5 Tips To Reduce Your Stress and Be More Productive

 

I think it is an understatement to say that claims professionals are under a lot of stress.  Nowadays adjusters are forced to do more with less, so in addition to the normal claim investigations they also have to do a billion other things along the course of a normal day.  Add in to that rigid auditing standards, service promises, increased claim counts, and the list goes on and on.

 

Below we talk about some easy ways to take some of the stress out of your life in order to improve your work-life balance.

 

 

  1. Don’t Get Intertwined in Social Media

 

In today’s world, everyone is a mouse click away.  Social media such as Facebook, Twitter, LinkedIn, and so on have made it possible that you can be connected to everyone, at all times, and the stresses of other people can become your stressors as well.  In fact people can reach out to you and vent about their own problems, which can take time away from whatever project you are working on.  So limit your social media interaction during work hours, and focus on the task at hand.  If you choose to get involved in a Facebook discussion about some hot political topic, do it away from work on your own time when it will not distract you as much.

 

  1. Leave Your Desk For A While

 

I know plenty of adjusters that work 10-11 hour days, and they rarely leave their desk except to go to the printer or to hit the bathroom.  Not only is this crazy, but it is also not healthy.  Getting up and walking around for a bit can be relaxing, especially if you can head outside for a while and get some fresh air.  Maybe go out to lunch every now and then and get away from that office atmosphere.  You don’t have to do it every day, even one or two days a week can make a difference.  The world is not going to fall apart just because you snuck out and got a piece of pizza on your lunch break.

 

 

  1. Decrease Your Social Engagements If Possible

 

Don’t get me wrong, heading to seminars or after work engagements can be a great way to network and share some down time with your friends or work peers.  But you have to keep your events in check.  If you have a crazy week and need the time to focus on other things, don’t be afraid to skip out on an engagement or two.

 

This can especially be true if you have kids that are active in sports or other things that can occur after your work hours during the work week.  Maybe the thing to decrease is the amount of activities they are involved in, since you have to be the one to pick them up and drive them to basketball practice.  Your kid doesn’t have to be on 3 basketball teams during the summer, and in doing this you can decrease their own time stressors as well. Or let them skip a few practices and go out for dinner, or go to a movie and spend some quality time with your children.  If they miss a practice or two I doubt that their ability to hit free throws will decrease.

 

 

  1. Put a Cap on the Hours You Spend at Home Working

 

Many adjusters and other professionals have the ability to access their work from any computer at any time.  This is a great thing to have when you need it, but it shouldn’t be something that you have to engage in all of the time, every single night, and every single week. If you fail to complete a few diary items, your employer is not going to go out of business and lay everyone off.  You have to prioritize what you HAVE to do at home after work hours, and what you COULD do.

 

The hard part here is that the life of a claims adjuster is never caught up.  Rarely can any adjuster be totally done with everything on every file at any given day. It’s like a constantly spinning wheel.  But there are plenty of things that can wait until tomorrow.  Your time after work is just that—your time.  If you choose to spend it plowing through countless medical records for a file then fine, but ask yourself if this is something that has to 100% be done right now and cannot wait until the following day back at the office.

 

 

  1. Take Time to Enjoy Your Hobbies, or Start a New One

 

If you love to golf, and you have had to skip your golf league the last few times because of working late, you need to make sure your time is a priority.  Working late can sometimes be unavoidable, but that doesn’t you can’t hit the driving range after you are done.  Whether it be hitting golf balls, hiking at the park, bowling, or going for a run, take the time to enjoy your hobby of choice.  Don’t put off that time and spending it in front of a computer.

 

These sports and hobbies are things you do to unwind and take your mind off the daily stress.  Not only will doing this reenergize yourself, but it will give you that quality “Me” time that everyone needs. Pencil that time in the calendar, and be sure to stick to it.  Make that a priority for once, instead of pushing it back time and time again.

 

 

Summary

 

In this profession we are all faced with a lot of different stressors, and they come at you from all angles.  Injured workers are stressed out because their balance of life is off due to an injury.  They are no longer working, no longer being productive, and they are worried about getting their own lives back in order.  So we not only have to deal with our own life stressors, but we have to figure out a way to try and solve the stressors of our claimants day in and day out.

 

Most of the adjusters use the excuse that “If I take some vacation time away from the office my workload only gets worse, which puts me farther and farther behind.” Part or all of this may be true, but you get vacation time or paid time off for a reason.  Nobody can work 365 days a year without going insane.  Pencil that time off in your calendar and stick to it.

 

 

Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.

Contact: mstack@reduceyourworkerscomp.com.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 


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

10 Helpful Tips For Managing Angry Work Comp Claimants

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

 

Here are a few important tips to remember:

 

  1. Stay Calm

 

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

 

 

  1. Listen & Be Patient

 

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

 

 

  1. Remain Professional

 

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

 

 

  1. Do Not Raise Your Voice

 

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

 

 

  1. Try Not to Argue

 

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

 

 

  1. Speak Slowly and Clearly

 

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

 

 

  1. Empathize & apologize

 

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

 

 

  1. Offer Solutions

 

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

 

 

  1. End the Call if the Person is Repeatedly Abusive

 

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

 

 

  1. Do not take it personally

 

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

 

 

Summary

 

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

Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 


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

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

 

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

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

 
4.  Is the treating doctor providing medical slips and records on a timely basis to support the worker being disabled?
If the answer to this question is yes, then the adjuster must dig deep to find evidence contrary to what the doctor is opining. This can be in the form of prior injuries, auto accidents, surgical records, etc.  Try to find good solid evidence that the treating doctor does not know about, then submit it and ask if the opinion changes.  
If the treating doctor is not supplying the necessary documentation needed, then there are grounds to suspend treatment with this doctor until the documentation required is received to make a decision on the ongoing compensability of the claim. Most claimants will get frustrated if their treatment is suspended.  Their doctor may be telling them the injury is work related, but there is no supporting documentation to draw that conclusion. 
 
5.  Use of covers letters and nurse case management
After all of the attempts to gather the information needed, there is still a dead end.  So what to do now?  One option is to draft a concise cover letter to the treating doctor outlining concerns.  Doctors like to know what they have to address in comp cases.  Every doctor has a unique style when it comes to these issues.   The treating doctor may actually help a defense if you draft a neatly organized cover letter outlining the facts of the case with the questions concerning the compensability.  Since the adjuster is not in the room when this patient is being seen, who knows what the worker is telling the doctor?  Another way to confirm these facts is using an onsite nurse case manager. The nurse can talk to the doctor before and after the appointment, and can be very useful in getting the information needed pertaining to any medical documentation desired.  The nurse may not be able to actually be present in the room during the exam, but talking to the doctor before and after the appointment may help connect the dots between what medical evidence is showing, and what the patient is actually complaining of in regards to the injury.  Coming to these conclusions will only help the adjuster arrive to the proper decision on the compensability of the claim. (WCxKit)
Summary
If the injured worker is treating with a primary care doctor not familiar with the comp system, be careful and thorough about gathering information.  Be sure to put the time in on doing a detailed background investigation and pass that information on to the treating doctor, so they can see exactly what you are seeing.  This will help them make the correct opinion on the overall compensability of the claim.  If the attempts fail, utilize an IME and nurse case manager to help bridge the process. The adjuster can never have enough information when it comes to making the proper decision on claims.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com Contact mstack@reduceyourworkerscomp.com

WORKERS COMP MANAGEMENT GUIDEBOOK:  www.WCManual.com
WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

3 Common Mistakes Your Workers Comp Claims Adjusters May Be Making

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



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


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


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


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

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


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

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

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


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


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

 

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

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com Contact mstack@reduceyourworkerscomp.com

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com
MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

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

 

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

The Many Twists and Turns of a Workers Comp Claim

 

 
Every now and then when I meet people and tell them about my past work as a claims adjuster, I sometimes get a blank stare in return. The question that usually follows is “What the heck is that?”
 
 
True, before I got into the claims world years ago, I had no idea what a claims adjuster was.  When I took my first job in claims, the job description sounded interesting.  I had a background in Economics, and knew that insurance costs were a typical part of the financial structure of a business along with many associated costs. But that was about my total knowledge of that industry. I had no idea what a claims adjuster was, or what I would be doing day in and day out.  It sounded like being a detective of sorts, and I figured I would be investigating fraud and people faking injuries to try and get a big fat settlement. [WCx]
 
 
After my 3 week training course, and many years on the job experience, I discovered it was a lot more than just investigating potential fraud. There was the investigation part of a claim, the medical part, and the litigation part of the claim. But how do the adjusters handle claims? Is there a common blueprint that all claims use? And if so, are there any variations? Let us discuss the life of a simple workers comp claim.
 
 
  1.  The claim arrives at the desk of the adjuster.
When an adjuster receives a new claim, it is fairly common practice that the adjuster has 24 hours to make the 3 initial contacts: the recorded statement of the claimant, the statement from the employer about what happened, and a call to the medical clinic to obtain the medical records and to talk to the doctor (if needed). After these contacts are made, an initial decision can be made on the claim on compensability or not. The employer holds a large key here, as the employer has the eyes and ears about the claim’s potential issues regarding the causal relation and the overall compensability. Also important are the medical records, since they also will hold a large part of the background of the injury, and they will also shed some light on if this is an acute, objective injury or something that is more subjective and a little harder to relate back to the alleged work incident.
 
 
  2.  A compensability decision is made on the claim
At this point, after the contacts are made and the medical records are obtained, the adjuster will make a decision on the initial outcome of the claim.  If this was a fall that resulted in a leg fracture, this will more than likely be a compensable injury. Unless you uncover some major degree of horseplay or a very direct violation of a stated safety protocol, that type of fracture claim is probably legitimate. 
 
 
More subjective strain-like injuries, however, are often more difficult to prove.  People come into work carrying baggage from outside of work activities, and those claims can take longer for a causal relation to be established.  The worker will say that it is related to daily work duties. The employer may add some other details, such as the employee is known to be moving to a new house over the weekend, or helping a friend roof a house for example.  When this type of gossipy evidence is introduced, the adjuster will take a step back and probably file for an extension to be able to complete an investigation before making a decision on the overall compensability of the claim. Background checks, witness statements, and an IME may be needed at this point to try and determine what, if anything, is work related. 
 
 
2(a) Let us say the employer has nothing too bizarre to add. The injury is reported promptly and the injured worker goes right to the clinic. The injury is witnessed, and nothing out of the ordinary occurred.  For the most part, the claim will be deemed compensable and the worker will be paid wage loss if applicable, until returning to work or released from medical care without restriction.
 
 
2(b) Now let us say the employer did add that they know of some other inside,or outside-of-work circumstances that could have contributed to the injury. The employee may be upset over a recent performance review, and shortly after filed a claim for an injury. The injury is not witnessed, and the employee was doing something that they do not normally do as part of the job.  The story of the injury has now changed depending on who else the employer talked to on the jobsite, and nobody seems to be able to confirm what exactly happened or why. At this point, the adjuster will place a dispute on the file, and point out to the employee that there are some inconsistencies in the investigation of the claim, and a decision cannot be made on whether the claim is indeed work related or not. The burden of proof falls on the employee; it is their burden to prove how and why the injury occurred during the course and scope of employment.  It is not the adjuster’s job. 
 
 
3.  The Claimant files for a legal hearing or obtains legal counsel
So now a dispute is placed on the file, and the employee is not very happy. The employee visits an attorney, and the attorney feels that there is a solid case to start with filing for a mediation or a hearing. When the adjuster receives notice of the legal counsel retainer, a call is placed to the claimant’s attorney. Plaintiff counsels will vary wildly in how workers comp claims are handled. Some are very involved, and proactive, and some are not. The adjuster will explain why the case is being disputed, and report there is not enough clear evidence to show that this worker was 100% injured in the course and scope of employment. If an IME is performed, and in the favor of the carrier, the adjuster will forward a copy to the attorney for review. The attorney may file for the deposition of that IME doctor, to try and poke holes in that doctor’s medical opinion. But typically, cases that go into dispute attempt to be settled before any major litigation goes forward. The timeline on when a settlement can be made can take many weeks or months, even years, and during this time the claimant will continue to get medical treatment and accrue wage loss, which increases the overall value of their claim. A settlement will consist of a compromise of the medical and wage expenses, and usually will include the full and final resolution of the claim of all issues past, present, and future.  Again the time span on a resolution can take many months, if not a year or two depending on the extent of the injury. The settlement generally cannot occur until the worker reaches the healing plateau, or are fully released from medical care with no further medical disability. If the workers comp judge agrees to the guidelines of the settlement, an Order is signed. Then the adjuster cuts the checks to the necessary parties, and the claim is resolved. [WCx]
 
 
 
Summary
Between when the claim is called in, and when the claim is resolved, it can take many more turns other than what is outlined here. For the sake of brevity, we keep it nice and somewhat neat. However any claim can spiral out of control at any time, prompting the need for surveillance, vocational evaluations, job placements, several IME appointments, witness statements, and much more. The point we are trying to make here is that it is easy to say that all claims follow this road, whether accepted or not. Claims adjusters wear many hats, and workers comp claims can be very complex. Severe injuries can occur at any time, and know that the more complex the injury, the more complex the claim can be. Even if a claim seems to be legit on the surface, there are many factors the adjuster has to look at before a claim can be accepted as compensable.

 

 

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

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com Contact mstack@reduceyourworkerscomp.com

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

VIEW SAMPLES PAGES

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

 

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

 

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

The Right Way and Wrong Way to Deny a Workers Comp Claim

 

There are a lot of ways to deny a workers comp claim. The easiest way is if the case is not work related at all. The reality is that most injuries are work related, or at least they arise out of the course and scope of doing the job.
 
 
But there are a lot of ways that an adjuster can suspend or deny a claim, even though it may be compensable in the beginning.  Injured workers have to follow certain legal statutes held up and reinforced by the Statutes within the jurisdiction.
 
 
Below, we discuss a few ways that claims can be suspended or coverage can be terminated, and what you should look for within each one:
 
 

 

1.  The injured worker avoids treatment or is trying to treat with non-conventional means

There has always been a negative stigma with the occupational clinic that works with employers.  Injured workers feel that these clinics do not have their own needs in mind, but rather the demands of the employer.  These clinics often have long wait times to see a physician, and by the time you actually get into the exam room the doctor spends two minutes with the patient and says the injury is not work related.
 
 
This may be the case, but with certain jurisdictions a person can treat with whomever they wish.  Sometimes the medical diagnosis given by a chiropractor is held in the same regard as the diagnosis given by an orthopedic surgeon.
 
 
Adjusters are quick to pull the trigger on filing a suspension once an injured worker bails out of the occupational clinic in favor of their own primary care doctor.  As stated above, however, this may not be against the rules at all.  If you see this happening on your claims, be sure to discuss the rights workers have with your claims adjuster to ensure you are not missing information.  Maybe the primary care doc is not providing medical records, and this is the cause of the suspension.  Or maybe the primary care doc is not treating the actual comp injury and they are sending the bills to the comp carrier for treating another condition.  In any case, be sure that you have all of the details before rushing to judgment.
 

 

2.  Terminating wage benefits when a worker does not show for light duty work

If an injured worker has medical restrictions, the employer should take every chance they have to find work within those restrictions.  This limits wage loss expense, and keeps the worker doing something worthwhile for their employer instead of sitting at home and collecting a paycheck. 
 
 
Adjusters are quick to hit that denial once a worker does not show for this light duty work.  You have to be careful here, however, as some statues have a clear definition of how a light duty work assignment is given to an injured worker.  A voicemail may or may not be sufficient.  The offer could have to be made in writing and delivered via certified mail with the employee given enough notice to show for the work assignment.  Sometimes the work tasks and hours have to be clearly stated, and if any of this information is left out it voids the work duty assignment.  If you have questions about these light duty work assignments,  discuss it with your claims adjuster and legal counsel to be sure you are doing it correctly on every claim.
 

 

3.  The injured worker misses their IME appointment

If a worker is sent for an IME by their claims adjuster and they do not show, this doesn’t mean that their claim can be totally denied.  Most jurisdictions will allow the adjuster to suspend benefits until the claimant attends their IME, but rarely will it allow a full outright denial just based on the worker not showing.
 
 
This may not be true if the worker misses several IME appointments.   It is important to make sure that the claimant is being notified of the IME properly.  Sometimes it will have to be with a certified letter delivered and signed for by the claimant.  If this is not done properly, the suspension that was filed is rendered worthless. Do your homework and make sure these cite letters are being sent correctly.
 

 

4.  The presence of pre-existing conditions

Perhaps the most common reason for a suspension or denial is the presence of pre-existing conditions where the injury is located.  Let’s use a back strain as an example.  If a worker injures their lower back lifting a bag, they may sustain a strain.  If the strain doesn’t resolve in due time, an MRI may be performed.  If this MRI shows arthritis in that same area, adjusters will commonly file a denial saying that pre-existing conditions are present and that the injury is not work related.
 
 
This may be true, but that may not mean that the claim is not compensable.  The worker still lifted the bag, and may have sustained an exacerbation on top of that pre-existing condition.  If the worker needs surgery, a case may be made where the surgery is not entirely due to the work incident and is not covered as part of the comp case. That may be true, but the carrier is still probably on the hook for the strain. Some jurisdictions may or may not allow this, so be sure you know what you are dealing with when it comes to pre-existing conditions and workers compensation.
 
 
Summary
The common theme for the above items is that even though you see an alley to dispute a claim, it may not be as strong as you think.  Be sure to discuss your concerns with legal counsel, and know the proper way to do tasks, cite letters, and make sure all adjusters are following the rules properly.  It will save a lot of headaches down the road.


 

 

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

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com Contact mstack@reduceyourworkerscomp.com

  


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com
MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

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

 

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

How To Make Your Workers Comp Claim Adjusters Dream Come True

Workers compensation claims adjusters run into all kinds of different accounts– from large to small; from the manufacturing field to the professional field; from the safe to the unsafe, and everything in between. Maybe there is no such thing as the “perfect” workers comp account for the adjuster to handle, but there are many things adjusters look for including:

 

1. Their main contact is involved in the claim
Every claim warrants a call to the insured or client. Sometimes this call is more beneficial than others, based on the client. Some accounts have a dedicated workers comp contact, usually someone in the HR department, who can help with the gathering of facts on the claim.  However, this person may not always have all of the information the adjuster needs.{WCx]
 
The perfect account will have a dedicated person who knows ahead of time what the adjuster needs and will readily share this information. This person knows to send the wage records and the personnel file, as well as knows about the injury details while having witness information and statements already taken. This contact knows what is needed, and knows not to put a personal “spin” on the details of the claim. This is all very helpful information for the adjuster, and it is something that the adjuster will request on every single claim that comes from that particular employer. The adjuster has one person to deal with while eliminating the need for countless phone calls to people at the employer who are all equally unhelpful.
 
 
 

2.  The contact responds timely

One thing that is sure to bother the adjuster is leaving messages and sending emails with no response from the employer. Face it; the adjuster is not making the effort to contact the employer just for fun. The employer holds very key information needed to make a compensability decision on the claim.
 
The perfect workers comp contact for the employer responds on the same day, preferably within the same hour as the adjuster left a message or sent an email. This helps the adjuster move forward on the claim, since typically the first phone call the adjuster makes is to the employer for accident details before the employee is called.
 
 
 

3.  The employer has a dedicated medical clinic that treats injured employees.

Too often employers allow injured workers to run to their own doctor, which will complicate the claim right away. The employee really does not know any better and just wants to get treatment for their injury.  It will automatically create an air of mistrust if the injured worker goes to a personal doctor, and then the employer or adjuster forces them to go to the occupational clinic.  Right away the employee will also adopt the “me versus them” attitude which does not help the claim. 



4.  The medical clinic knows the employer, and knows there are light duty work options available.

All too frequently, doctors are quick to place people out of work since they believe the only work available is the job they were doing at the time of the injury.  It is very common, especially early on in a claim, that injured workers cannot perform all of those job tasks. This creates lost wage exposure and increases the overall cost on the claim.
 
The perfect clinic knows the employer has light duty work options and will list medical restrictions that are useful to the employer and the adjuster. The doctor details lifting restrictions, and durations, and is quick to schedule a follow-up within 7days from the first appointment. Adjusters hate it when a doctor puts a person on a monthly follow-up appointment regimen since that means four weeks will go by before work restrictions or an “off work” status is changed or updated. The more the clinic physician knows about the employer, the more helpful it is for both employer and adjuster.
 
 
 

5. The employer is involved just enough to be helpful

Adjusters love to count on an employer to help provide information. But, too much information may not be helpful to the claim. Just because the employer has tons of information does not mean that it helps the adjuster. The informed employer has to know what to provide, what to elaborate on, and what not to provide. The same is true with employers who do not provide enough information. Some adjusters might prefer to have more information versus not enough, but the employer has to know where to draw the line. Adjusters do not need to know about certain industry issues, or what competitors are doing, or how past carriers used to handle claims. The perfect account provides the perfect information.  This can be established by meeting the adjusting team and going over what is and is not needed. In the end it saves all parties time and makes everyone more efficient. [WCx]
 
 
Summary
There may not be any such thing as the “perfect” workers comp account.  However, if employers and adjusters work together knowing what information is needed and take the time to create personal interest in all of the claims, the whole process runs a lot smoother and is more efficient. 

 

 

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

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com Contact mstack@reduceyourworkerscomp.com

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

VIEW SAMPLES PAGES

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

 

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

 

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

Four Biggest Mistakes of Workers Comp Claim Adjusters

 

 
Adjusters are faced daily with the task of making many different decisions on many different types of claims.Every claim is in different stage it is easy to lose track of some of them. 
 
 
Mistakes can come in a variety of different scenarios, and below we discuss four common oversights that the adjuster can make.[WCx]
 
 
1. Wage calculation errors
Many adjusters handle claims in more than one state at a time. Each state has its own way of calculating wage loss (See our State by State guide here for information on your jurisdiction), and some are more intricate than others. Because of this, it is common for an adjuster to make an underpayment or overpayment due to these differing wage calculations. 
 
 
The most common mistake within this realm is a waiting period calculation error. Almost every state gives the employer and carrier a chance to get the injured worker back to light duty work before having to pay full wage loss benefits. Using Michigan as an example, there is a two-tiered system: the first 7 seven days are the actual waiting period where no wage loss benefits are paid. This gives the employer time to obtain medical restrictions and to find a replacement job. The worker has to accrue this time as being totally out of work.
 
 
On the 8th day the benefits for wage loss begin.   If the claimant is still out of work after 14 days, then he also picks up the first 7 days of missed wages. 
 
 
In Wisconsin there is a 3 day waiting period (See Wisconsin law) and pay benefits start on the 4th day,.  If the claimant is still out of work after 7 days, the first 3 are picked up and paid.  
 
 
Each state has its own way of calculating wage loss, and it is easy for an adjuster to confuse the waiting period duration. Some states also have other little sidebars, saying that if light duty work is offered and refused, then of course no wage loss will be paid. But how was the job offered to the employee? Was a certified letter mailed and received by the employee? When was it mailed? Did a supervisor just leave a voicemail for the injured worker to come in to work? As you can see, there are a lot of variables within the wage loss genre. The best advice is if there are questions about whether wage loss should be paid, consult local legal counsel.
 
 
2. Failing to file State forms timely, resulting in a penalty fine
The filing of state forms is similar to the wage loss waiting period.  Some states have a very strict time period which an adjuster must file forms indicating that benefits have or have not been paid.  If the adjuster fails to do so, the carrier may receive a nominal fine that must be paid to the State. Some States have no fines at all in this regard.
 
 
Even more severe is the failure of the carrier to report a claim to Medicare when the worker is receiving workers compensation medical and wage benefits. At the time of this article, the fine is $1,000/per claimant, per day. Obviously because of the amount and penalty, carriers are very vigilant about making sure to get the required information on the claim to Medicare, but a lot of times this is the duty of the adjuster. The employer is not really affected by this measure, but it is a very important thing to be cognoscente to ensure all parties are aware than an injured worker is a Medicare recipient as well.
 
 
3. Failing to follow up with a treating doctor or IME doctor
Since the adjuster has several irons in the fire at once, it is very common to forget to follow up with the doctor. Failure to get the IME report needed can result in an overpayment of workers comp wage loss pay. If the IME was 5/1/12, and the report is not gotten until 6/1/12;  the worker can easily be overpaid if the IME terminated benefits due to the worker no longer being injured (since the benefits should not be received at all). Some states require the employer to pay wage loss until the IME report is received, and some only require payment until the actual IME appointment date. Be sure to know what the payment requirements because failure to do so may result in a fine against the carrier and/or bonus wage loss pay to the injured employee.
 
 
4. Failure to pay wage loss benefits timely upon completion of the investigation
Most states give the carrier and adjuster time to investigate if a claim will be compensable. If the adjuster needs more time, most states require that a form be filed for an extension to the investigation. Failure for the adjuster to file that form can result in a fine.  This is usually payable to the injured worker in the way of extra wage loss benefits to compensate the worker for the time without pay, especially if the claim is deemed compensable. Many states vary wildly in this regard, so consult local counsel on questions regarding investigation timeframes and when the best time is to file for an extension. [WCx]
 
 
Summary
These 4 topics discussed above only scratch the surface on potential errors an adjuster can make during the life of a claim. Just because someone is an adjuster does not mean that they are necessarily a great one. Being an adjuster means juggling many things at once, and meeting the employer’s best interests when dealing with the claims of injured workers. 
 


 

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

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com Contact mstack@reduceyourworkerscomp.com

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com
MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

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

 

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

Good Adjusters Know When to Settle Your Workers Comp Claims

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

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

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

 
 

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


 

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

 

Free WC Calculator: www.LowerWC.com/calculator.php

Learn about our book: www.WCManual.com

 


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

 

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

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Six Things that Annoy Claim Adjusters

More about issues and buzzwords that are sure to disgruntle the claims adjuster. These are meant to be lighthearted, but for the most part they are correct. So here we go. The content is provided by an interview with a claims adjuster at a major carrier.
 

 
1. Fibbing about never having a workers comp claim before
It is understandable that there is a little distrust between the claimant and insurance adjuster in the beginning. If there was ever a claim of any sort before, the claimants do worry about not being entitled to the benefits. A lot of this has to do with the fear of the unknown. A small percentage of people make being a career claimant their full time job. Yes, really.
 
 
But do not get off on the wrong foot early on in the claim. I think most people feel that all carriers “share” information on people. That is true to a point, but not all the time. ISO reports and other ways of sharing information are out there and available to every adjuster, it is just a matter of finding it. The adjuster will probably run through the motions of doing an initial background check with just about every claim they receive. This is part of the initial claim set up. The carrier does this to protect itself against fear of the unknown. Carriers deal with thousands of claimants per year, and they will do what they can to ensure that they are paying claims that should be paid, guided by the statutes within the jurisdiction they do business in.[WCx]

 
Sage advice is that honesty is always the best policy. Just because there is a claim or two in the past does not mean the current claim will be doomed. But the more attempt to hide it, the more it will come back to haunt. The adjuster’s job is to get the help needed and to get the employee returned to work good as new. If they find claims in the background that were not shared with them, it will become a beacon on the radar. Be assured that the adjuster will go the distance in overturning every rock they have to in order to feel they have completed a thorough investigation. So just be honest, remember the adjuster is there to help not fight. Adjusters take it as a point of pride that the claims they pay are legitimate.
 
 
2. Grunting and groaning on the phone while talking to the adjuster
Being in pain is no fun. Just the fact there is a claim to file indicates having some sort of medical issue. But please do not drive the point home by being unable to complete a sentence without groaning in unbearable pain. We understand there is pain, but can a decent laceration be that disabling? Sure everyone has their own pain threshold, and some people can deal with pain better than others deal, but again please just act normally. The more over the top it is, the less believable it becomes. The doctor will also indicate in the notes the pain appears out of proportion to the injury. This is known as one of the several “Waddell’s signs” that are used to judge pain and injury behavior. Like I stated …. just be honest. There are no Oscars for the performance.
 
 
3. Trying to charge $40/hour for attendant care services or demanding 24-hour/day medical attendant care
Some states leave wages open for family attendant care. Adjusters prefer to allow the use of the husband/wife as caretaker for assistance with activities of daily living. This makes it easier in recovery, instead of the carrier bringing in an outside vendor and person to do this work for them. It is also cheaper this way, but do not overcharge for hours and duties performed by the caretaker. Nothing will irritate the adjuster more than receiving a bill for 24 hrs per day, 7 day per week attendant care. Obviously this is not reasonable or acceptable. In fact most jurisdictions will have caps and price limits on what is entitled anyway, so again just bill for the services needed and nothing else. The more the issue is pushed, the more of a red flag the adjuster will raise that there are some secondary gain issues going on.
 
 
4. Lying about the mileage to be reimbursed
The same goes true for mileage. If the claimant tries to say that the therapy facility is 50 miles away, that makes no sense. Especially if the adjuster resides in the same city. These are all red flags that the adjuster will see and cause more surveillance. And the adjuster can use their own resources (such as Mapquest) to get exact mileage.
 
 
 
5. Being a “Google physician”
The internet has certainly made the physician’s job more difficult. Most people will Google the injury and find out as much information as they can.  But the injured worker does not qualify as a medical physician. Try to talk shop with the adjuster, but the adjuster has handled claims like these for years, and they know the timeframe and the improvement step to make, and when they should be made. Any derivation from that timeline template raises the red flag and a watchful eye.  So again instead of this helping the scenario, it is hurting it in the long run.  It is ok to look around online for some information, but there are also many unreliable resources out there, and do not be misled. The focus should be on doing what the doctors and therapists advise, not on what the “internet doctor” suggests.
 
 
6. “Risk drivers”
To finish this article off, I thought I would include the Carrier. I have worked at a few different carriers in my time. And though they all differ in little ways, they are more similar than different globally.
 
 
Two words that have irritated adjusters since the dawn of time are “risk drivers.” These are the non-injury facts that can contribute to disability. Risk drivers can include obesity, diabetes, having a young child at home (being off of work decreases daycare costs), not wanting to go back to work in general, pending layoffs at the employer of the injured, smoking, and on and on. There are thousands of possible risk drivers. Some do have actual bearing on the claim, and some are ridiculous. Just because one risk driver can apply to one person, it may not affect another person in the same way. It is all theory, and they all succeed in complicating the claim. Most adjusters don't care about what “could” happen; adjusters want to know what will actually affect the claim, and why it will do so. Adjusters do not care about theory, because the theory may not affect the claim at all. It is just aggravating and pointless to hear those words “risk drivers.”  [WCx]   Hum… what does this mean for data mining?

 
Summary
So there it is, words, and issues that annoy adjusters. These will never go away, and will probably increase in use as time goes on. But the main point here is that all of these issues can affect a claim negatively. So if you are a claimant and reading this take note to be honest. It will help the claimant, the adjuster, and the injury scenario. The more honest everyone is, the better the claim can be handled, and the faster the claimant can recover and get back to work. 
 
 
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 GUIDEBOOK:  www.WCManual.com
 
WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php
 
 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

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