Improving Communication with Your Adjuster Can Save You Big Money

 

Communication Can Be Significant Problem
 
Self-insured employers unintentionally, but routinely, sabotage the results they get on their workers’ compensation claims from their third party administrator (TPA) adjusters.  Of course self-insured employers do not set out to get sub-par results from the adjusters.  And, it should be understood that most TPA adjusters want to provide quality claims handling.
 
The reasons for less than expected claim handling results vary greatly from one adjuster to another, but there are some common threads in the employer—TPA relationship that create poor claims handling. A significant portion of the claim handling problems lies in the communications between the self-insured employer and the TPA adjuster. Often an employer will assume the adjuster knows what to do (and the adjuster does), but then the employer will be dissatisfied with the claims handling results because the adjuster handled the workers’ compensation claim differently from what the employer expected. 
 
 
Improve Communications With These Recommendations:
 
·         Talk to your adjuster regularly to understand what is being done, and what needs to be done, on the larger work comp claims they are handling for you
 
·         Be ready to offer input, but don’t try to micromanage the claim handling
 
·         Provide all necessary supporting documentation as quickly as possible including Employer’s First Report of Injury, payroll records, pre-employment physicals and health questionnaires, personnel file, etc. 
 
·         Don’t surprise the adjuster with critical information that you have, or become aware of, by not providing it to the adjuster timely.
 
·         If you become aware of any new information on the claim, share it immediately with the adjuster.  If you do not, the adjuster will more than likely spend time acquiring the information you already have
 
·         Let the adjuster(s) know how you prefer to communicate – whether you prefer emails over phone calls, or phone calls rather than e-mails
 
·         Strive for timely response to all e-mails and to timely return all missed phone calls
 
·         Let your adjusters know you expect a team approach to the claims handling and show respect for the work the adjuster does to create mutual respect
 
·         Be consistent in your communications of your claims handling philosophy in regards to claims handling.  Don’t take a hard nose, defend at all cost approach to one claim and on the next nearly identical claim, overpay the claim to get rid of it.
 
·         Be consistent in your claims handling philosophy or the adjuster will quickly decide you ‘don’t know what you want’
 
·         Never let your personal like or dislike of a particular employee influence your guidance to the adjuster on a claim
 
·         Discuss with your adjuster how much a particular claim is worth and what you will be willing to pay to settle the claim.  If you withhold what you are really willing to pay on the claim, then at time of the mediation or hearing, up the ante significantly, the adjuster is going to wonder why you had both the defense attorney and him/herself spend needless hours working on the claim that could have been settled much earlier
 
·         Don’t change your evaluation of a claim unless new, pertinent information that was not previously known comes to light
 
·         With an eye toward improving your relationship with the adjuster(s) ask your adjuster(s) what can be done to improve the communications between your company and them.  Then, be willing to listen to constructive criticism and act on what is said. If you are not self-critical and not willing to acknowledge the adjuster’s input, then asking them how to improve communications will not benefit either of you
 
·         If you see an adjuster making the same mistake over and over, communicate with the adjuster about the problem, ask the adjuster how the problem can be corrected, agreed on how the issue will be handled in the future, and then follow up to be sure the adjuster makes the necessary correction(s)
 
 
Be aware that every adjuster works differently, and every adjuster is under organizational pressure to accomplish as much as possible on many other claims.  Show your willingness to work with and to assist the adjuster in getting the work comp claim resolved.  Treat the adjuster will respect and communicate your desires to get the best possible claims handling.
 
 
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
 
©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.

But My Carrier Said So

Comp System States What You Can & Cannot Do

 

Have you ever asked anyone in the comp system – agent, broker, carrier, the Board, attorney – what you can and cannot do before, during, and after a claim? Chances are you have, and chances are you accepted it. Nearly everyone does. But people who handle comp problems for a living come to accept the fact that the simplest questions are answered with a laundry list of conflicting answers.

 

How do the pros handle this? Years ago, your correspondent decided to limit arguing matches by accepting whatever method the other party proposed, as long as it would get us closer to the correct result without dangerous compromise.

 

 

Two Different Answers to Same Question

 

Recently, an employer needed to see information in its work comp files in order to engage in effective cost control. The broker was involved and in the AM stated that the carrier could not release the desired information. A call to the carrier confirmed this.

 

Why couldn’t they release a list of prior claims they had obtained? “It would violate medical privacy laws.” A ten minute call to the carrier showed that they would not budge. But how did the carrier obtaining the info from other carriers NOT violate those same privacy laws? “It just is.” But the carrier agreed to release the info if the worker’s signed release could be obtained. (A bit of work, but doable. OK, well do it.)

 

In the PM, the very same broker forwarded prior claim info to the same employer, but on a different claim.  “What?!” The answer was simple. The second claim had a different carrier who read the law differently. The same two people getting two contradictory results on the same issue. Happens all the time.

 

 

 

Never Assume Rules Are Chiseled in Stone

 

An employer can use this example in many ways, not just in comp. When relying on the statements of others about what can, and cannot, be done NEVER assume that the statements were chiseled in granite and signed with letters of fire. But don’t argue.

 

Check with others. If necessary, call the staff attorney at the comp board. Yes, properly approached (and promised anonymity) they will give an answer. After a while you will get a feel for the range of uncertainty. Then, work with the method closest to your needs.

 

Effective, efficient people seldom win arguments but usually produce results.

 

 

Author: Attorney Theodore Ronca is a practicing lawyer from Aquebogue, NY. He is a frequent writer and speaker, and has represented employers in the areas of workers’ compensation, Social Security disability, employee disability plans and subrogation for over 30 years. Attorney Ronca can be reached at 631-722-2100. medsearch7@optonline.net

 

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.

 

©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.

How Your Carrier or TPA Should Process Claims Intake

 

It is pretty hard to be proactive on your injury claims if you struggle to get the claim to your carrier/TPA.  Several Carriers now have a complete, customizable system to make this task easier on you the employer. 

 

In the past, if an injury occurred you would pick up the phone, call the carrier or your agent, and give them the pertinent information over the phone.  From there, those people would complete the injury report and the job would be complete.  Nowadays, the need for information has become more and more prevalent.

 

 

Different Ways Carriers/TPAs Should Accept Claims:

 

 

  1. Email the claim info to the intake center

 

We live in a world of electronic communication.  This form is not only faster, but more efficient.  Carriers give their insured’s forms to complete, and then they can scan and email them to the intake email address.  This also gives the employer a copy of the information, so they can keep it on file. This is a fairly failsafe option, and very common in the insurance world.  [WCx]

 

 

  1. Fax an injury report to the carrier

 

If email is not your thing, most carriers will supply you with forms to complete and fax to your intake center.  This is a fairly easy task, but it can lead to some problems.  Because they can be written out by hand, faxing can make the print hard to read for the carrier employee to input into their system.  Even worse is when the employer does not complete all of the necessary fields.  This stalls the claim, because the carrier employee has to call the employer and confirm the information that they need for claim setup. Submitting claims via the fax machine is no longer the preferred option.  Carriers make it an option, but rarely will they prefer fax over the other electronic forms of communication.

 

 

  1. Call the injury details in to your carrier or agent

 

Even in today’s electronic world, calling in the claim is still a very popular option.  Calling the claim in is a bit more labor intensive for the employer, but there is comfort in actually talking to someone.  If requested, carriers will give you a dedicated phone line to call which goes right to their intake center.  Top carriers/TPAs will offer adaptable call scripts to ensure questions specific to your business are answered every time.

 

.

  1. Submit the injury report via the internet

 

Most carriers can provide the employer with a secure website in order for the employer to report the claim.  This way the employer sees exactly with the intake employee would see from the carrier side, and if you do not have all of the information that the page needs you can always save your work and come back to it once you have the information that is needed.  This eliminates a phone call, being placed on hold, and repeating information to the intake employee.

 

 After you submit the claim you will receive a tracking number that is verification the claim was received and will be assigned to an adjuster.  This has become a common form of injury claim reporting and it has proven to be efficient. 

 

 

  1. Submit the claim information using intake software

 

As popular as website reporting has become, the new wave is giving the employer the software needed to report the claim direct and right into the new claim system the carrier uses.  Almost all carriers/TPAs use a type of claims software to handle their claims and intake process. To make themselves more integrated with their insureds they have allowed employers certain access to this software, including the ability to report a new claim.  This process has many benefits It has decreased phone calls for both parties, and it allows the employer to see into the claim and some of the claim notes to find out whatever info the employer is looking for, be it wage information, injury reports, loss runs, reserves, and the like.  The employer will not have access to the entire claim due to HIPPA privacy laws involving medical records, but they will have a lot of access for the most part.  This is the current trend, and more and more carriers are marketing this as a way that can separate them from other carrier competition. [WCx]

 

 

  1. Key points to remember when submitting a claim

 

No matter how you choose to report the claim, you have to be sure of a few things prior to reporting.  Make sure you have all of the information the carrier needs, including date of birth, social security number, claimant address, injury details, wage history if applicable, the last day worked, the return to work date, if you have light duty work for this employee, the employer address and contact person, contact person information such as phone number and email address, type of injury, and so on.  Without all of this information submitted with the claim, the adjuster will have to contact the employer to obtain it.  No matter how insignificant the injury, these are all facts the adjuster will need in order to do a proper investigation into a claim.  A lot of times the insignificant claims are the ones that can turn into more severe claims when conditions warrant.

 

 

  1. Key points to look for from your Carrier / TPA

 

  • 24 / 7 reporting
  • Escalation Procedures for Critical Claims:  Critical losses require immediate attention, ensure your carrier/TPA has established procedures for once the claim intake is complete.
  • Immediate Distribution of Confirmation Letter: Necessary for you to confirm and acknowledge the information delivered during intake.
  • Integration with the Claims Management Process:  The intake process has to be integrated with the claims management process for the system to run on an optimal basis.  Any breakdown in this structure will lead to less than perfect results.

 

 

Summary

 

Having a streamlined claims intake process is not only beneficial to the employer, but also to the carrier as well.  By being able to have the information they need, the adjuster handling the claim can hit the ground running and work on ways to be proactive on the claim rather than being slowed down chasing information.  The first days in a claim are often the most vital, and any steps you as the employer can take are the most important.  You will see claim expense savings sooner by being thorough rather than by being complacent about the whole process. 

 

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

 


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

 

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

 

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

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

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

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

1.    Know your adjuster and their team

If you do not have a lot of claims per year, or you are a smaller shop with limited exposure, you may not really know which carrier/TPA office location will be handling your claims. Maybe they start off in one city, such as Boston, then end up in Philly. Or maybe they start off and end in Milwaukee. Do you really know who has your claims, where they are, and who to contact with questions?
 
 
If you call your agent/broker, they may have the answer to this question. But with insurance carrier/TPA offices becoming more and more consolidated, even your Agent may not be 100% sure. So reach out to your carrier/TPA and find out if a dedicated local office will be handling your claims. Or, maybe they will start out at their Home Office in Boston, and then be transferred out to a local office in your state if it is a lost time claim, a claim that needs special investigation, or a claim that has issues with compensability. If you know who to call or email with questions, it will make filing claims and getting answers to your questions that much easier and quicker.
 
 
2.    Communication is key
The main reason a claim derails from running smoothly is a lack of communication. Whether it is from the employee not talking to the adjuster, or a miscommunication between the employer and the adjuster, communication is extremely important when dealing with any aspect of claim handling. Be sure to check with your adjuster on all your open claims, and get an update on what is going on, and what their plan is to resolve the claim.  
 
 
Even if you only have a handful of claims per year, your input is valued more than any other. After all, you as the employer are their client, and the carrier/TPA wants to make you happy. Adjusters will appreciate someone out there that cares about what they are doing to move these claims along. Scheduling regular claim updates is also a great way to prevent a claim from slipping through the cracks. Plus the more you as the employer are involved, the more the adjuster knows they have to keep an eye on your claims since you will be checking up on them. The more you are involved, and the more you communicate, the better your claim will be handled.
 
 
3.    Answer all questions the adjuster asks
If an adjuster has a question about something, no matter how insignificant it may seem to you, it is probably really important to the adjuster. Several states require reporting to the State Bureaus of Work Comp, and missing information will hold an adjuster up from completing their filings. Even minor missing info such as a date of hire is important to the adjuster. They need complete info as part of their job for their state filings, so if they have questions about personal info, phone numbers, hire dates, wage history, etc. do what you can to get that info for them so they can move on with the claim. 
 
 
Details such as the hire date could also key them in on certain aspects of the claim. If it is a new hire, maybe that explains why a worker cut their hand, or strained their back. Wage info is always needed when there is lost time. If the adjuster needs the wages, they probably can’t pay your worker until they get that info. A date of birth is needed for state filings, but it is another key to the claim, since an older worker may mean that this particular claim won’t resolve as easily as it would with a younger worker. The examples here are endless, and the bottom line is to get any requested info to your adjuster on a timely basis. You don’t have to stop what you are doing to look that info up, but try to get it for them within a few business days. The sooner you do, the quicker it is off your desk and the less chance you have of forgetting about it.
 
 
4.    Bring your adjuster and their team out for a tour of your facility
If you are a large enough employer to churn out 50 claims per year, you probably will know who your adjuster is by name. You may even know who their manager is by name. But do you actually know who they are, other than just by name? Employers that have a lot of claims may know a little about their adjusters through casual conversation, such as if they are married and have kids, if they are sports fans, etc. 
 
 
A way to strengthen the relationship is to have them come out to your facility for a tour. Not only can you put a face to a name, but it greatly helps your adjusters by seeing the premises. Adjusters can look at the machines, observe the workers doing their jobs, and get a better idea and understanding of what you guys do day in and day out. This helps them mentally process the claim by knowing what your injured workers are talking about when they are describing what they were doing when they were injured. If you describe a machine injury to 10 people, you could get 10 different ideas of what happened. But if you show your claims team the machines and how your operators run them, and then they know exactly what a worker is talking about when they were injured.
 
 
5.    A “Thank you” goes a long way
As we have said time and time again, the work of a claims adjuster is often a very thankless job. Sure, it is the adjuster’s job to handle these claims, but often it is a stressful, high demand profession. Taking the time to thank your adjuster for their hard work will mean a lot to them, and they will take that compliment and use it to handle any of your issues right away. Your adjuster certainly will not forget your praise, and you can get them to work that much harder for you now and in the future. (WCxKit)

 

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

Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com. Contact: RShafer@ReduceYourWorkersComp.com.
 
 
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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.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact: Info@ReduceYourWorkersComp.com

Seven Basic Guidelines for Talking to Your Adjuster

First, keep in mind, your adjuster, wants you to be happy with the work product. Second, your adjuster is a claims professional with the responsibility to direct and control the claim. A sharp adjuster welcomes your input and information you provide to assist in managing your claims. You can create a strong working relationship by implementing these seven guidelines.

 

  1. Establish Rapport

Rapport means knowing your adjuster on a level deeper than work. Asking about vacation or a child’s school program shows interest in the adjuster as a person and builds a bond making it easier to discuss difficult issues. Establish rapport, and then be ready to discuss your claim(s).

 

 

  1. Be Focused

Before calling the adjuster review your claim(s) file notes; jot down your questions and the reasons for asking. Knowing your reasons allows the adjuster to provide a focused answer. Otherwise the adjuster may draw conclusions and give answers not fully covering what you need to know.

 

  1. Be Respectful

Do not berate or question the adjuster’s competence. As the claims professional it is the adjuster’s job to be current in claims handling in accordance with best practices described in your insurer/TPA service contract. If you are dissatisfied with the adjuster’s claim handling, ask questions to learn why the adjuster acted (or not) a certain way and mutually resolve any issues. If you have a real problem with the adjuster’s performance, speak to their supervisor and make sure to have examples of the issues you are concerned about.

 

  1. Ask Open Ended Questions

Asking open-ended questions allows the adjuster to explain the status of a claim and a future course of action. Yes/no questions elicit yes/no answers and come over as an interrogation rather than a request for information. An interrogatory style may put the adjuster on the defensive and close off the flow of information.

 

  1. Have a Positive Attitude

When approaching your adjuster be positive in both your words and tone of voice. After all, the adjuster is working for you and wants to do a good job. When expectations are met a sincere compliment of appreciation and a “thank you” keep your adjuster motivated to continue to provide good service to your company. Copy the adjuster’s supervisor on your applause for excellent performance.

 

 

  1. Be Willing to Listen

If in your opinion the adjuster’s efforts have come up short. Ask about the “failure” using open-ended questions, give your reasons, and then LISTEN carefully to the adjuster’s response. Careful listening allows you to hear any valid reasons as to why the claim is not going as you wish. Together you and the adjuster can identify problems and you can suggest solutions to assist the adjuster in producing a better quality claim product. [WCx]

 

  1. Cooperate and Plan

Finally, after discussing all your questions and achieving a complete understanding of the claim’s current standing, future activity is planned by asking these type of questions: “Since I want to follow up with you, what is your plan to move the file forward?” “When do you expect to accomplish your action plan?” “Who else do we need to keep in the loop and how will that be done?” and “What suggestions do you have about how our company can reduce our workers comp 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.

 

 

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

 

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

 

New York Workers Comp and the Employer the First Thirty Days after an Accident Report

The role of the employer after an accident is vital. Unfortunately, it is a misconception that it consists solely of filing a report (C-2) with the carrier and Workers Compensation Board within 10 days. That might be the barest minimum legally possible, but it is rarely adequate for anyone involved in a claim and certainly not for the employer and employee.

 

 

An employer trying to complete the Board’s prescribed form for reporting an injury is immediately confronted by puzzling requirements. Many of the questions are for small details which are never part of a compensation adjudication (the employers industrial code) while others allowing a woefully small amount of line space for what might require a lengthy explanation (how did the accident occur). Other parts of the form seem to assume that an accident must have occurred, even though many employers are equally certain that it did not.   (WCxKit)

 

 

(Attach additional documents to the C-2, where necessary to explain fully what happened.)

 

 

The employer should realize that its role is much larger than a single C-2 form. To assist in the proper resolution of a claim (even though that sometimes means a dismissal) the employer should be aware that they frequently have far more information than is requested. The information may be forwarded to a carrier and the Board, taking care that confidential medical information may require special handling.

 

 

An employer should make the carrier aware of relevant information which it possesses about the employee’s physical limitations at time of hire, so that these are not automatically assumed to be a consequence of a new injury.

 

 

The employer can also list for the carrier known prior injuries, especially those resulting in a lawsuit or compensation claim. The employer can also list prior employers, with dates of work and name address and phone number of the employers.

 

 

The employee may have periods of absence due to illness or injury. These should be made known to the carrier. Since a claim is being filed for medical disability, such information must be available to treating doctors and independent examiners.

 

 

The employer’s role also extends to maintaining a relationship with the employee. The law imposes upon the employer (not the carrier) the obligation to see that appropriate medical treatment is provided. Calling the employee to make sure that they are under care is entirely appropriate and much appreciated by the worker’s family.

 

 

The employer can also begin return to work measures. Asking the worker about the treating doctor’s opinion about possible return to work is not intrusive. In fact, it is essential. (WCxKit)

 

 

Being involved means a lot more than the completion of a single form. Remaining an active presence results in faster adjudication, quicker return to work, less wage loss and fewer contested issues.

 

 

Author Attorney Theodore Ronca is a practicing lawyer in Aqueboque, NY. He is a frequent writer and speaker and has represented employers in the areas of workers compensation, Social Security disability, employee disability plans, and subrogation for over 30 years.  Mr. Ronca has 21 years experience in searching and retrieving medical records and many other types of documents for defense workers Compensation claims. Contact Attorney Ronca at 631-722-2100 or medsearch7@optonline.net

 

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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.

 

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

 

Seven Ways Carriers and TPAs Ensure Quality Control

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

 

  1. Multi-level screening of adjuster candidates

 

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

 

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

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

  1. Sixty-day status report

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

 

 

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

 

 

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

 

 

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

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

 

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

 

 

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

 


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

 

 

Our WORKERS COMP BOOK:  www.WCManual.com

 

 

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

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

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

SUBSCRIBE:  Workers Comp Resource Center Newsletter

 

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

 

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

 

Four Useful Tips Can Go a Long Way in Managing Workers Comp

When you have a high-exposure file that turns out better than you had expected and costs come in way under what you had budgeted for, it is easy to see the cost-savings that are associated with that loss. If you saved $50,000, that’s a nice lump of savings for your balance sheet. 
 
But those little savings you make throughout the course of a year add up as well. It’s difficult to see it in the short-run, or by the month, but looking at it over the course of a year, it can really add up to a nice savings in your budget. We discuss some ways those little savings can add up below. (WCxKit)
 
 
1-Using quality vendors to get better results:
Sometimes the better vendors just cost a bit more than others. This is usually due to the fact that they have better talent working for them, and there are associated costs included with that. However, if these more expensive vendors get your workers back to you ready for work quicker, then you save again on the wage loss issue. This means that these vendors have already paid for themselves if you weigh their costs versus the cost of wage loss for your injured worker.   Talk with your carrier about who the best vendors are in your area for IMEs, surveillance, and nurse case management. Don’t shy away from them just because their costs are a tad higher than their competition. They can save you money in the long run by providing you with excellent service, and by getting those injured workers back to work quicker than their counterparts.
 
 
2-Enhanced communication with your TPA/Carrier:
Lack of proper communication can lead to increased claims expense. If the adjuster doesn’t know that you have light duty work available, they may not be pushing hard enough to get work restrictions for your injured worker. Maybe the adjuster doesn’t know you have a dedicated medical clinic and/or physical therapy facility and failed to direct the injured party to treat at those clinic locations. 

Maybe the injured worker took vacation time or sick pay for their time off of work, and they didn’t tell the adjuster that so they got paid twice-once by your company and once by the Carrier. Although most times the adjuster will catch this, sometimes they do not. This leads to an overpayment that the carrier must try to recoup, and if they fail to do so the cost of that ultimately gets pushed to you in the result of a higher premium due to increased claim costs. Whatever the event may be, you need to be in regular contact with your adjuster.   

Perform claims reviews and ask the adjuster on each claim what their plan is for getting the claim resolved.  The more you discuss the claim, the more ideas you both can come up with, and that may be what is keeping your worker off of work. By working together, you will save costs. Most adjusters would prefer too much communication versus not enough, plus this will keep the adjuster on their toes and they will be keeping a close eye on your claims, preventing one from falling through the cracks which will further waste claims dollars.

 
 
3-Using the other departments your TPA/Carrier has to offer:
Most Carriers/TPAs have multiple departments that will work with you to reduce your exposure. Loss prevention, ergonomics, dedicated adjusters to your account, medical/nurse resources, medical bill review, etc.   All of these services may be provided free of charge by your Carrier/TPA, and the end result of utilizing these services will be lower claim cost to you. Implementing the action plans that these departments come up with is designed to lower your costs. So talk with your Carrier/TPA and find out what resources they have to help you reduce cost. They will be happy to work with you, and you will be happy since your claims expense will decrease over the course of a year.
 
 
4-Utilizing a 3rd party company for all of your RX needs:
Pharmacy costs are constantly rising. Almost every injured worker comes out of their doctor's appointment with a prescription for some medication in their hand. There are a lot of 3rd party pharmacy companies out there willing to work with you to reduce these costs if you funnel your injured workers to their pharmacy programs. Find out what kind of pharmacy management program they provide. The best sell their services unbundled.  Look for prospective as well as retrospective elements of the cost control program. This can lead to huge cost savings, even on the minor claims, and will help the most with the more severe claims, since those injuries usually require prescriptions that cost more, and they length of the prescriptions last longer. This is a significant way to reduce your costs, and you will see large savings at the end of the year. (WCxKit)
 
 
Summary:
There are a lot of ways to reduce your costs. Not only in the larger higher exposure claims, but in the small minor claims as well. If you think about it, every little savings you can make can add up to a lot by the end of the fiscal year. Remember there are ways to cut costs on every claim, no matter how insignificant the claim may be at the time. You have to think both ways, in the short term and long term. Whatever it may be, the end result is you saving money, and that is never a bad thing
 

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

ABC's of Workers Comp Management:  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.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

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