Adjuster Qualifications & Responsibilities Archives

An Adjusters Wish List To Santa

December 13, 2012 by Michael B. Stack Leave a Comment

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.

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.

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.

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.

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.

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.

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.

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.

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

Filed Under: Claim Management Tagged With: Adjuster Best Practices, Adjuster Qualifications & Responsibilities, Adjuster-Hiring for Work Comp, Reducing Workers Compensation Costs, workers comp, Workers Compensation

10 Helpful Tips For Managing Angry Work Comp Claimants

November 21, 2012 by Michael B. Stack Leave a Comment

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:

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

Filed Under: Claim Management Tagged With: Adjuster Best Practices, Adjuster Performance, Adjuster Qualifications & Responsibilities, Adjusters and Claims Handling, workers comp, Workers Compensation

22 Things Your Workers Compensation Adjuster Should Not Do

March 6, 2012 by Rebecca Shafer, J.D. 1 Comment

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:

Knowingly misrepresenting the benefits available under the state’s workers compensation law
Failing to contact the injured employee (hoping the employee will not pursue the claim)
Failing to investigate the claim properly
Denying compensability without a valid reason
Failing to file all necessary state forms
Recording the employee’s statement when the employee is under the influence of medications or distracted by pain
Failing to provide a copy of a recorded statement or written statement when one is requested
Recording telephone calls without the other party’s knowledge of the call being recorded
Knowingly documenting the file notes with inaccurate information
Intentionally not returning phone calls of the employee or medical provider in an effort to discourage the claim
Failing to pay indemnity benefits timely trying to coerce the employee in to returning to work prematurely
Failing to authorize needed diagnostic testing without reason to not authorize
Failing to pay for permanent partial disability
Paying less than the workers comp statute calls for when settling a permanent partial disability
Offering to settle and close out future benefits for an amount significantly less than what the adjuster knows to be fair
Advising the employee not to hire an attorney
Threatening to reduce the settlement of the claim if the employee hires an attorney
Discussing any aspect of the claim with an employee known to be represented by an attorney
Settling the claim before the extent of disability is known
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
Providing the employee’s personal information to parties who do not have a legitimate need to know
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.

WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com

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

Filed Under: TPA and Claims Administration Tagged With: Adjuster Best Practices, Adjuster Performance, Adjuster Qualifications & Responsibilities, claim practices, Unfair Claims Practice Act, workers compensation adjuster

Know These 5 Ways to Keep the TPA Relationship Running on all Cylinders

February 16, 2012 by Robert Elliott, J.D. Leave a Comment

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

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

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

1. Know your adjuster and their team

If you do not have a lot of claims per year, or you are a smaller shop with limited exposure, you may not really know which carrier/TPA office location will be handling your claims. Maybe they start off in one city, such as Boston, then end up in Philly. Or maybe they start off and end in Milwaukee. Do you really know who has your claims, where they are, and who to contact with questions?

If you call your agent/broker, they may have the answer to this question. But with insurance carrier/TPA offices becoming more and more consolidated, even your Agent may not be 100% sure. So reach out to your carrier/TPA and find out if a dedicated local office will be handling your claims. Or, maybe they will start out at their Home Office in Boston, and then be transferred out to a local office in your state if it is a lost time claim, a claim that needs special investigation, or a claim that has issues with compensability. If you know who to call or email with questions, it will make filing claims and getting answers to your questions that much easier and quicker.

2. Communication is key

The main reason a claim derails from running smoothly is a lack of communication. Whether it is from the employee not talking to the adjuster, or a miscommunication between the employer and the adjuster, communication is extremely important when dealing with any aspect of claim handling. Be sure to check with your adjuster on all your open claims, and get an update on what is going on, and what their plan is to resolve the claim.

Even if you only have a handful of claims per year, your input is valued more than any other. After all, you as the employer are their client, and the carrier/TPA wants to make you happy. Adjusters will appreciate someone out there that cares about what they are doing to move these claims along. Scheduling regular claim updates is also a great way to prevent a claim from slipping through the cracks. Plus the more you as the employer are involved, the more the adjuster knows they have to keep an eye on your claims since you will be checking up on them. The more you are involved, and the more you communicate, the better your claim will be handled.

3. Answer all questions the adjuster asks

If an adjuster has a question about something, no matter how insignificant it may seem to you, it is probably really important to the adjuster. Several states require reporting to the State Bureaus of Work Comp, and missing information will hold an adjuster up from completing their filings. Even minor missing info such as a date of hire is important to the adjuster. They need complete info as part of their job for their state filings, so if they have questions about personal info, phone numbers, hire dates, wage history, etc. do what you can to get that info for them so they can move on with the claim.

Details such as the hire date could also key them in on certain aspects of the claim. If it is a new hire, maybe that explains why a worker cut their hand, or strained their back. Wage info is always needed when there is lost time. If the adjuster needs the wages, they probably can’t pay your worker until they get that info. A date of birth is needed for state filings, but it is another key to the claim, since an older worker may mean that this particular claim won’t resolve as easily as it would with a younger worker. The examples here are endless, and the bottom line is to get any requested info to your adjuster on a timely basis. You don’t have to stop what you are doing to look that info up, but try to get it for them within a few business days. The sooner you do, the quicker it is off your desk and the less chance you have of forgetting about it.

4. Bring your adjuster and their team out for a tour of your facility

If you are a large enough employer to churn out 50 claims per year, you probably will know who your adjuster is by name. You may even know who their manager is by name. But do you actually know who they are, other than just by name? Employers that have a lot of claims may know a little about their adjusters through casual conversation, such as if they are married and have kids, if they are sports fans, etc.

A way to strengthen the relationship is to have them come out to your facility for a tour. Not only can you put a face to a name, but it greatly helps your adjusters by seeing the premises. Adjusters can look at the machines, observe the workers doing their jobs, and get a better idea and understanding of what you guys do day in and day out. This helps them mentally process the claim by knowing what your injured workers are talking about when they are describing what they were doing when they were injured. If you describe a machine injury to 10 people, you could get 10 different ideas of what happened. But if you show your claims team the machines and how your operators run them, and then they know exactly what a worker is talking about when they were injured.

5. A “Thank you” goes a long way

As we have said time and time again, the work of a claims adjuster is often a very thankless job. Sure, it is the adjuster’s job to handle these claims, but often it is a stressful, high demand profession. Taking the time to thank your adjuster for their hard work will mean a lot to them, and they will take that compliment and use it to handle any of your issues right away. Your adjuster certainly will not forget your praise, and you can get them to work that much harder for you now and in the future. (WCxKit)

Summary:

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

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

Our WORKERS COMP BOOK: www.WCManual.com

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

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.

Filed Under: Broker Issues & Relationships, Claim Management, Communication with Employees, TPA and Claims Administration, WC 101 Tagged With: Adjuster Qualifications & Responsibilities, Communicating with Employees, Communication with your TPA/Carrier, TPA and Claims Administration

7 Things Workers Compensation Adjusters Do All Day

December 22, 2011 by Rebecca Shafer, J.D. 2 Comments

Do you ever wonder what your workers compensation adjuster does all day? If you see the adjuster living easy, you may be surprised. The adjuster’s day is full of activities, requiring the adjuster to prioritize which actions are needed the most. Some of the daily routine you would see from the adjusters would include the following activities.

So, what will you see during your visit to the claims office?

1-The phone rings constantly

The typical workers comp adjuster has 100 to 125 indemnity files, depending on the jurisdiction and the experience level of the adjuster. Each of those 100 to 125 files has a claimant, one or more medical providers, and an employer. That alone makes for 300 to 375 plus potential parties that will want to speak with the adjuster. On top of that you have plaintiff attorneys, defense attorneys, triage nurses, nurse case managers, surveillance companies and state work comp boards that may call the adjuster. On a slow day the adjuster may only spend half of her time on the telephone. (WCxKit)

2-The e-mails come in fast

In this day where everyone expects instant service, the use of e-mail to convey messages and documents has surpassed paper mail. With attorneys, employers, employees and nurse case managers sending information by e-mail, it is normal for the adjuster to get 50 to 100 e-mails per day. While many of them can be copied right into the claim file, a significant portion of them require a response or other action by the adjuster.

3-The paper mail is voluminous

While the amount of paper mail has declined over the years, a two inch or five inch stack of new mail to be reviewed each day by the adjuster is still the norm. The mail has to be evaluated and the appropriate response taken on each piece of mail. Sometimes the response is only to send it to be scanned into the electronic file, but often a written reply or a phone call is needed.

Included in the paper mail are the faxes that come in each day. While most attorneys and employers are transmitting documents via e-mail, most medical providers are still using paper forms, paper bills and paper reports. These items are often easier for the medical offices to transmit by fax than by e-mail, so receiving numerous faxes each day add to the paper mail stack.

4-The consultations are frequent

A major portion of those telephone calls mentioned above are for the purpose of making decisions on what to do. The adjuster will often gather information by consulting with others. The adjuster will discuss the claim with the nurse case manager, the defense attorney, the employer, and other sources to make a judgment on the best course of action on a particular claim.

When the adjuster is not on the phone discussing a claim or reading the e-mails or reading the paper mail including faxes, the adjuster will often enter into consultations within the claims office. The adjuster will confer either with her supervisor or fellow adjusters on various aspects of a particular claim to gain insight or opinions of other claim professionals that have dealt with a particular situation or set of facts.

5-The decisions are major

The primary reason the adjuster enters into the consultations noted above is because the decisions the adjuster makes can have an impact on the life of the injured employee and all of the decisions have a financial impact on the employer. If the adjuster makes the wrong decision, either the employee or the employer or both will be hurt financially.

6-The appreciation is missing

While you are sitting there observing what the adjuster does all day, you will notice that the adjuster’s job often benefits both the employee and the employer. But it is the rare employer or even the rarer injured employee who expresses any appreciation for the work the adjuster does on the work comp claims. The most the adjuster hopes for is the claims supervisor will say “good job” when the claim is concluded. (WCxKit)

7-The adjusters best practices

While the adjuster is in constant modes of communication as noted above, the adjuster has a set of job requirements that have to be met.

Making contact with the employee, the employer and the medical provider on every new claim
Responding to all the communications noted above in a timely manner
Setting and maintaining accurate reserves on all of the assigned files
Making sure all indemnity payments are made timely
Making sure all medical bills are paid
Keeping in touch with the employees, the employers and the medical providers on a regular basis
7. Submitting the appropriate forms to the state work comp boards/industrial commissions
Identifying fraudulent claims
Pursuing subrogation when a third party is the cause of the employee’s injury
Attending mediations, either in person or by phone
Evaluating settlement opportunities and decisions

If you sit chair side by the adjuster, do not count on the adjuster having any time for chit chat, so just observe. They will have planned for your visit, and will have time to show you through your files. As you can see from the above the adjuster’s job fills the entire day, and then some. If you do sit and observe what the adjuster does all day, you will probably leave amazed at the dedication and hard work of the work comp adjusters.

WORKERS COMP MANAGEMENT GUIDEBOOK: 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.

Filed Under: Claim Management, TPA and Claims Administration Tagged With: Adjuster Qualifications & Responsibilities, Working with Your Adjuster

Know 8 Costly Mistakes Workers Comp Adjusters Make

July 5, 2011 by Rebecca Shafer, J.D. Leave a Comment

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.

Our WC Book: http://corner.advisen.com/partners_wctoolkit_book.html

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

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

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

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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.

Filed Under: Insurance Issues, Rates, Premiums, TPA and Claims Administration Tagged With: Adjuster Best Practices, Adjuster Qualifications & Responsibilities, Working with TPA and Insurance Company

8 Ways to Grade Your Workers Compensation Claim Adjuster

June 16, 2011 by Rebecca Shafer, J.D. Leave a Comment

Often it is assumed the designated adjuster(s) working on your workers compensation files is a good adjuster. But, you know what “they” say about “assuming.” Use these eight tips to judge your adjuster(s) overall ability and effectiveness.

1. Timely Contact with All Parties

Track how often the adjuster makes timely contacts. If your Best Practices say claimants, medical providers, and the employee's supervisor must be contacted within 24 hours of the first report of an accident, expect your adjuster to be making timely contacts with all parties at least 90% of the time. The higher the percentage, the better. Timely initial contacts go a long ways toward establishing the future tone of your claims and establish the adjuster as the person in charge. (WCxKit)

2. The Accuracy of Reserves

When you look at your loss run and compare what the claim settled for against the claim reserves you gain insight into the ability of the adjuster to evaluate the claim. If you see a lot of reserve changes right before the claim settles, then the adjuster is either inexperienced at evaluating the claim or is indifferent to the impact reserves have on your company. If you see the reserves on the claim were established since the adjuster obtained key medical information on the injured employee, you know the adjuster is looking out for your financial interests.

3. Responsiveness

Does the adjuster always answer the phone when you call, or do you often have to leave messages and wait a few days to hear back? When you send e-mails, do you get a prompt response, or do you forget what the subject of the e-mail was by the time the adjuster responds? A good adjuster tries to keep you informed about your claims and takes the time to respond to your questions and needs. The quicker the response from the adjuster, the better the adjuster.

4. Payments Timely

If your employee complains the TTD or TPD check did not arrive on time, then the adjuster is not organized (or may have too many claims to handle properly). You should expect never to hear from an employee about the indemnity check not arriving. If your employees are receiving dunning notices from their doctors on medical bills, then the adjuster is not processing the bills timely. While any adjuster may occasionally have a medical bill or other missed expense, you or your employees should not be constantly getting reminders on medical bills.

5. The Number of Employees Lost to Attorneys

The good adjuster stays in contact with employees out on workers comp. The great adjuster builds rapport with the employees and the employees make an effort to keep their adjuster informed as to their medical progress and their ability to return to work. The poor adjuster has a higher percentage of employees represented by an attorney then the good adjuster. As the percentage of employees represented by attorneys is impacted by the legal climate in your locale, you must consider the results of your adjuster compared to other adjusters in the same locale.

6. Knowledge of Workers Compensation

When you have a question about workers comp in general, the good adjuster can answer it for you, (or at least get you the answer). If the adjuster does not know the answer, or tells you it would be better for you to talk to a workers comp attorney or the adjuster's supervisor, the adjuster's workers comp knowledge is weaker than it should be. The good adjuster knows all the ins and outs of state statutes and is willing to share that information with the employer.

7. Claim Quality Audit Scores

Often claim offices do not want to talk about their claim quality audit scores. This often arises out of a concern that the employer may not understand that the 100% perfect claim file seldom happens. However, the good workers comp adjuster scores in the 90+ percentile. Ask the adjuster for a copy of the most recent audit score. The good adjuster is glad to share it with you. The weak adjuster probably has reasons why it cannot be shared.

8. Closed Files Reopened

Every adjuster knows the best file is the closed file. However, it is seldom a good idea to close a file prematurely. The good adjuster makes sure all aspects of the claim are resolved, all medical bill paid, all indemnity checks issued, and all expenses paid before closing the file. If you see more than a few reopened files on the loss run report, than the adjuster is closing claims prematurely. (WCxKit)

None of these 8 criteria alone indicate a good or poor adjuster. When the adjuster is strong in all 8 areas, you have a great adjuster working your claims. If the adjuster is weak in most of these areas, it is time to consider requesting another adjuster to handle your workers comp claims. Having a strong adjuster on your claim files makes your life easier and saves money. A few select TPA's DO actually "grade" their adjusters, giving monthly bonuses to those that excel, and get high grades – nearing 100.

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 or 860-553-6604.

Our WC Manual: http://corner.advisen.com/partners_wctoolkit_book.html

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

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

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

SUBSCRIBE: Workers Comp Resource Center Newsletter

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

Filed Under: Broker Issues & Relationships, TPA and Claims Administration, WC 101 Tagged With: Adjuster Qualifications & Responsibilities, Choosing an Adjuster, Working with Your Adjuster

Stair Stepping Reserves Occurs When Work Comp Adjusters Ignore Claim Basics

June 6, 2011 by Rebecca Shafer, J.D. Leave a Comment

Whenever a claim quality auditor or actuarial auditor sees numerous small upward changes in the workers’ compensation claims reserves, he knows he has a case of an adjuster stair-stepping the reserves. If you draw a graph of the reserves, it looks like a set of steps—flat, up, flat, up, flat, up

When the adjuster keeps raising the reserves in relatively small increments to pay medical bills, indemnity or expenses, a basic principle of accounting is ignored. Sound accounting for an insurance company or self-insurer is to set aside money to meet the financial obligation brought on by the claim against the insurance policy. When the adjuster does not establish the correct reserve, the insurer’s financial balance sheet is inaccurate, either overstating or understating its assets. With stair-stepping of reserves, the insurer assets are overstated on the balance sheet, as the liabilities—the claim where the reserves are understated—are incorrect.

The ultimate cost (also known as total cost) of the workers compensation claim is the amount that should be shown on the reserves at all times. When the claim is assigned to the adjuster, all the information needed to establish the ultimate cost of the claim is not known to the adjuster, hence there will often be changes in the amount of reserves over the life expectancy of the file. The initial reserves should be based on the adjuster's experience with similar claims, but as facts change – the employee has surgery, the employee's level of disability is greater or lesser than normal, the claimant has co-morbidity issues that lengthen the recovery process, etc. – the reserves should be raised, or lowered, as needed. However, if the adjuster is raising the reserves to pay for this week's medical treatment, and raising the reserves next month to pay for the next doctor's visit, the adjuster is “stair-stepping the reserves."

The difference between the adjuster who increases the reserves correctly and the adjuster stair-stepping the reserves is the number of reserve changes. A few well-reasoned and carefully thought out reserve changes is the proper way of making reserve changes. Many small reserve changes without any thought as to the ultimate value of the claim is stair-stepping the reserves.

To avoid stai-stepping the reserves, the adjuster needs to know several things including:

1. the expected recovery time for the employee,

2. the average weekly wage and the indemnity rate (as all indemnity calculations flow from these numbers)

3. the ability of the employer to return the employee to work on modified duty or light duty while they recover from their injury

4. the approximate cost of the medical procedures the employee will have for the type of injury incurred,

5. the reputation of the medical provider for returning employees to work or keeping them off work

6. the anticipated level of permanent disability the employee will have

7. the cost of services for medical case management, legal, and other claim associated cost

8. the requirements of the workers compensation statutes where the employee will receive benefits

The claims office will have either an electronic or paper reserve worksheet calculation page where the adjuster can fill in the calculations for each of these items to obtain an accurate projection of the future / ultimate cost of the claim. This will result in the accurate projected value of the claim and the correct amount of money for the adjuster to place in reserve for the claim. When the adjuster skips the reserve worksheet calculation step, they often end up stair stepping the reserves. (WCxKit)

Stair stepping of reserves by adjusters should be avoided, and can easily be done by the utilization of the known information about the medical, indemnity and expenses for the individual claim. Proper reserving keeps the insurers financial balance sheet accurate, while stair stepping reserves understates the insurers liability.

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 or 860-553-6604.

WC IQ TEST: http://www.workerscompkit.com/intro/

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

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

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

SUBSCRIBE: Workers Comp Resource Center Newsletter

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