How To Ensure Your Adjuster Is Being All They Can Be

Workers comp adjusterIf you have ever felt an adjuster assigned to one of your workers’ compensation claims was not making a proper effort to investigate a questionable injury claim, you are not alone. Every large claims office has some really good adjusters, some acceptable adjusters and some unmotivated adjusters who are just going through the motions to make it to the next weekend.

 

If you contact an unmotivated adjuster about the status of their claims handling, the adjuster will tell you, that she is doing everything she can on the claim. The reason the adjuster will say that is because the adjuster knows that the employer most often does not know what can be done on the claim. If you want to really shake up the unmotivated adjuster and to get the adjuster moving forward full speed on the investigation of the claim, review the following list of investigation suggestions with the adjuster.

 

Check List of Investigation Tools:

 

  • Employer’s First Report of Injury form
  • Employee’s written report of claim form (in states where it is required)
  • Insurance Services Office filing (formerly known as the Central Index Bureau)
  • Contact with claim adjuster(s) on claimant’s prior work comp claims
  • Contact with prior employer(s) on claimant’s prior work comp claims
  • Medical records from claim files of prior work comp claims
  • Contact with work comp board/industrial commission for their records on prior claims (some states will not cooperate, other states do cooperate)
  • Employee’s detailed recorded statement
  • Recorded statement of any witnesses to the accident
  • Supervisor’s recorded statement
  • Police report on vehicle accidents
  • OSHA reports, whether federal OSHA or a state OSHA
  • Any other government agency records
  • Discussion of the claim with the employee’s attorney, if the employee is represented
  • Contact with any third party involved in the claim – driver of other vehicle in auto accidents, manufacturer of machinery that injured employee, manufacturer of defective product that caused employee’s injury, etc
  • Telephone contact with each medical provider to have the most recent medical report(s) faxed to the adjuster
  • Medical records for all medical appointments
  • Photographs of the accident scene
  • Diagram of the accident scene
  • Having the claimant call the adjuster after each doctor’s appointment to report on medical progress
  • Nurse case manager’s input on serious injury claims
  • Field case manager to meet with the employee and doctor, and to attend medical appointments with the employee
  • Review of claimant’s social media sites – Facebook, Twitter, LinkedIn, etc.
  • Employer’s personnel file on the employee, including job application, new employee forms, disciplinary records, etc.
  • Employer’s safety records for the accident location
  • Employer’s public notice of plant location closing, lay-offs, union issues, etc.
  • Referral of the claim to the Special Investigation Unit (the unmotivated adjuster may be quick to do this, as this passes the buck to someone else to do a complete investigation).
  • Outside Vendor Services (Investigation steps that can be taken, but not normally performed by the adjuster, but overseen by the adjuster).
  • Surveillance
  • Activity check
  • Neighborhood canvass
  • Background check
  • Credit check
  • Public records review / civil records searched
  • Criminal records check
  • Skip tracing
  • Clinic records sweep (checking for medical treatment at all clinics in the area of the employee’s address)
  • Hospital records sweep (checking for medical treatment at all hospitals in the area of the employee’s address)
  • Pharmacy records sweep (checking for prescriptions filled at all drug stores in the area of the employee’s address)
  • Video re-enactments of the accident
  • Examination under oath

 

Unfortunately, there is no central system where an adjuster can check to see if the employee is currently working another job. The use of a private investigator for surveillance can fill this void, but without knowing where an employee might be working, this is often a hit-and/or-miss approach.

 

It would be a very rare claim where it is necessary for the adjuster to take all of the investigation steps listed above. The key to an investigation is for the adjuster to take as many of the investigative steps as needed to verify the validity of the claim, or to disprove the claim.

 

We realize this checklist of the investigation steps your adjuster can take is incomplete. We welcome our readers to contact us with additional investigation techniques they would add to our investigation checklist.

 

 

 

Rebecca ShaferAuthor 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 co-author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:.

Contact: RShafer@ReduceYourWorkersComp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

 

©2019 Amaxx LLC. 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.

A Day in the Life of a Busy Workers Compensation Insurance Adjuster

If you have ever wondered what your workers comp adjuster does in a day, please read this fictional, but true-to-life account of an adjuster’s typical day. Let’s take a look at what a typical adjuster does during the day and reflect on how we can help him/her help us better manager our programs. Although this blog refers to workers compensation adjusters, the work day of others is probably about the same. One noted exception is a “field adjuster” who may work on the road, for example, in auto claims.

 

Most adjusters who have been on the job for a realize their workload will always be greater than they can ever attend to properly. This won’t stop most of them from trying to cover everything that needs to be done. It is not unusual for the dedicated adjuster to arrive at the claims office early and be one of the last employees to leave at night.

 

It is usually the workers comp adjuster who arrives first at the office and makes a pot of coffee for herself (or himself) and her co-workers. After a few sips of coffee, the adjuster turns on her computer and brings up her diary (her computer calendar) of all the claims she needs to work on during this day. However, before she starts to work on any of her claims, she turns to the telephone and retrieves all her voice mails from claimants (employees), employers, medical providers, attorneys, nurse case managers, her supervisor, various vendors and others who have called her about her claims. (WCxKit)

 

The adjuster than compares her voice mail messages with her diary to see where she can combine the diary and voice mail to save time on the files. After she combines the diary and the voice mails, she prioritizes the claims and creates her work agenda in the order of importance.

 

During her workday, the workers comp adjuster has frequent and sometimes complex contacts with many parties. For the next couple of hours the adjuster will be on the telephone contacting employers, employees and medical providers to obtain additional information about the progress or status of the claims.

 

If the adjuster is good at multitasking, she will be entering file notes on each claim as she is talking to each person. If she is not comfortable with multitasking, she will write up her files notes immediately following each phone call and before she starts the next phone call.

 

By the time the adjuster is done with her phone calls for the morning, the daily mail should have arrived at her desk (or have been scanned into the computer system). The adjuster then turns to reviewing each item of correspondence and entering her file notes on each medical report, attorney’s letter, etc.

 

The adjuster never get through her morning phone calls that she makes and the daily mail without receiving additional phone calls from people. Depending on the claim office philosophy or the adjuster’s preference, the adjuster will stop working on the incoming mail and take the phone calls as they arrive, or allow them to start accumulating again in her voice mail.

 

It is an old claims office adage – “Your interruptions will get interrupted.” The adjuster must decide for herself if she is more proficient by taking each phone call as it arrives, or by grouping them and returning the phone calls once in the morning and once in the afternoon.

 

Between telephone calls and correspondence, the adjuster’s morning is packed with other things to do.

 

If the supervisor has assigned a new workers comp claim to her, she must put on hold all the items on her agenda and make her three-point contacts with the employer, employee and medical provider. If she has a worker’s comp board hearing, she may have to leave everything and attend the hearing. If she has a settlement conference, she may attend the settlement conference in person, or by telephone. If she has a crisis of some type on any of her files, she will stop work on her daily agenda and deal with the crisis. Our third party-administrators and insurance companies have many adjusters who are the primary contact for many of us in the workers’ compensation field.

 

After a quick lunch, often eaten at her desk in order to save time, the workers comp adjuster starts her afternoon round of phone calls, mail review, outgoing correspondence and file reviews. In the middle of all these activities, the adjuster will often take time out to discuss complicate claim issues with other adjusters or to provide mentoring to inexperienced adjusters. Over the cubicle wall discussions of claims and procedures will occur throughout the afternoon as she assists other adjusters with their claims. (WCxKit)

 

Every day the adjuster is interpreting and applying the workers comp statutes, the insurance policy coverage and her employer’s work policies and procedures. The exercising of judgment and initiatives is a routine part of the adjuster’s daily task. The adjuster not only makes many decisions during the day, but also has to communicate effectively those decisions both verbally and in written communications.

 

In the states with complicated state forms to file on every claim, the adjuster will often set aside a specific time each day to be sure the state mandated forms are completed and filed either electronically or by mail as required within her state.

 

By the time the adjuster turns out the office lights at night, she will have had an impact on the lives of several claimants as she has assisted them in obtaining the medical and indemnity benefits they are owed. She will have also had an impact on the insurer as she has provided the benefits the employee is entitled to while protecting the assets of the insurer from being overspent. It’s not easy being a workers comp adjuster but it is often a satisfying and fulfilling job.


Author Rebecca Shafer,
 J.D., Consultant, President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing.  Contact: Info@ReduceYourWorkersComp.com  or 860-553-6604.


WC Round Table LinkedIn:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

WC Calculator:  http://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.


©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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