and more information.  This is great when running reports and doing other tasks, but it takes up hours of my day inputting every little thing off of a clickable menu to add into the profile of a claimant.  Is all of this really essential to the handling of the claim?  I really don’t think so.  All I am asking for is a little user friendliness for the adjuster.  Clicking the mouse is great, but not when I have to scroll through hundreds and hundreds of ICD-9 codes looking for a head contusion.

 

 

  1. Less Micromanagement

 

The executives of my company must have been real good girls and boys last year, because it seems like there are more of them than ever.  Sometimes I feel like Peter Gibbons from that movie Office Space when he mentions that he has 8 different bosses.  Santa, I know you just want to make sure everyone is happy, but it is very hard to work when I am not sure which boss I will be reporting to on any given day.  Each boss has their own style, and apparently it is my job to interpret those nuances and make them happy. Some bosses like wordy, lengthy reports while others prefer succinct emails as updates on files.  Some bosses need to authorize me setting up an IME on a file, and others even want to pick the doctor for the case.  Even worse, I cannot make a decision on a file as to whether it is even compensable or not. Santa, you know I have been doing this job for 15 years.  I think I am competent enough to determine if a minor back strain with no lost time from work is compensable or not.

 

 

  1. Decreased Claim Count

 

In addition to the above, I would love it if I had less files to handle on any given day.  By doing this, I would be able to do my job so much better, instead of just putting out whatever fire popped up on this particular day.  Now I know this may mean that my company may have to hire more people, but I think that is a good thing.  Lots of people are looking for work.  Smart, young, educated people who would have fantastic claims careers.  So give them a shot, and let them on board. The more adjusters the merrier.

 

 

  1. Decreased Phone Calls

 

Since I have been mentioning adding more staff to my company, can’t we also add a team of people whose job it is to answer incoming calls?  I mean, they could be capable of giving out our fax number, or our billing address.  You see Santa every phone call takes precious time away from my actual job of investigating and handling claims.  Sure, these annoying phone calls might only be 2 minutes in length, but it I get 20 of them per day, imagine all the time per month I am wasting!  I’d even be willing to help out the phone people if they cannot handle the call.  Tell them they can transfer the call to me anytime they want to.  But please, consider the creation of this new department. I would be a hero to my claim team.

 

 

  1. No More Report Layout Changes

 

I know that change is important, and inevitable, but why does management always change the reporting protocol and layout at the exact time when I figure out the old changes?  Now, I have to learn a new layout all over again.  Not only does this slow me down, but I have to attend 3 separate training sessions, going through each new field one by one, and this is taking up a lot of my time.  Now when I get back to my desk, I have 5 new voicemails I have to return by the end of the day, or else I get in trouble and my boss gets upset with me.  What was wrong with the old layout?  Must we constantly keep reinventing the wheel?  Reporting is just meant to be a guideline of what is going on with the claim, not a breakdown of day to day activity that covers the span of the last 7 months.

 

 

  1. Recognition for Doing a Great Job on a Claim

 

Santa this is very important.  My boss rarely if ever comes by my cubicle to tell me that I did a good job on a certain file, and that our client is very happy with the way I have been handling their claims.  A tiny compliment like that would make my day—even my week!  This doesn’t cost the company a dime, unless of course they would like to take me out to lunch to thank me for a job well done.  I really like lunches outside of the office, and I think it might motivate me to continue to do a good job.  It is surprising what a free soup and sandwich can do for my morale.

 

 

  1. Workplace Flexibility with Telecommuting, Working from Home, etc.

 

Now I know this is a long shot, but maybe just maybe could we try a few work at home days during 2013?  As you know, I have an hour commute each way to and from the office, usually in heavy freeway traffic.  I have adjuster pals of mine at other companies that get to work 2 days per week at home.  Not only do they not have to drive to work on those days, but they tell me they actually get more work done, because the distractions of the office aren’t there.  So give it a shot, it might make all of us more efficient in the end.

 

 

Summary

 

So there you have it Santa.  I think the above seven wishes would be awesome.  I know that you probably cannot make all of them come true, but I would be happy with 2 or 3 out of 7.  Well, who am I kidding—I would be happy if even one of these things were implemented!  So do what you can big guy, and I promise I will be the best adjuster you have ever seen in 2013 and beyond.  Until next time, have safe travels on your big day and we will talk to you next year.

 

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.

10 Helpful Tips For Managing Angry Work Comp Claimants

You are never going to please all people all of the time.  Nothing could be more correct, especially in the insurance industry.  The claims profession is littered with conflict over many things right from the start.  Experienced professionals know how to properly diffuse a tense situation.  But it is an asset that is learned over time.

 

Here are a few important tips to remember:

 

  1. Stay Calm

 

Regardless of the negative attitudes or unpleasant tones an angry caller may have, it is essential that you do not get emotional as well.  Using phrases such as “I hear what you are saying” or “I understand” can help to calm angry callers.  Remember they usually have no idea what is going on or why these decisions are being made on their claims, so take the time let them vent a bit then calmly explain to them the situation.

 

 

  1. Listen & Be Patient

 

Do not attempt to interrupt angry callers.  Be patient and let them finish speaking.  Sometimes they just need to vent their frustrations.  After that they will relax a bit and work with you to resolve their issue.  Explain to them what is going on, and what options they may have for moving forward.

 

 

  1. Remain Professional

 

Above all remain professional.  Remember you are in the customer service industry, and there is a lot of competition out there.  Every phone call should be dealt with in a professional matter, no matter the conversation.

 

 

  1. Do Not Raise Your Voice

 

Raising your voice or talking in a sarcastic tone is only going to irritate your claimant further, which will resolve nothing.  If anything, you can get in trouble with your supervisor.  Many carriers record telephone conversations, and if this discussion gets pulled for review you are going to look foolish.

 

 

  1. Try Not to Argue

 

Your main goal in diffusing a heated conversation is to resolve the problem.  But a direct argument will rarely resolve anything.  Instead, explain to them what is going on, and what they can do to help themselves.  It may be that getting medical records or a more detailed report from their doctor is the piece of evidence you need to complete your investigation.  Remember the claimant does not have the experience that you do in handling claims day in and day out, so cut them some slack and try to help them instead of just arguing point/counterpoint.

 

 

  1. Speak Slowly and Clearly

 

Nobody likes to have to repeat themselves, so speak in a clear voice.  Also try to avoid talking in legal terms or in claim shorthand.  The claimant will probably have no idea what you are talking about, which will frustrate them.  Pretend you are explaining the issue to someone who has zero experience in this situation, and you may end up with better results than you planned.

 

 

  1. Empathize & apologize

 

How would you feel if you are in the same situation?  What would you want to be said to you to make you feel better about the call?  Claimants want to know that you understand where they are coming from, and they want the reassurance that you can help them with whatever issue they may have. Even if you know the caller is wrong, take a moment and apologize for the confusion.  Many callers simply want acknowledgment from the carrier that a mistake may have been made, if applicable to your scenario.  An apology is the first step to overcoming their anger and opening a dialogue about resolving the issue.

 

 

  1. Offer Solutions

 

People are coming to you with questions about their claim, or why a decision was made.  But oftentimes these decisions are not written in stone.  Denied claims can be accepted later, and vice versa. Maybe your claimant can file for mediation on their denied claim.  Or maybe they did not submit enough information in the beginning for their claim to be accepted.  Whatever the reason may be, explain to them what options they have for moving to the next level.  If you cannot answer a question immediately, let them know that you will work on it and get back to them with some answers or options and go from there.

 

 

  1. End the Call if the Person is Repeatedly Abusive

 

Your goal is to bring a successful closure to each phone call.  However, you do not have to tolerate abuse.  Kindly interject with an “Excuse me” if necessary and inform the caller that their language or behavior is not acceptable, and it will not help them resolve their conflict.  It is well within your ability to end the call if the person continues to be belligerent and abusive if you have asked them to calm down several times beforehand.

 

 

  1. Do not take it personally

 

In the end, this is your job.  A lot of claims adjusters have a lot of hours of work invested into each file, and sometimes they can wear their heart on their sleeves.  But at the end of the day, you have to accept the decisions you made on a claim.  I recall a young adjuster I knew that was first starting out in work comp, and he used to agonize over his decision about whether a claim was compensable or not, and if he was making the right call.  This is a good asset to have, but only if it is a healthy concern.  The process that is in place with supervisor reviews and audits is there to catch your errors, if you have any, and to help you make confident decisions on claim outcomes.  Trust in the process in place, and believe in your decisions that you make. Sometimes you have to go with your gut decision.

 

 

Summary

 

An adjuster is on the phone for the majority of their day, every day.  And in the field of claims, conflict will arise.  There is just no way to avoid it.  But you have to be armed with the proper way to handle yourself on the phone–not just for certain calls but for every call.  Implement the tips above, and hopefully you will be known around the office as a person that can diffuse any tough situation that is thrown their way.  Knowing how to work the phone is one of the best assets an adjuster can have.

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.

What To Do When Your Workers Comp Employee is Seeing Their Primary Care Doctor

 

Often times in workers comp cases, injured workers will go treat with a primary care physician, even if that is technically not allowed This is due to the fact that there is a negative stereotype attached to “clinic doctors” or what many workers call “the workers comp doctor.”  Contrary to popular belief, these doctors do not work for the insurance carrier.  Sure, these physicians may seem more aggressive than the primary care doctor, but that is for several reasons.  The most important one is being that they have no vested financial interest in obtaining a comp case as a long-term patient.  The old adage goes that “treating doctors get paid to treat”, and they like to keep the waiting rooms filled up day after day, and they do so by not being as aggressive as necessary. 
So what if the injured worker is able to skirt around the system and run to a primary care doctor?  Is the employer stuck with this doctor forever, and what can be done to keep the claim moving forward?  How should one go about getting the information needed for the claim? (WCxKit)
 
1. If this injured party has had prior treatment for this complaint with this doctor, be sure to request a copy of the chart and ask for all records.
Say this worker has had similar complaints of back pain in the past, and the records show that he did treat with this doctor in his past comp claims.  This means that with a signed medical release, the doctor should grant access to these records, and any other records that pertain to back treatment.  If this doctor has dictated notes, it can yield several clues of possible injury outside of the course and scope of employment. This of course is solid ground for a dispute on the case, since you the actual injury may not be related to the worker’s actual employment.  
Also included in the notes will be objective evidence of what actually is wrong with this patient.  If he has all subjective complaints, then that injury may not be as severe as the claimant is suggesting. The bottom line is gathering medical records can provide several medical clues as to what is happening and  will only help the case.
 
2.  How does this doctor relate this injury to the patient’s stated injury that arose out of employment?
The main key in any comp case is the causal relation statement.  This is where the doctor takes the subjective and objective complaints and evidence, and ties them back to the worker’s employment.  A lot of primary care docs that do not have a lot of comp experience will purposely be as vague as possible when it comes to this issue.  A common statement a doctor will make is one similar to “The patient did not have any prior complaints of injury other than something happening at work; therefore, it must be work related.”  This is not exactly true, since even though a person may be at work and have pain, it does not mean the work actually caused the pain or injury.  Sure, work can contribute to this scenario, but the adjuster has to get to the ultimate cause.  If a person has back pain, and there is a strain injury at work, it does not necessarily mean that the carrier has to pay for surgery that corrects degenerative conditions. Work may have exacerbated these pre-existing medical conditions, but it is a stretch to say that work actually caused the arthritis.  It is possible is a few circumstances, but overall the common result is admitting that work caused a temporary exacerbation of a pre-existing condition. 

 
3.   If performing an IME or Peer Review that disagrees with the treating doctor’s causal relation, and the treating doctor disagrees with the IME doctor, how is that primary care doctor addressing this issue and what evidence are they using to solidify the opinion?
The second most common scenario is an IME doctor disagreeing with the primary care doctor’s opinion of causal relation. This is when claims will head into litigation, since there is a medical dispute about the origin of the injury.  We have seen a lot of treating doctors say they disagree with the IME doctor, but then they do not elaborate.  If this is the case, the adjuster will almost always side with the IME doctor, terminating medical coverage for this injured worker. In the occasion that the treating doctor makes an argument but still disagrees with the IME doctor, they may agree to disagree.  Again this helps the adjuster, because that adjuster will side with the IME doctor, and overall it will take a Magistrate to make the final opinion on which doctor they find more credible.  As the doctors are going back and forth arguing about who is correct, try to see what the treating doctor is using as the basis for the opinions.  It should be objective medical evidence, and not based on subjective complaints.  If it’s all subjective complaints, then that will only strengthen a suspension. 

 
4.  Is the treating doctor providing medical slips and records on a timely basis to support the worker being disabled?
If the answer to this question is yes, then the adjuster must dig deep to find evidence contrary to what the doctor is opining. This can be in the form of prior injuries, auto accidents, surgical records, etc.  Try to find good solid evidence that the treating doctor does not know about, then submit it and ask if the opinion changes.  
If the treating doctor is not supplying the necessary documentation needed, then there are grounds to suspend treatment with this doctor until the documentation required is received to make a decision on the ongoing compensability of the claim. Most claimants will get frustrated if their treatment is suspended.  Their doctor may be telling them the injury is work related, but there is no supporting documentation to draw that conclusion. 
 
5.  Use of covers letters and nurse case management
After all of the attempts to gather the information needed, there is still a dead end.  So what to do now?  One option is to draft a concise cover letter to the treating doctor outlining concerns.  Doctors like to know what they have to address in comp cases.  Every doctor has a unique style when it comes to these issues.   The treating doctor may actually help a defense if you draft a neatly organized cover letter outlining the facts of the case with the questions concerning the compensability.  Since the adjuster is not in the room when this patient is being seen, who knows what the worker is telling the doctor?  Another way to confirm these facts is using an onsite nurse case manager. The nurse can talk to the doctor before and after the appointment, and can be very useful in getting the information needed pertaining to any medical documentation desired.  The nurse may not be able to actually be present in the room during the exam, but talking to the doctor before and after the appointment may help connect the dots between what medical evidence is showing, and what the patient is actually complaining of in regards to the injury.  Coming to these conclusions will only help the adjuster arrive to the proper decision on the compensability of the claim. (WCxKit)
Summary
If the injured worker is treating with a primary care doctor not familiar with the comp system, be careful and thorough about gathering information.  Be sure to put the time in on doing a detailed background investigation and pass that information on to the treating doctor, so they can see exactly what you are seeing.  This will help them make the correct opinion on the overall compensability of the claim.  If the attempts fail, utilize an IME and nurse case manager to help bridge the process. The adjuster can never have enough information when it comes to making the proper decision on claims.
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

WORKERS COMP MANAGEMENT GUIDEBOOK:  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.
©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.

3 Common Mistakes Your Workers Comp Claims Adjusters May Be Making

As we often write about here on Lowerwc.com, adjusters are faced with many duties to perform every day.  Some of these tasks are simple and take minutes, while some tasks can take up the majority of a day.



Below a few easily overlooked items are discussed that can potentially lead to adjuster or carrier errors while handling workers comp claims.


1. The adjuster does not wait to get all of the medical records before deeming a claim compensable
Sometimes a claim can seem like a no-brainer. Case in point, a worker falls down at work and gets injured. This may be an isolated, witnessed event that results in a worker getting injured in the course and scope of employment.


But the medical records can show things to be contrary to what the initial investigation found. The worker did indeed report a fall with injuries right away, a coworker saw the employee fall, and the medical supports objective evidence of an injury. However, what did this worker tell the doctor?There are cases where an employee is injured as a result of horseplay, and some states that can make the claim not compensable. 


There was a case once where a worker did exactly this scenario. He worked the night shift and stated that his leg hit a cart and caused an ankle contusion. He had a coworker state the same, and all of the paperwork submitted with the claim supported those details.  What he did not say was that he told the Emergency Room doctor he was trying to flip himself into a rolling cart, and his leg hit the side of the cart causing the injury. In this particular jurisdiction, that was deemed as horseplay. After all, attempting to jump into a moving cart was not exactly in his job description! 
 

2. Accepting a case as compensable too soon
As a result of the above #1 item, the adjuster may accept the claim as compensable too soon. Most hospitals and clinics have a delay when the transcribed medical records are requested.  If all that is taken into account is what is stated by the employer and employee, the adjuster is missing one important piece of the puzzle, the detailed transcribed medical records. Just receiving a medical note or slip with the diagnosis and work restrictions usually is not enough for most adjusters. Part of a detailed investigation involves completion of 3-point contacts: The employee statement, the employer statement, and the complete medical record.


This is equally the case when dealing with a claimant that is impatient. Adjusters have several cases in the initial stages, and completion of an investigation can take some time. Just because a claimant is calling 10 times per day does not mean the adjuster should compromise the integrity of the investigation. If filing an extension is necessary for the investigation because the medical records are not in yet, then so be it. This is part of the job.

Claimants need to know up front that it can take some time. If the claimant is not satisfied with the time it is taking to get their medical records, then the injured worker can get involved by assisting the adjuster in asking the hospital to rush the records. After all the compensability of a workers comp claim is hanging in the balance. Frequently the hospital will comply, or at least move that case to the top of the heap so the parties can make a decision on the claim.
 
 
3. Adjusters pay medical bills without the notes attached
Sticking with the theme of medical records, a lot of clinics will just send their bills to the adjuster without the medical bills attached.  Significant over-payments can occur if bills are paid without knowing the services provided.

In jurisdictions where a claimant can treat with the claimant’s own doctor, be especially careful. This person could be going to the doctor for anything, and just because the bill lands in your inbox does not mean that it is automatically related to whatever work injury the worker may have experienced. Payment of these bills is considered “leakage” since monies are being paid on a claim when they should not be. If there are claims that have been around for many years, and are paid bills without the notes attached, then who knows how many bills have potentially been paid in error. The total could be in the thousands of dollars, and trying to recoup those monies from the provider can lead to a nightmare of phone calls. It is so easy to avoid this by making sure to know what is being paid for and how it is related to the work incident.


Summary
So there you have it, three scenarios where adjusters can make payments in error. This is not going to happen all of the time on every claim, but those claims are out there. More importantly those adjusters are out there making these simple errors every day. [WCx]


If you think that errors are being made on claims, then pick up the phone and ask for the claim payment log.   You should also ask for the claim to be audited by a manager or supervisor just to alleviate issues. Recouping monies paid in error is far more labor intensive than just doing what was supposed to be done in the first place which is handing claims correctly, and making payments correctly.
See our general article on Best Claim Handling Practices for an overview.

 

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

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com
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 us at: Info@ReduceYourWorkersComp.com.

Good Adjusters Know When to Settle Your Workers Comp Claims

The number one distinction between the excellent workers compensation adjuster and the average adjuster is the ability to distinguish when the claim should be settled. The lazy or indifferent adjuster will often push to settle a workers comp claim quickly, regardless of cost. The excellent adjuster will also want to get the claim settled quickly, but will be patient for the most opportune time to settle thus minimizing the overall cost of the claim. The excellent adjuster will have a working knowledge of the underwriting of workers compensation coverage and realize the amount spent on each claim has an impact on the employer’s workers comp insurance premium.

 
 
The professional adjuster starts moving the claim toward settlement immediately upon receiving the new injury claim. The adjuster understands everything that is done on the claim can impact the settlement, whether it is confirming coverage, making initial contacts, completing a thorough investigation, obtaining medical information, or arranging the return to work or any other action taken by the adjuster.  The adjuster knows that by following Best Practices throughout the claim handling, the most economical settlement will be reached. [WCx]
 
 
The adjuster has to walk a fine line in the settlement of the claims. The adjuster has the task of making sure all applicable workers compensation benefits are provided to the injured employee while at the same time being sure the correct amount is paid on every benefit provided whether it is medical treatment, indemnity benefits, vocational rehabilitation, legal fees, or other expenses. The biggest potential for a mistake on the overall cost of the claim is the decision on when and how to settle the claim.
 
 
 
In almost all situations it is not to the employer’s/insurer’s advantage to consider settlement of the claim before the employee has reached maximum medical improvement. If the employee is anxious to settle the claim before the medical provider has provided a long-term perspective on the employee’s future medical status, the adjuster should consider the effort to settle the claim prematurely as a red flag waving, and carefully review the validity of the claim.
 
 
There are three financial consideration questions the adjuster should utilize in determining when to settle the claim. 
 
  1. Is there a cost savings by settling the claim now versus continuing to pay weekly indemnity benefits and on-going medical cost?
  2. Will settling the claim now eliminate unnecessary legal cost?
  3. Will settling the claim now eliminate the risk of a more adverse outcome?
 
 
When the employee has reached maximum medical improvement and has been given a disability rating, the workers compensation statutes of the jurisdiction will specify how much the injured employee is entitled to in compensation. Consider the employee, who as a result of his injury will never be able to return to any type of employment. For example, the state limits disability benefits to 500 weeks, and 100 weeks have already been paid to the employee. If the employee’s weekly benefit is $600 and the employee will be paid for another 400 weeks, or a total of $240,000, does it make sense to settle the claim now or is it better to leave the claim open for 400 more weeks? 
 
 
The answer depends on the amount the employee/employee’s attorney is willing to settle the claim for. The settlement amount must be equal or less than the present value of the money the insurer would invest to produce the income stream needed to pay the employee. For instance, the insurer would need to invest $200,000 to produce the income stream over the 400 weeks. If the employee wanted to settle the claim for $175,000, it would be in the best interest of the insurer to settle.  However, if the employee demands $225,000 to settle the claim; the insurer would do better to continue to pay the $600 per week, as their eventual total cost of the claim would be less.
 
 
A common mistake made by adjusters is to litigate the claim when the claim should be settled. If the adjuster has properly established the settlement value of the claim, the time to resolve the claim is when the settlement value has been established, not months or years later after extended litigation. If there is nothing to be gained by delaying the settlement further, the time to settle the claim is when the value of the claim can be established, whether or not the claim is in litigation.
 

My general rule of thumb is: if the claim is going to be settled, do it now rather than later, because every week the claim is ongoing indemnity costs are being paid, so why wait an extra 6 months vs. settling it now, assuming  all other things are equal.

 
 

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This is assuming that the employee’s attorney will encourage the employee to settle for the proper value of the claim. There are plaintiff attorneys that will intentionally refuse to settle the claim for the proper value in an effort to extort additional compensation from the insurer. In those cases, the adjuster is better off not to settle the claim until the employee’s attorney is willing to encourage a fair settlement. If the adjuster overpays on the claim to get it settled, the plaintiff’s attorney will remember and make excessive settlement demands on all future claims with the adjuster and/or insurer.
 
 
There are situations where it is better to settle the claim for what could be considered a high amount. For an example, the employee was seriously injured. The medical provider has placed the employee at maximum medical improvement with a fairly high permanent partial disability rating. The employee’s attorney is maneuvering to get the employee declared to be permanently and totally disabled. The medical information and vocational information is such that there is a possibility that the employee could be found to be totally disabled by a workers comp judge. To avoid what could be a much larger settlement, the adjuster (normally with the concurrence of the claim office management) will make a decision to settle the claim for a higher than normal amount to avoid the potential of having to pay even more due to adverse ruling on the claim if it is not settled.[WCx]
 
 
Overall, the time to settle the claim is when the most economical outcome will be produced.  The adjuster should always keep this in mind once the employee has reached maximum medical improvement.


 

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.

 

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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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22 Things Your Workers Compensation Adjuster Should Not Do

Self-insured employers often get into trouble for not being knowledgeable of the requirements of the Unfair Claims Practice Act in the state(s) where it is being self-administered for workers compensation claims. The failure to act in a totally ethical manner can lead to litigation by the party wronged and to fines and/or the suspension of the self-insured’s authorization to be self-insured by the State.

 

 

The workers compensation adjuster, who is often dealing with attorneys out to maximize the cost of the workers comp claim, or with employee claimants who are attempting to commit fraud, may be tempted to fight fire with fire. The adjuster should always handle the claim in a totally ethical manner.  If an adjuster is doing any of the following, stop everything and discuss the adjuster’s actions with the adjuster. [WCx]

 

 

Unfair claim practices by the adjuster include:

  1. Knowingly misrepresenting the benefits available under the state’s workers compensation law
  2. Failing to contact the injured employee (hoping the employee will not pursue the claim)
  3. Failing to investigate the claim properly
  4. Denying compensability without a valid reason
  5. Failing to file all necessary state forms
  6. Recording the employee’s statement when the employee is under the influence of medications or distracted by pain
  7. Failing to provide a copy of a recorded statement or written statement when one is requested
  8. Recording telephone calls without the other party’s knowledge of the call being recorded
  9. Knowingly documenting the file notes with inaccurate information
  10. Intentionally not returning phone calls of the employee or medical provider in an effort to discourage the claim
  11. Failing to pay indemnity benefits timely trying to coerce the employee in to returning to work prematurely
  12. Failing to authorize needed diagnostic testing without reason to not authorize
  13. Failing to pay for permanent partial disability
  14. Paying less than the workers comp statute calls for when settling a permanent partial disability
  15. Offering to settle and close out future benefits for an amount significantly less than what the adjuster knows to be fair
  16. Advising the employee not to hire an attorney
  17. Threatening to reduce the settlement of the claim if the employee hires an attorney
  18. Discussing any aspect of the claim with an employee known to be represented by an attorney
  19. Settling the claim before the extent of disability is known
  20. Overstating the damages and exposures so that the adjuster’s supervisor will extend excessive settlement authority, allowing the adjuster to make a quick (but overpaid) settlement
  21. Providing the employee’s personal information to parties who do not have a legitimate need to know
  22. Having a financial interest in any vendor utilized on the claim

 

Mistakes, oversights, and poor claim handling are not unfair claims practices. The workers compensation adjuster often has more work to do than it is possible to get done. With the telephone ringing constantly, the e-mail flooding in, having numerous deadlines for filing forms, numerous deadlines to prepare for mediations or conferences, and numerous other items that need to be completed, it is normal for some things to fall through the cracks. When the adjuster does not contact the injured employee timely, or does not respond to a settlement demand from the employee’s attorney, it is normally because the adjuster has more to do than is possible to get done. It only becomes an unfair claims practice when the adjuster intentionally decides not to take a needed action in an effort to impact the overall outcome of the claim. [WCx]

 

 

Almost all adjusters are honest and have the best interest of both the employee and the employer at heart. If you do notice any of the above 22 issues occurring, stop and discuss the issue with the adjuster. Often there is an ethical and valid reason for the adjuster’s action which will become apparent when you learn more about the reason for the adjuster‘s actions. Only when the adjuster sets out to act dishonestly should you be greatly concerned.

 

 

 

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.

 


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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.

 

Know 8 Costly Mistakes Workers Comp Adjusters Make

 
It is not easy being an adjuster – worried claimants, demanding plaintiff attorneys, state forms, overly concerned employers, totally unconcerned employers, constant phone calls, tons of emails, mediations and hearings, medical providers who do not report, and medical providers billing above fee schedule all make for a stressful job with too many things to do. In such an environment, it is easy to make mistakes – mistakes that cost the insurer money. These costs are passed on to the employer in the form of higher workers compensation premiums.
 
 
8 costly mistakes the adjuster can make:
1. Failing to Investigate
It is way too easy for the adjuster to rationalize that if the employer reported the work comp claim, then it must be compensable. Monday morning claims (that usually happen away from work over the weekend) and claims that were not reported when they occurred are two of the most common types of work comp claims that need to be thoroughly investigated. But often there is no investigation. The failure to investigate results in payment of work comp claims that were not owed and should not have been paid.(WCxKit)
 
 
2. Not Recognizing Subrogation
Work comp adjusters are trained in workers compensation claim handling. The work comp adjuster is usually not trained to handle liability claims and therefore will often not recognize a third-party liability situation where there is a right of recovery from another party. Every work comp adjuster should learn to ask, “What caused the injury?” and, “Was anybody else involved?” This is such an issue that some insurers have set up a separate subrogation department with staff trained to recognize liability situations and opportunities for recovery of the amount paid on the workers compensation claim.
 
 
3. Letting the Defense Attorney do the Adjuster's Job
When the employee's attorney files for a hearing or a mediation and the adjuster has not properly investigated the claim or does not have the claim file properly organized, defense attorneys and their paralegals will not have a word of complaint – they will simply charge their hourly rate. If the claimant's recorded statement was never taken, no problem, they will take a deposition. If medical records are not organized, they will be put into order by whoever the treating physician was or by the chronological occurrence date. Of course, the paralegal or junior partner, who does what the adjuster should have done, will bill the insurer for time spent doing the adjuster's job.
 
 
4. Not Reading the Medical Reports
A work comp adjuster will often scan the treating physician's report but skip reading the diagnostic records, nurse's notes, and various other additional documentation, especially in long, complicated cases with extensive medical information. This can be a costly mistake because buried deep in the medical documents will be information on pre-existing medical conditions or intervening causes – such as another accident. This information will change who is responsible for medical care and the amount of time an employee is away from work.
 
 
5. Ignoring Unofficial Information
The employee with the “severe back injury” is seen at the bowling alley by one of his co-workers. The co-worker tells a supervisor, who tells the work comp coordinator who tells the adjuster. The adjuster has read the medical report in which the claimant told the orthopedic doctor he could not bend over. The adjuster dismisses the information from work comp coordinator as gossip or hearsay and has “too much other work to be chasing rumors.” The claimant stays off work and perfects his bowling game while the adjuster continues to pay medical bills and weekly indemnity checks.
 
 
6. Failing to Direct the Defense Attorney
Often the overworked adjuster will give the claim to the defense attorney and say, “You handle it.” The proper course of action is for the adjuster to work in partnership with the defense attorney. In this situation the adjuster advises the defense attorney on when to litigate and when to settle. Many defense attorneys will go through the motions of depositions and hearings, and after months or years recommend the claim be settled. The adjuster should have discussed the claim early on with the defense attorney and instructed the defense attorney to defend or settle the claim. Too often unnecessary legal cost is incurred because the adjuster did not specify a course of action on the claim.
 
 
7. Not Utilizing Medical Case Management
Different insurers and different third-party administrators have varying guidelines on when the adjuster should utilize medical case management. Neither the extreme of using a nurse case manager on every work comp claim (unless a senior nurse reviewer is utilized on all claims) nor the extreme of never utilizing medical management should be the adjuster's norm. The wise adjuster will save the insurer money by bringing in a nurse case manager on every surgical intervention, every compound fracture, and every hospitalization. When the adjuster does not have medical management involved in the file, the medical providers practicing defense medicine will have optional medical procedures performed that would have been avoided with a nurse case manager controlling the medical care.
 
 
8. Working on Autopilot
It takes a minute of the adjuster's time    each week    to verify employee's medical treatment and return-to-work status. It is easy to put indemnity checks on autopilot –they are computer issued each week without the adjuster's approval. What often happens is the employee returns to work while the indemnity checks continue to go out. Some honest employees will return the overpaid indemnity benefit, but many will keep the extra money rationalizing it is for their pain or inconvenience. Other examples of autopilot on the claim file is placing the claim on a "long diary," with the adjuster figuring everything will be resolved by the time the adjuster sees the file again on their diary (calendar).
 
 
If you see your workers compensation adjuster making any of these mistakes, politely bring it to their attention. Advise the adjuster not to allow an insurer to make unnecessary payments on your claims.
 

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

7 Things Claim Office Supervisors Wish Adjusters Did Better

 
Every adjuster has an individual style when it comes to handling claims. Just like snowflakes, no two adjusters are exactly the same. Yes – they may be similar in deciding if a claim is compensable, but how they arrive at that result that varies. It is safe to say claims supervisors must monitor each adjuster differently.
 
7 areas supervisors wish their adjusters would improve:
 
1. Document The Files
When it comes to documentation in the file, everyone is different. Notes should be succinct, and tell the story without droning on and on. Adjusters are very busy handling several different issues at once, and, at times, some information is overlooked. What a supervisor may think is important to document in the file notes the adjuster may not, and some facts can be overlooked. That does not mean the adjuster is not aware of these facts, it just means they are not in the actual file notes. It is all about documentation when it comes to handling files since you do not know who at the executive level is looking in the file. A happy medium needs to be reached when deciding what HAS to be in the file, versus what can be skipped.(WCxKit)
 
 
2. Research Medical Diagnoses
No matter how many years experience an adjuster has, the brutal truth is the adjuster is not a medical doctor. Diagnoses are becoming more and more complicated with several types of degenerative conditions complicating acute injuries. The job of the adjuster is to separate what is pre-existing from what is acute and possibly work-related. Sometimes when adjusters see the word “degenerative” or “arthritis” they automatically lean toward denial of the claim.
 
 
However, in the world of workers comp a common issue is exacerbation of pre-existing conditions — this is seen especially in back strains. Someone may have a pre-existing disc herniation. That does not mean when attempting to lift that box the back was not strained a little leading to a temporary exacerbation of the pre-existing condition. Adjusters can be quick to wrongfully deny a claim, and in the end it comes back to haunt them in litigation.

Adjusters need to know what type and duration of treatment is needed before they can correctly deny ongoing treatment or set up an Independent Medical Evaluation (IME) to terminate ongoing benefits. Using medical guidelines can help. Consulting with a board-certified M.D. is even better. Consider subcontracting with a physician review service so your adjusters have the services of M.D.s to review claims; these services can be purchased on an outsourced basis. Include senior nurse reviewers in the process. Let your clients know about these services.
 

 
3. Communicate with Insureds
With caseloads increasing for the average adjuster, it is hard to find the time to sit down and explain to the employer about a medical condition, or to discuss why a claim was denied, or to pick up the phone and update the employer on open files. Adjusters need to remember the employer is their client, and proper customer service is what can separate their insurance company from their competition. Giving adequate time to every employer, leads to a great relationship between all parties and, in turn, makes dealing with future issues much easier.
 
 
4. Communicate With Claimants
Many adjusters forget the average claimant knows little about the way the claims process works. Without proper communication, the claimant has no idea what is going on, why the claim was denied, why they cannot see their own doctor, or why it is taking so long to receive a check if the claim is deemed compensable. This can lead to litigation, and even worse bad faith claims made against the carrier, which can become a severe issue for the insurance company and the client employer.
 
 
If an injured worker comes back to work and complains about the way in which the claim was handled to the supervisor, you can bet that will result in a phone call to the claims manager, which can lead to discipline for the adjuster. It should be mandatory (but it is not) on every claim that the adjuster takes time to explain to the claimant what their rights are, what the insurance company’s rights are, and to address any questions or issues a claimant has in regard to the claim at any time.
 
 
5. Balance Aggressiveness
This varies by adjuster. Some are overly aggressive, whereas some are a bit more liberal in the way they interpret claims statutes. This can be both good and bad. If a claim is denied due to over-aggressiveness, it can lead to wrongful litigation and possibly penalties against the carrier for bad faith claims. In turn, some claims are accepted when they should be denied. Obviously, that is a serious issue as well and the financial leakage ensuing on a wrongfully accepted claim can be disastrous for the carrier. This can include embarrassment and possible discipline for the adjuster handling the claim as well as ramifications for that adjuster's manager.
 
 
6. Background Checks and Investigation
An adjuster has several tools to do background checks on claimants, including the Insurance Service Office (ISO) database, the SIU (Special Investigating Unit) department background research, outside vendor surveillance, and court research. The ISO keeps a database on all personal injury claims by name, social security number, and address to help adjusters identify repeat claimants who have an auto bodily claim, a general liability slip, fall claim, and a workers comp claim all going at the same time, for example.
 
There are a lot of repeat offenders out there who make a living going from employer to employer, settlement to settlement.  Due care needs to be taken on the part of the adjuster to put the time in when background checks are needed, since the results can lead to case denial.
 
 
7. Vendor Use
When vendor marketers come in to an insurance carrier’s office, they are typically very personable and offer a variety of services to make the adjuster’s life easier. Sometimes, adjusters use a certain vendor because they like that company or are personal friends with the marketer. Even though that particular vendor is ineffective or overly expensive, the adjuster continues to send them business for the sake of the personal relationship. Do not tolerate this scenario and include manager involvement to be sure vendor use is appropriate, effective, and performed at the time the services are needed. (WCxKit)
 
 
Summary
Every adjuster is different. The manager’s role is to make sure claims are being handled ethically and properly within the practices set by the carrier. Typical adjusters wear several hats during the course of a day doing their job, and each one deserves proper attention and care. If adjusters fail at any of their tasks, it makes everyone look bad and costly penalties can be assessed when someone fails to take appropriate care of the situation at hand.
 

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

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