Know Four Types of Workers Compensation Adjusters

Carriers have classes of adjusters usually correlating with each adjuster’s amount of experience. Although class names vary, they are usually divided into medical-only, lost time/Indemnity, litigation, and catastrophic adjusters.
 
 
1 – Medical-only adjusters
Medical-only adjusters, an entry level position, are trainees with little to no experience. They handle minor medical claims involving simple lacerations and minor strains/sprains not involving any lost wages or complicated medical injuries/conditions. When an employee has a few clinic visits the employer sends the claim in with the bills and the adjuster sets up the claim, processes the bills, and closes the claim.
 
 
Medical-only adjusters conduct the initial interview with the employer and the employee. The interview itself does not go into great detail or investigation as the injuries are usually minor with uncomplicated outcomes.
 
 
When claims are time limited (60 to 90 days) and the claimant continues to receive medical treatment, the claim may be transferred to the lost time adjuster. Look upon extended claims as a “red flag” indicating a possible reason the employee is not returning to transitional or full duty work. Sometimes Lost Time adjusters handle medical-only claims, especially when they are "enhanced situations" where there is a complexity such as ongoing medical expenses.
 
 
2 – Lost time/indemnity adjuster
Lost-time/indemnity adjusters are more experienced, with knowledge of local legal statutes and a high degree of medical training in handling occupational claims. Their expertise is with claims running past 90 days involving more severe injuries such as a complicated lacerations, level 2/3 sprain/strains, surgical repairs, or pending surgeries. When employers question claim compensability, the claim is immediately assigned to the lost time/indemnity adjuster.
 
 
The adjuster takes a recorded, detailed statement, and interviews the employee and any witnesses to the injury. Sometimes a visit to the premises is needed to investigate certain claims. (WCxKit)
 
 
Claims are handled until the claimant is either released from care, or the claim goes into dispute. These claims may remain with the adjuster for months or even years.
 
 
3 – Litigation adjuster
Litigation adjusters handle claims involving lawsuits. These adjusters share the same level of experience as the lost-time adjuster. However, they have advanced training in legal issues and in investigating the compensability of occupational claims.
 
 
When a compensable claim is disputed, and the claimant retains counsel and files a Notice for a Hearing, the claim goes from the lost-time adjuster to the litigation adjuster. The litigation adjuster works with in-house or outside counsel gathering details on the injury, and appears for hearings and mediations to quickly resolve the claim at minimum legal expense.
 
 
The litigation adjuster usually cannot speak directly to a claimant due to the retainer of plaintiff counsel. Therefore, the adjuster relies heavily on the employer’s investigation and facts of injury, if known, and works on gathering medical records, witness statements, police records, prior plaintiff litigation history, and any other facts about the claim, gathering evidence to use in defending the claim. The claim is handled through settlement or trial and then closed.
 
 
4 – Catastrophic adjuster
This level of adjuster is the most complex, handling very difficult claims, usually ones where the claimant has a severe injury requiring multiple surgeries, amputations, loss of sight, hearing loss, or internal medical issues such as asbestosis or chronic joint degeneration due to occupational exposure, etc. Employers hope for few of these type claims, but it is a bullet that cannot be dodged forever.
 
 
General/catastrophic adjusters have many years of experience in the Insurance industry, combined with advanced medical and litigation training and experience. They also have advanced claim investigation training, and may possess a law degree or are licensed attorneys. They delve very deeply into the complexities of the claim in an attempt to resolve all issues of medical treatment expense and ongoing incurred wage loss. Sometimes they suggest large settlements or annuities to avoid ongoing claim costs for life or advanced vocational retraining, a very expensive proposition lacking a guaranteed positive outcome.
 
 
These types of serious claims may last for years, and sometimes involve vocational retraining and job placement for the claimant when the sustained injury is so severe return to work is impossible.
 
 
Summary
Carriers typically have four levels of adjusters, ranging from the newly appointed claims trainee to the severe/catastrophic claims veteran. The important thing for the employer to know is in the event of a severe claim, your carrier retains the proper adjuster to handle all aspects of the claim in order to protect your best interests.

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

 
 
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.

How to Handle Workers Comp Hearing Loss Claims

Employees who are subjected to high level of noises on the job without proper hearing protection will eventually lose some or all of their ability to hear. To complicate the amount of hearing loss resulting from the job, everyone loses their ability to hear to some degree as they age. The issue that confronts the workers compensation adjuster is paying the employee for the work related hearing loss, but not compensating the employee for age related hearing loss, or for hearing loss due to non-work related activities like snowmobiling, using a chain saw and hunting/target shooting.
 
 
The investigation of a workers compensation hearing loss claim involves the detailed review of the medical records related to the employees hearing. Often obtaining the medical records can be a challenge for the work comp adjuster. When a 60 year old employee files a hearing loss claim, locating and obtaining the hearing test records for employment 30 years earlier is difficult. It becomes even more complicated if the employee worked for a different employer 30 years ago, that is no longer in business. (WCxKit)
 
 
The medical record the work comp adjuster is looking for in their search of the employees medical history is called an audiogram. An audiogram is a test conducted in a sound proof room by an audiologist or by an otolaryngologist. The results of the test are displayed on a graph that reflects the ability or inability of the employee to hear various levels of sounds.
 
 
The results of the audiogram measure the employees hearing impairment using the American Medical Associations Guides to the Evaluation of Permanent Impairment (in most states, some states use other measuring systems). The employees ability to hear is measured in Hertz (Hz) with a Hz being the measurement of sound waves per second. The ability to hear is normally measured at 500, 1,000, 2,000, 3,000, 4,000, 6,000 and 8,000 Hz. 
 
 
The work comp adjuster will have the employee tested by an audiologist or otolaryngologist to determine the employees current hearing ability. The results of the current audiogram will be compared to the audiogram previously completed on the employee to ascertain the increased in hearing loss, if any.
 
 
If the new audiogram reflects an increase in the employee’s hearing loss, the employee will need to be examined by an otolaryngologist to determine if the hearing loss is due to a conductive loss, a perceptive loss or a mixture of the two types. A conductive hearing loss is caused by a defect in the middle ear or external ear due to disease or injury. It is not caused by noise in the work place. A perceptive hearing loss is may be caused by noise in the work place, or aging, or infectious disease. If the otolaryngologist determines the hearing loss is a conductive hearing loss, the claim can be denied. If the otolaryngologist determines the hearing loss is a perceptive hearing loss, or a mixture of the two types of hearing loss, the claim will continue.
 
 
In most states the settlement of a hearing loss is done by a schedule of injuries which specifies the amount an employee can be compensated for the loss of hearing in one ear – a monaural hearing loss, or the loss of hearing in both ears – a binaural hearing loss. By comparing the employees prior audiogram(s) with the new audiogram, a percentage loss of hearing can be established which is applied to the schedule of injuries chart.
 
 
The most common problem the work comp adjuster will run into in handling the hearing loss claim is locating the previous audiogram(s). If the previous audiogram(s) can not be located, or if there were no previous audiogram(s), the adjuster will be confronted with the employee or the employees attorney claiming all the hearing loss is due to the current job, with assertions that the employee had perfect hearing prior to starting work for the current employer. (But the 60 year old employee won’t mention that his favor hobbies are hunting and snowmobiling, and that he never wears any type of hearing protection while hunting or riding his snowmobile).
 
 
While the adjuster will prevail on the otolaryngologist to establish the amount of hearing loss that can be connected to the employees job position, there are much better ways of fighting (and winning) the hearing loss claims. Here are some suggestions on what the employer can do to eliminate or at least reduce the size of hearing loss claims:
 
1.     All employees who are constantly exposed to noise or who will sometimes be exposed to excessive noise should have an audiogram completed as a part of their pre-employment hiring requirements. This will provide a baseline in case of a future hearing loss claim. The pre-employment audiogram should be kept as a part of the employees records forever. (Just because the employee leaves your employment does not prevent the employee from filing a hearing loss claim decades later). If the employee does present a hearing loss claim in the future, the audiogram will limit the potential claim payment to the amount of hearing loss that occurred during the employment with your company. [An optional approach is to administer an audiogram to the employee prior to their departure for a new job or retirement, but then you may be buying a bunch of small hearing loss claims.]
 
2.      Know your noise level. Many employers know that their factory, construction site, equipment or machinery creates noise, but do not know how loud it actually is or if the level of noise will harm the employee’s hearing. Do a risk assessment by having the decibel level of your work checked. By recording the noise level, the risk manager can determine the best ways to reduce the noise level. Any noise level exceeding 85 decibels should be addressed.
 
 
3.      If the employee is regularly around lawn mowers, chainsaws, jackhammers, table saws, bulldozers, etc., where they are constantly exposed to noise levels above 85 decibels, an audiogram should be completed yearly. [OSHA is currently reviewing their requirements on sound levels with new recommendations expected in 2011 that may lower the decibel levels requiring hearing protection to 80 decibels].
 
4.      All employees who work in an environment where they are continuously exposed to noise should be required to wear hearing protection. Quality earplugs or earmuffs are much less expensive than paying for a hearing loss claim. Employees annual performance reviews and wage/salary increases should be tied to their compliance with the mandatory use of hearing protection. 
 
 
5.      All employees should be provided with safety materials that emphasis hearing protection.   Not only should the safety materials cover hearing protection at work, but also it should cover their away from work activities and the damage loud noises (including loud music in headsets) will do their hearing. (WCxKit)
 
 

The use of audiograms is the best way to measure the amount of hearing loss. A program requiring an audiogram of every new hire will reduce the employers exposure to hearing loss claims. The best way to handle hearing loss claims is to prevent them from occurring to began with. The employer who encompasses hearing protection into their safety program will eliminate most hearing loss claims and reduce the cost of the hearing claims that do occur. 

 

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 or 860-553-6604.

 
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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

Know the Difference Between Lost Time and Medical Only Claims – Shades of Gray

One of the country’s  largest Third Party Administrators (TPA) got into an embarrassing situation about a decade ago on the self-insured program of a Fortune 500 company. The embarrassing situation? The TPA did not know the difference between a medical only claim and a lost time claim when it came to billing. 
 
The risk management of the self-insured company noticed its allocated loss adjustment expenses (various claim related expenses including the cost of claims handling) was much higher than anticipated. The cause was an increase in the number of lost time claims and a decrease in the number of medical only claims. Claims the self-insured company thought should have been billed as medical only claims were being billed as lost time claims. The claims servicing agreement between the TPA and the self-insured company called for medical only claims to be billed at $125.00 each and the lost time claims to be billed at $950.00 each. The extra billing of $825.00 per claim was making a major difference in the allocated loss adjustment expenses of the self-insured.
 
The resulting fall-out from this embarrassing situation was the TPA had to re-think its billing structure for workers' compensation claims. Historically TPAs bill a flat rate per file on self-insured programs, with one rate for medical only claims and a second rate for lost time claims. This allows the self-insured programs to estimate their allocated loss adjustment expense. This approach worked well when the injured employee went to the doctor, was treated and released to return to work with no time lost from work. This approach also worked well when the employee was off work for an extended period of time, eventually recovered and returned to work. What got the TPA into trouble were the work comp claims not fitting neatly into either category.
 
What do you call the claim where the employee is dedicated to his employment, works through his injury, never misses a day from work, but receives a 5% permanent disability rating?   What do you call the claim where the employee is off work less time than the state mandatory waiting period, but due to a burn or severe laceration has a scar and is entitled to disfigurement compensation? What do you call the claim when the employee never misses any time from work for her injury, but continues to treat weekly with her chiropractor for years?
 
Claim category definitions now used for billing purposes normally include Incident Reports, Medical Only Claims, Enhanced Medical Only Claims, Other than Medical Only Claims, and Occupational Disease Claims. Each claim category definition has a flat rate dollar amount billed for handling a claim.   The following is how some TPAs are now defining claim categories.
 
Incident Reports
An incident report (also called Record Only) would be appropriate when no payment is contemplated. The incident is reported in order for the TPA to make a record of it by inputting the data into the risk management information system being used. An incident report would be entered into the system without a reserve as no payment would be made. 
 
Incident reports examples include an employee receiving a paper cut and a band-aid but no medical treatment off the premise, or a book falling off a bookshelf and hitting the employee, but the employee continuing to work without medical treatment.
 
Medical Only
A medical only claim is any claim involving medical attention, but no time lost from work beyond the state mandated waiting period, and does not include any permanency of injury. Any treatment at a medical facility or treatment by medical personnel off the premise of the employer qualifies the claim for medical only status, regardless of whether or not a bill is generated and regardless of who pays for the medical care. 
 
The medical only claim includes the receipt of the claim by the TPA and data input into the risk management information system about the claim, plus the reserves set to pay the claim. If no medical bill is provided to the TPA, the TPA can closed the claim without payment, but the TPA will still be paid for the handling of the medical only claim.
 
Enhanced Medical Only
This is the claim definition category most TPAs adopted in recent years to deal with the medical only claims entailing more work than the typical medical only claim. An enhanced medical only claim will be any medical only claims where the medical treatment of the employee continues for six months or longer, or the cost of all medical care exceeds $1,500.00. The enhanced medical only claim also includes the receipt and data input into the risk management information system about the claim, plus the reserves to pay the claim.
 
Other Than Medical Only
Notice the title for this claim definition…….it does not say Lost Time claims. This claim category definition would include any claim not fitting the definition of incident report, medical only claim or enhanced medical only claim. This includes all lost time claims beyond the state mandatory waiting period, any claims with permanency and any claims with disfigurement (in the states requiring  monetary compensation for disfigurement). 
 
Claims requiring investigation are included in the “Other Than Medical Only” category. This could be the investigation of compensability, or subrogation, or the degree of permanent injury or any matter in dispute. Also, the handling of claims with light duty restrictions where there is a loss of wage earning capacity are classified as “Other Than Medical Only.”
 
Occupational Disease Claims
This claim definition category includes medical only, enhanced medical only and other than medical only claims which are obvious occupational diseases like asbestosis and black lung. This category would also include those states classifying repetitive trauma as an occupational disease claim. (workersxzcompxzkit)
 
Summary
The claim servicing agreement between the self-insured company and the TPA should have definitions of claim categories to eliminate the potential for the embarrassing situation discussed above. Please note no two TPAs define claim categories exactly the same.

Author Rebecca Shafer, Risk Consultant/Attorney, President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers' Compensation costs, including airlines, health care, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. She can be contacted at: RShafer@ReduceYourWorkersComp.com or 860-553-6604.

Podcast/Webcast: Occupational Health Strategies
Click Here:

WC Calculator: http://www.reduceyourworkerscomp.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.
 
©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.

How to Make Handling a Medical Only Claim Interesting

 
 The handling of medical-only  workers’ compensation claims may seem routine or even mundane. Let’s look beyond the surface to see there’s more than meets the eye. Many of the questions considered in evaluating a claim for compensability apply whether the claim is a medical- only or involves indemnity payment. The first step in handling either type of claim involves determining whether there is coverage. So, take a look at the policy dates and be sure the injury date falls within the coverage period. 
 
Also confirm the claimant works for the named insured on the policy and he or she is covered. Owners or officers of a company may have opted out and employees “hired” from a temporary agency may be covered under the agency, not you’re named insured. 
 
Review the  first report of injury and be aware of “red flags” including  — Monday morning injuries (may really have occurred over the weekend), un-witnessed accidents, injuries reported late or after termination, injuries reported just as seasonal work is ending or injuries occurring in an area where the employee would not normally be expected to work. This is just a partial list of things to consider, even when reviewing medical-only claims. 
 
Scrutinize the medical bill(s) and read the explanations next to the boxes on the Health Care Financing Administration (HCFA) form. The bill tells you whether the charges stem from an auto accident, employment or another accident.
 
You can also verify the employee’s date of birth and social security number to be certain you have the correct bill. The bill also indicates if this is an initial visit for the current complaints. If it’s not the initial visit, it’s an indicator to pursue other medical records possibly providing an accident history inconsistent with the reported injury, thus warranting additional investigation.  
 

Author Robert Elliott, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers' Compensation costs, including airlines, health care, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He can be contacted at: Robert_Elliott@ReduceYourWorkersComp.com or 860-553-6604.

Podcast/Webcast: How To Prevent Fraudulent Workers' Compensation Claims Click Here http://www.workerscompkit.com/gallagher/podcast/

Fraudulent_Workers_Compensation_Claims/index.php

We accept articles about WC cost containment. Contact us at: Info@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.
 
©2009 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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