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.

Adjuster Selection Attributes That Will Save Workers Comp Costs

Self-insured employers with successful workers’ compensation claim management programs know one key fact – the better the adjuster, the lower the claim cost. Whether the self-insured employer has dedicated and/or designated adjusters at the third party administrator, or utilize their own in-house adjusters, the selection of the best adjusters can be tricky. 
Too often self-insured employers make the mistake of judging adjuster quality based solely on the ability of the adjuster to maintain rapport with the employer. While rapport is important, there are several other key traits the self-insured employer needs in each adjuster handling their workers’ compensation claims. Successful adjusters have many attributes. Four primary attributes the self-insured employer should look for in the adjuster selection process are:
  • Communication
  • Documentation
  • Proactive
  • Courteous
 
Communication:
Few things are more dangerous to the self-insured employer than the workers’ compensation adjuster who does not communicate openly and often. Major claim developments that are unknown to the self-insured employer can wreak havoc. With open communications between the adjuster and the employer, the employer is kept informed of each claim’s progress. Open communications allows for the exchange of information about the claim and ideas on how to assist the injured employee while moving the claim forward. Open communications with the adjuster is not for the employer to micro manage the claims, but to facilitate collaboration and claim progress.
 
Documentation:
The best workers’ compensation adjusters thoroughly document their files. Each phone call, e-mail, medical bill, medical report, attorney letter, state filing, etc., should be documented either in the file notes, the documents section of the file, or both. If the adjuster accepts employment elsewhere, takes ill, or for some other reason is unable to continue the handling of the claim, the next workers’ compensation adjuster who picks up the handling of the claim should be able to review the file and know immediately both the former course of the claim and the current status of the claim. 
 
Proactive:
The adjuster who allows the workers’ compensation claims to take their own course, rather than directing and influencing the claims, provides little benefit to the self-insured employer. The adjuster who takes charge and actively manages each aspect of each claim keeps the number of unpleasant surprises to the minimum. Ordinary claims that are not actively managed by the adjuster frequently take a wrong turn and become more complex (and more costly). The proactive adjuster will coordinate and manage the medical care either directly or through a nurse case manager. The proactive adjuster will arrange for the employee to return to work light duty. And, the proactive adjuster will coordinate all other aspects of the claim before there is a need for action.
 
Courteous:
When a workers’ compensation adjuster is not courteous to everyone in every facet of their claim handling, the resolution of the claim becomes more difficult to achieve. Courtesy is much more than the adjuster being polite on the telephone. Each missed telephone call should be returned as soon as possible, preferably the same day. Each email that needs a response should be promptly replied to.   Each paper correspondence that requires an answer should be addressed right away. 
Courtesy is especially important with injured employees. While a non-injured employee would over-look any unintentional slight, an injured employee who is already anxious about his/her future health and employment, will often take any bluntness or perceived lack of courtesy as the employer and the work comp adjuster not caring about their well-being. A lack of courtesy by the adjuster frequently results in the injured employee obtaining an attorney, which delays the claim resolution while increasing the claim cost.
 
Other Attributes of an Excellent Adjuster:
While the four attributes listed above are key to the successfulness of an adjuster, there are several other traits the self-insured employer should look for in the selection of an adjuster. The following attributes are also important, and should be evaluated in the adjuster selection (and retention) process. 
  • Negotiation skills
  • Organizational skills
  • Time management skills
  • Customer service skills (customer being both the self-insured employer and the injured employee)
  • Work ethic
  • Ability to prioritize competing demands
  • Compliance with Best Practices
  • Technical expertise
 
If you find all of these attributes in one adjuster, it is definitely an adjuster you want to handle your workers’ compensation claims. While few adjusters will be strong in all of these areas, the greater the number of positive attributes the adjuster candidate has, the better his/her selection will be for your company.
  
 

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
 
©2013 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.

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.

Selecting High Quality Third Party Administrator Adds Directly to Your Bottom Line

There are many programs a self-insured employer can implement to have a positive impact on the cost of their workers compensation.  Safety, aggressive transitional duty return-to-work, effective medical cost containment, and solid fraud prevention programs all will have a positive impact on the cost of workers compensation.

 

 

The one area of workers compensation cost control that is frequently overlooked is the quality of the third party administrator (TPA) handling the claims.  All the savings from the safety, return to work, medical management and fraud prevention programs can be easily lost by the selection and continuation of a poor TPA.  If the workers comp adjusters at the TPA do not handle the claims correctly and efficiently, the cost of the claims will be significantly higher and will cost the self-insured employer far more than they might realize. (WCxKit)

 

 

 

The skilled workers comp adjusters who followed the established Best Practices for Workers Compensation claims handling will have substantially better outcomes financially then the adjusters who take short cuts.  Workers comp adjusters are human and when they are taught by TPA management to meticulously follow the Best Practices, they have great results.  When adjusters are taught to give lip service to Best Practices and are assigned too many claims by TPA management, the end result is the overpayment of claims.

 

 

If the self-insured employer selects their TPA by the lowest bid to provide their claims handling services, they may or may not get quality claims handling.  There are several measurements of quality the self-insured employer should look at in selecting and retaining a TPA from year to year.

 

 

Prior to making a decision on the selection of a TPA, ask all the TPAs submitting proposals to handle claims to submit a copy of their Best Practices for review. Eliminate from consideration any TPA who has vague Best Practices. Each of the Best Practices should state precisely what their criteria are and a time frame for accomplishment.  For example:  If the Best Practices state “will keep in regular contact with the injured employee”, that is marginal.  If the Best Practices state “will contact the injured employee the day the claim is assigned and after each doctor’s visit”, that is excellent.

 

 

Ask the TPA what is the average experience level of their workers compensation adjusters. Experienced adjusters tend to make fewer mistakes than inexperienced adjusters (and the self-insurer is the one who pays for the mistakes made by the adjusters, regardless of experience level).  Experienced adjusters know what to investigate, when to investigate, what to deny and when to settle.  They know the doctors, lawyers and workers comp boards.  They know how to move claims to a conclusion.

 

 

Experience of the adjusters is not the sole criteria.  Ask what the tenure is for the staff.  If the staff have had a lot of turn-over, there may be underlying problems in adjusters working for the TPA.  Also, turn-over and changing adjusters on the claims can have a negative impact on the outcome of the claims.

 

 

Ask the TPA for the average number of lost time claims assigned to an adjuster. If the TPA states the adjusters have on average 175 lost time claims, expect a poor outcome in most of the lost time claims.  If the TPA states it will vary by jurisdiction, by experience level, and by the number of litigated/board cases, you will have a much more sensible answer.  On average, an experienced adjuster can handle approximately 125 claims at a time, in a state with a moderate amount of state forms to process and in an area where most injured employees are not represented by an attorney.  If the state has complex forms and is highly litigious, for example, California, the average case load for an experienced adjuster may be only 100 claims. Much depends on practices and staffing within the claim office such as whether each adjuster has administrative support for obtaining medical records and pay bills; The more support provided to adjusters the more claims they can handle.

 

 

Ask the TPA what their practice is in assigning claims.  If the TPA rotates the assignment of claims, the self-insured employer will end up with multiple adjusters working on the claims.  If the TPA uses designated adjusters (where the adjuster handles all the claims for the self-insured employer, plus claims for other employers) or the TPA uses dedicated adjusters (where the adjuster handles claims only for one self-insured employer), the self-insured employer will have a better overall outcome on claims as the adjuster(s) thoroughly learn the requirements of the account and know what is expected of them by the self-insured employer. (WCxKit)

 

 

Ask the TPA for a list of clients it services in the area.  If the TPA is reluctant for you to know its other clients or is reluctant for you to contact its other clients, that is a red flag.  If the TPA readily provides you with a list of clients, contact some of them at random and ask what their overall level of satisfaction is with the TPA.  Good references from other clients is a definite positive, while a polite refusal to provide any input on the TPA selection should be a negative, especially if other clients are also reluctant to give a positive recommendation.

 

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.comContact: 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.

 

 

Our WORKERS COMP BOOK:  www.WCManual.com

 

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

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

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

SUBSCRIBE:  Workers Comp Resource Center Newsletter

 

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


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

 

Seven Ways Carriers and TPAs Ensure Quality Control

pic11Quality control does not just apply to files, it can also apply to personnel handling files. When you make that choice for a carrier or third-party administrator (TPA), you want to be confident the adjusters and managers handling your claims are qualified to do so, and that they are representing your company in the best way possible. Below we discuss some general employee screening tactics along with some quality control tactics used on claim files.

 

  1. Multi-level screening of adjuster candidates

 

Most carriers/TPAs actually prefer to hire entry-level candidates that have no experience. When you talk to your adjuster to see how they got started in this business, a good percentage of them will say they just “fell into the business.” This happens because of the way  HR departments look for new candidates.(WCxKit)

 

Carriers/TPAs will require their candidates to be college graduates. It also helps to have a degree in some area that applies to insurance. This could be economics, accounting, finance, human resources, criminal justice, etc. That is not to say someone with a different degree would not qualify, but it is probably not the carrier/TPA’s first choice for the perfect candidate upon first glance. The best carriers/TPAs provide career path training so trainees know what they must do to move to the next level. In addition to onsite training, virtual training may be offered so new adjusters can commute virtual to training.

 

As the adjusters move forward with their careers, they attain the AIC (Associate in Claims) designation from the AICPCU (The Institutes), which is a nationally recognized program. At each career path level the adjuster also has in-house and some external courses to complete to meet their educational requirements to be promotable. There is also annual compliance training, which includes insurance fraud awareness training.

 

 

The candidate will also have to pass a credit check, and a normal criminal background check. They also have to be verified to be eligible to be considered as a “fiduciary agent” since they will be making payments for your carrier/TPA on behalf of another party. So it makes sense that you have to be good with money, and have no blips on your personal history that could be construed as potentially negative to employment with said company.

 

 

  1. Proper, extensive, continued training and education
    Going back to carrier/TPAslooking for candidates with little to no experience, this is because the carrier/TPA does not want anyone bringing bad habits into a company that they may have learned other places. Once hired, they will be sent to an extensive claims school, or formal training program – normally these are in-house training facilities. They will learn the skills from veterans of the insurance industry. They will handle fake claims to go through the motions, and the education on the medical aspect can be fairly thorough.

 

 

Once they are established adjusters, continued education is still required. An adjuster usually has to obtain a certain amount of extra training and education every year. This is obtained by attending legal/medical seminars, taking online courses, or obtaining an insurance designation such as an AIC (associate in claims). In most cases, it does not matter how many years of claims adjusting you have under your belt, carriers/TPAs still require you to stay current with legal changes, medical techniques, etc. The adjuster role is one that is constantly being improved and educated at all times.

 

 

  1. Two week manager brief review on new files
    When new filescome in, unless it is a very minor claim or a “report-only” claim with no medical treatment, the claims manager will review the file at or around the two-week mark. This way, the contacts have been made, a medical diagnosis is obtained, and it is fairly clear if a claim is lost time or not. The manager can then set another date for review depending on the future outlook and risk drivers on the claim, and go from there at the 60-day mark.

 

 

  1. Sixty-day status report

A 60-day status report is the first formal report on a claim the adjuster makes to the file. This report will usually go in the file, and will be reviewed by the unit manager. This report summarizes the contacts made, the medical obtained, and the future outlook on the claim. It also will address the reserve amounts. Most carrier/TPAs will place a default reserve in the file once they get assigned to it, and they will address those amounts at this 60-day mark. The manager again will review the report, make recommendations on the file, and place another date to further review the file as needed.

 

 

  1. Status report: 120-150 days in
    This report willassign the current and future exposure on the claim. By 150 days, It will be fairly clear if this will be a long-term large exposure claim or not. By this time, an injured worker may have had surgery, or has surgery pending. Or, using the flip side, at the 150-day mark the worker may be released from medical care and the file will be set to close.

 

 

Reserves will also be placed in the file for the long-term exposure. This is when the large reserve increases will be made depending on the file exposure based on risk drivers. Again, by this time in the file, it will be known what the future should hold.

 

 

  1. Roundtable of higher-exposure files
    For a complex file, around the 150-day mark, a roundtable may be set to discuss the claim with senior adjusters, managers, and probably the employer. If several parties are involved, they will be brought together to discuss the future of this claim. If the exposure is there, the file may be assigned to a senior-level adjuster. The roundtable is used to brainstorm the file and come up with ways to limit exposure. This could be by assigning a nurse case manager, review by legal counsel, or creation of a light duty job to reduce wage loss exposure. Whatever the reason for the roundtable, it is a common tool used to the carrier/TPA to come up with ways to move the file onward towards the common goal which could be return to work, release from medical care, or overall redemption of the claim through a settlement.

The best TPAs include medical professionals on the roundtable teams such as mental health professionals to determine if there is a mental health component to the claim and, if so, RNs with mental health expertise may be assigned to the claim.

 

  1. Following up with involved parties
    Whatever the claimmay be, quality control is best assessed by proper communication with all parties. Adjusters should be talking to employers to keep them up to date. Adjusters should be talking with their on-site nurses or with their vocational counselors. Adjusters should be talking with plaintiff counsel or defense counsel to keep the file moving towards resolution. Carrier/TPAs always preach trying to keep all parties current and up to date with the activity of the file. Lack of communication is a recipe for disaster, no matter what the exposure is on the claim. (WCxKit)

 

 

In summary, carriers or TPAs have several tools they use to maintain that the work product they put out is of top-notch quality, no matter what the exposure. We have touched upon a few here, and these will vary slightly from carrier to carrier and from TPA to TPA. You should ask your adjusters and managers at your carrier/TPA what they do to maintain quality, and let them take you through the process. The more you know, and the more involved you can be, the better outcome your claims will have.

 


Author Rebecca Shafer
, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

 

 

Our WORKERS COMP BOOK:  www.WCManual.com

 

 

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

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

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

SUBSCRIBE:  Workers Comp Resource Center Newsletter

 

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

 

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

 

29 Things to Look For When Hiring An Adjuster

If you self-administer your own claims, you already know hiring the best workers’ compensation adjuster(s) is a necessity. The challenge is in knowing what job skills and personal characteristics to look for in an adjuster beyond the normal experience and education job interview you may ask.

 

JOB SKILLS

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:

  1. the factsof the accident, with the supervisor’s name and the names of witnesses
  2. informationon the injury (make it a burn or a fractured limb with the need for surgical repair, or other complicated injury)
  3. the Employer’sFirst Report of an Accident form for your state (with wage information but no mention of the employee’s second part-time job)
  4. have facts(like horseplay or intoxication) that create questions in regards to compensability
  5. have facts(like sub-contractor or seasonal worker) that create questions in regards to coverage,
  6. the employeetreating at an unapproved medical provider

 

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

  1. opinionas to coverage for the claim
  2. opinionas to compensability for the claim,
  3. to outlinethe investigation steps to take (interview the employee, the supervisor, and witnesses? contact the medical provider?)
  4. providea reserve calculation sheet showing how reserves will be set for the claim,
  5. showhis/her calculations of the average weekly wage
  6. list thestate forms needing to be filed, and when
  7. handlethe 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 properly establish the average weekly wage 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:

  1. Self-stress managementas the workers’ comp adjuster position can involve difficult people, deadlines, conflicting demands, pressure from both outside and inside the organization, and frequent change.
  2. Reasoningto understand relationships between facts, information from various sources and to data.
  3. Creative thinkingas the facts and issues vary from one claim to the next.
  4. Problem solvingability to analyze the facts and use proper reasoning to solve the problem when confronted with both relevant and irrelevant facts.
  5. Oral communicationability to obtain information from various sources and to convey information in a clear and precise manner.
  6. Written communication skillsto convey information in a well organized manner
  7. Interpersonal skills to deal with people who are injured, difficult, or even hostile.
  8. Self-motivationto set personal goals and to take the initiative to accomplish personal objectives and company goals.
  9. Honesty and integrityin all aspects of her interactions with everyone.
  10. People skillsincluding tactfulness, empathy, understanding, and concern.
  11. Planning abilityto set priorities, organize work, to achieve short term and long term goals.
  12. Customer service skillsto maintain rapport with employers and provide guidance and assistance to them.
  13. Self esteemto maintain a positive image of self and the company and to display it in a professional manner.
  14. Mathematical abilityin establishing indemnity benefits and reserves.
  15. Conscientiousabout the details of the work.
  16. Plays wellwith 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. (workersxzcompxzkit)

 

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, J.D., Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact:  RShafer@ReduceYourWorkersComp.com  or 860-553-6604.

FREE WC IQ Test: http://www.workerscompkit.com/intro/
WC Books: http://www.reduceyourworkerscomp.com/workers-comp-books-manuals.php
WC Calculator: http://www.reduceyourworkerscomp.com/calculator.php
TD Calculator: http://www.reduceyourworkerscomp.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.

©2010 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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