Is Your Adjuster Playing Favorites With Your Claims

Adjuster Will See Thousands of Claims

 

Throughout the course of an adjuster’s career they will handle hundreds if not thousands of claims.  Most of these claims will be audited for company and state compliance, and plans of action will be discussed on all of them.  Whether to deny or accept claims can be based on a multitude of factors using the comp statues and company policies as guidelines.

 

There are no two claims that are exactly alike, the same way that there are no two adjusters that are identical.  There is room for interpretation in this field of workers compensation.  Adjusters will review the details of a claim and make a decision on the compensability based on their investigation.  But not all of these factors are based purely on law alone.  There are plenty of personality factors that are taken into account, especially when dealing with subjective claims where the claim is questionable.  But why would one person’s claim be accepted, when another person with similar circumstances could be denied?

 

 

Reputation of the injured worker

 

One of the questions a claims adjuster will ask the employer is if this claimant is a credible worker.  Since the employer deals with this worker day in and day out, they get to know whether this worker is a “troublemaker” or “dramatic” over the course of time. Some workers are known for being drama kings and queens, where they can complain about every little thing.  Other workers are workhorses, complaining little if at all about the work and just putting their nose to the grindstone and getting the job done day after day.  When it comes to subjective injury, especially one that is not witnessed, the claims adjuster will hold a lot of weight on the worker’s credibility. Sometimes this fact alone can determine whether or not a claim is accepted or denied, where the adjuster will lean towards denial of the claim based on credibility of the worker alone.  This is by no means applicable to all cases, but it can come up in the minor ones.  This fact can be very true if the worker has a history of reporting injuries about every little nick or strain.

 

On the other hand, if a “good” worker has a subjective injury, and little to no injury history, then you can bet that the employer will pass that on to the adjuster. Chances are that this claim would be accepted just based on the fact that this particular worker is never hurt, a good worker, and because they reported an injury means that they are probably in need of some medical assistance to recover.  Whether this is considered ethical or not is in the eyes of the beholder, but it is a reality.

 

It can be viewed as negative in the eyes of an adjuster if the worker was recently moved, assigned a different job, suffered a wage decrease, or was recently disciplined.  It can be seen as “getting back” at the employer if one of these events happens and all of the sudden a worker claims an unwitnessed subjective strain injury.  Whether it was warranted or not, employees can harbor some resentment towards their employer for whatever “wrong” was committed.  A lot of workers see filing an injury as a way to get back at their employer.  But just because they file an injury doesn’t mean that it will be accepted. This will come down to the investigation of the adjuster on the aspects of the claim.  Sure an injury was reported, but if it was not witnessed and the doctor cannot find anything wrong with them, did an injury actually occur?

 

 

 

90% of Claims Are Accepted

 

Keep in mind that for the most part, approximately 90% of claims are accepted.  The adjuster sees payment of a few medical bills as less costly than if they deny the claim and the worker files a lawsuit for comp benefits.  If this were to happen, the adjuster is now faced with legal fees which would probably be triple what the claim would cost if they had just accepted it, so they may accept it based on that fact alone. It will depend on the facts of the case, the reputation of the employee, and the medical details.  If nothing seems to add up, then you can bet the claim will be denied or disputed. The burden of proof is always on the injured worker.

 

 

Rapport Between Adjuster and Injured Worker

 

Maybe the most important factor in claims such as these will be the rapport between the adjuster and the injured worker.  Sometimes the relationship is like oil and water.  If this is the case, the adjuster may default to questioning everything, and making the claimant do everything by the book exactly.  If the relationship is rocky the adjuster leans toward an overall denial versus acceptance.  Especially true will be those claimants that call the adjuster over and over and over again, but not in a positive way. Saying that the “squeaky wheel gets the grease” is not always true. Sure it is common for someone to have questions about their claim, but when it turns negative in nature, adjusters are taught to notice that something may be up. That will make them take another look at the claim to make sure everything adds up.

 

On the other side of the coin, let’s say the adjuster and the injured worker click for whatever reason.  The employer sees the worker as a “good guy” and the investigation doesn’t turn up anything to go crazy about.  In this scenario, adjusters are likely to give an injured worker the benefit of the doubt.  This adjuster can let a few things slide and can push the claim towards compensability versus a denial, based on their relationship alone.

 

 

Is This Ethical?  Not Really.

 

So is this ethical?  Just because two people do not seem to see eye to eye, does that mean that their claim should be denied due to a personality conflict?  The answer depends. Ethical adjusters can look past any personality flaws and focus purely on the facts of the case, and they can make their decision on compensability based on that alone.  For all intents and purposes that is the proper way that adjusters should conduct themselves.  However, this is not reality.

 

This is where managers and audits should come in to play.  Even if everyone on Earth did not like said claimant, that should not mean that this worker cannot get their fair shake when they file for a work injury. This point should be taught to newer adjusters, and the veteran adjusters should be reminded of this from time to time.  This is the proper and professional way to conduct the determination of claims, day in and day out, no matter how little or how often you have to argue with a claimant.  Personal feelings and attitudes need to be left in your car in the parking lot when you come in to work. They should not influence if a claim is accepted or denied.

 

 

Summary

 

Adjusters will get along with some people, and they will have conflict with some people.  That is the nature of the business.  But professional adjusters can leave their personal opinions outside of the workplace, and handle claims based on the merits of their investigation.  If the employer does not see this happening, then something needs to be said to the adjuster.  Everyone deserves the right for a fair, non-biased claim investigation and determination.

 

 

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.

 

Selecting a Claims Management System for a Self Insured

Sometimes a self-insured has a hodgepodge of systems to handle claims. These are often referred to as RMIS – risk management information systems. An auditor recently found, to his dismay, that a self-insured was recently using a 20-year-old version of a computer claims management system with numerous patches, upgrades and revisions. The claims management system often broke down; the claim audit itself was delayed due to one of the breakdowns. Litigation management was kept on a separate computer system. While documents were being scanned into the claims files, a parallel paper file was kept on each claim due to the claims management system’s inadequacies and failures.

 

The manager was unable to run some basic reports – closings for each month, total new claims per month, total open claims in the office for the month, etc. The IT Department had to help obtain basic claims office management data. Due to the inadequacies of the claims management system, the claims manager could not run his own analytical reports. (WCxKit)

 

 

The Cost of an Outdated Claims Management System: Flying by the Seat of the Risk Manager’s Pants

 

COST was the self-insured’s explanation of why they had such an outdated claims management system. The self-insured thought it cost too much to obtain a better system although it knew the deficiencies of their current system was causing the claims office to waste a lot of time. However, the self-insured had not quantified the cost.

 

It turns out that the self-insured spent more each month with their vendor to keep the old system going than it would cost to pay for a new claims management system. It was as if the self-insured spent $500 every month to keep an old car going, when they could have spent $500 each month paying for a new car.

 

The self-insured’s risk manager was at an extreme disadvantage in obtaining data needed to properly manage their claims and exposures. Without information, maintaining claims quality and analyzing progress or declines in the performance of the claims office was, as the claims manager said, “flying by the seat of my pants.”

 

Both the risk manager and the claims manager were making judgments and decisions based on their gut, rather than verifiable information. They both agreed they needed a better claims management system and hoped that the next revision of their current claims management system was going to make it better, a new transmission in their 20-year-old car.

 

If the next revision of the 20-year-old claims management system is unsuccessful, if the new transmission doesn’t fix the overall old vehicle’s performance, this self-insured should purchase a modern claims management system. While the process may be scary due to their concerns of making a poor choice, the selection of a claims management system designed to meet their needs can be done. However, as we advise when beginning a workers’ compensation cost reduction analysis –the biggest step is to just START – pick one thing and GO.

 

 

Finding the Right Claims Management System

 

To find a claims management system that will provide for their needs, this self-insured should consider:

 

  • Purchasing or leasing from a vendor as their IT department does not have the resources to develop their own.
  • Contacting other large self-insureds (RMIs are a good place to start) to see what systems they use and how they would rate those systems.
  • Identifying several options and
  • Obtaining detailed information from vendors on how their claims management system is integrated with medical case and litigation management.
  • Vendors who have experience at conversion of data from their old system to the new claims management system.

 

This self-insured should also consider several aspects of how the new system itself works. One of these is what does their claims system need to do? Does it need to enter file notes, create diaries or digital copies of documents, process payments, track reserves, write letters, state form filings, litigation management, medical management, etc.

 

The next issue the self-insured needs to consider is how the claims system will operate on a daily basis. Is the system:

 

  • Easy to input data, to navigate and for new employees to learn.
  • Able to respond immediately – a five second delay to change pages will add up to an extremely large amount of wasted time over millions of page changes during the life of the system.
  • Able to encrypt sensitive information like social security numbers, passwords and medical information.
  • Able to run sophisticated analytics, both canned reports and ad-hoc reports for data mining.
  •  Able to keep the reporting database separate from the transactional database to allow for data reports without impacting system performance. (WCxKit)
  • Complete with a disaster recovery plan with a back-up of all data.

 

 

Summary

 

When moving from an old to a new claims management system, it is important to evaluate your company’s needs, the qualifications of the vendor and the capabilities of the new claims management system. A quality claims management system will improve risk management’s effectiveness, improve claim management and save time for the claims staff while reducing overall operation costs.

 

 

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.

Young Father Collects 190,500 in Workers Comp, Cannot Pick Up Son

 

British Print Factory Worker Gets Comp; Out of Work Nearly 2 Years
 
Long Term Injury, Off Work Almost 2 Years
 
A British print factory worker who has been left with a long term injury and remains off work almost two years after injuring his elbow in a fall at work has received £190,500 in compensation, according to the Health and Safety Executive (HSE).
 
Since the accident in 2010 the young father of one was left unable to pick up his toddler and has been unable to return to his job as a printer for Impression Ltd, where he worked for six years. [Wcx]
 
Fell Fixing Problem with Roll of Paper
 
The 35-year-old from Chester-le-Street, was attempting to fix a problem with a roll of paper on a machine and as he stepped backwards his foot struck a pallet truck parked directly behind him, causing him to fall.
 
His right elbow was fractured and dislocated. He needed emergency surgery and two weeks later a second operation to replace his elbow joint. Unfortunately he also needed a third operation when his elbow still hadn’t healed. He has been told that he may need further surgery in the future. 
 
The victim now has limited movement in his dominant right arm meaning that he cannot pick up his son and is restricted in what he can do to help at home. He lost his job with Impression UK and is looking for alternative work.
 
Employers Should Honor Duty for Safe Working Environment
 
According to the victim, “This accident has turned my life upside down. I haven’t been able to return to work. I still can’t pick up my son or even change his nappies. I’m extremely worried about what job I can do in the future. This compensation will help us manage financially and gives me something for all the pain I have been through.” [Wcx]
 
Karen Reay, Unite Regional Secretary for North East, Yorkshire & Humberside, remarked, “Our member has been left with a long term disability and his future working life is now uncertain. Employers have a duty to ensure that the working environment is safe. He was focused on doing his job, trying to fix a machine, unaware of the dangerous tripping hazard behind him. Had the employer taken a more responsible attitude to health and safety this accident could have been prevented.”
 
 

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

 

 

 

 


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.

Comorbidity and Workers Compensation

Among the most difficult workers compensation claims for the adjuster to resolve are the situations where the injured employee has the simultaneous presence of the work related injury and another medical condition.  In science, morbidity refers to a diseased state, disability or poor health due to any reason.   Comorbidity refers to having two unrelated medical issues at the same time which impact the individuals recovery from either condition. The workers compensation adjuster will often cringe when they learn that the injured employee is also suffering from other health issues, as the adjuster knows the claim will most likely turn into a long, drawn-out affair.
 
 
While any health issue can create a comorbidity problem, the more common employee health issues the work comp adjuster will have to deal with include:
 
1.      diabetes
2.      obesity
3.      drug addiction
4.      tobacco addiction
5.      alcohol addiction
6.      depression
7.      hypertension
8.      mental health issues
9.      heart problems
10.  immune system issues
 
 
Any of these personal health issues can create a complicating condition that interferes with the employees recovery from the on-the-job injury. The comorbid condition will either delay the employees medical recovery, or complicating the employees ability to return to work, either on modified duty or full duty. (WCxKit)
 
 
The cost of the medical treatment and the cost of disability benefits of the workers comp injury are normally far higher when there is a comorbidity issue. For instance, a study by Duke University Medical Center showed that obese employees filed twice as many work comp claims, their medical expenses were nearly 7 times higher than non-obese employees and the obese employees were off work 13 times as long as the non-obese employee who incurred the same type and degree of injury.
 
 
Other research has shown a strong correlation between the existence of a comorbid condition and higher claim cost. 
 
Some of the research results include:
 
1.      People who smoke are six times more likely to have complications with a wound healing.
2.      Depression, where it existed prior to the injury, or was developed because of the injury, often delays the employees return to work.
3.      Hypertension, while a prevalent complicating condition, that increases the claim cost, the increase in claim cost is lower than most other comorbid conditions.
4.      No comorbid condition lowers the overall workers compensation cost in either medical expenses or indemnity benefits.
5.      Employee's who smoke or have an addiction to alcohol frequently become addicted to narcotics if narcotics are prescribed for pain.
6.      Pity the work comp adjuster who has a severe injury claim for a morbid obese, depressed, alcoholic with diabetes who got hurt on the job. The likelihood of every getting the employee back to work is nil, statistically speaking.
 
What the Employer Can Do:  

Implement a Wellness Program
While
it may be tempting to say “thats the adjusters problem”, the employer can have a positive and direct impact on the cost of workers compensation claims by addressing the health issues of the employee before an accident occurs. Many of the conditions that create a comorbidity problem are potentially preventable, and if not preventable, treatable before the injury occurs. There are several steps an employer can take to create a holistic approach and reduce the increased cost of comorbid claims.
 
These steps include implementing components of well-ness programs including:
 
1.      A weight reduction program offered through your human resources office.
2.      A healthy work culture that prevents smoking at the work site and offers smoke cessation program.
3.      A healthy work culture that offers water and healthy snacks in the snack machines, rather than sodas and candy.
4.      An encouragement of physical activity at the workplace including taking the stairs and parking at the end of the parking lot to walk to the factory or office building.
5.      Health insurance premium discounts for individuals who do not smoke and maintain a healthy weight
 
 
Use Nurse Case Management
When an employee
who has a preexisting medical condition is injured on the job, early intervention in the medical care by a nurse case manager can impact favorably the future outcome of the work comp claim. The nurse case manager can work with the adjuster, treating physician and employee to coordinate the medical care and manage the underlying pathology creating the comorbid condition. (WCxKit)
 
 
With an aging workforce brought on by the baby boomer generation reaching their 50s and 60s, the number of work comp claims complicated by hypertension, obesity, diabetes and other comorbid conditions will continue to increase. By the employer being aware of how the health issues of the employees impact their cost of workers' compensation, the employer can steps to improve the overall health of the employees, lowering both the cost of workers compensation and health insurance.
 

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.
Contact: 
RShafer@ReduceYourWorkersComp.com 

 

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

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Info@ReduceYourWorkersComp.com

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