How To Make Your Workers Comp Claim Adjusters Dream Come True

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

 

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

2.  The contact responds timely

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

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

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



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

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

5. The employer is involved just enough to be helpful

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

 

 

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

 

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

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

VIEW SAMPLES PAGES

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

 

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

 

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

22 Things Your Workers Compensation Adjuster Should Not Do

Self-insured employers often get into trouble for not being knowledgeable of the requirements of the Unfair Claims Practice Act in the state(s) where it is being self-administered for workers compensation claims. The failure to act in a totally ethical manner can lead to litigation by the party wronged and to fines and/or the suspension of the self-insured’s authorization to be self-insured by the State.

 

 

The workers compensation adjuster, who is often dealing with attorneys out to maximize the cost of the workers comp claim, or with employee claimants who are attempting to commit fraud, may be tempted to fight fire with fire. The adjuster should always handle the claim in a totally ethical manner.  If an adjuster is doing any of the following, stop everything and discuss the adjuster’s actions with the adjuster. [WCx]

 

 

Unfair claim practices by the adjuster include:

  1. Knowingly misrepresenting the benefits available under the state’s workers compensation law
  2. Failing to contact the injured employee (hoping the employee will not pursue the claim)
  3. Failing to investigate the claim properly
  4. Denying compensability without a valid reason
  5. Failing to file all necessary state forms
  6. Recording the employee’s statement when the employee is under the influence of medications or distracted by pain
  7. Failing to provide a copy of a recorded statement or written statement when one is requested
  8. Recording telephone calls without the other party’s knowledge of the call being recorded
  9. Knowingly documenting the file notes with inaccurate information
  10. Intentionally not returning phone calls of the employee or medical provider in an effort to discourage the claim
  11. Failing to pay indemnity benefits timely trying to coerce the employee in to returning to work prematurely
  12. Failing to authorize needed diagnostic testing without reason to not authorize
  13. Failing to pay for permanent partial disability
  14. Paying less than the workers comp statute calls for when settling a permanent partial disability
  15. Offering to settle and close out future benefits for an amount significantly less than what the adjuster knows to be fair
  16. Advising the employee not to hire an attorney
  17. Threatening to reduce the settlement of the claim if the employee hires an attorney
  18. Discussing any aspect of the claim with an employee known to be represented by an attorney
  19. Settling the claim before the extent of disability is known
  20. Overstating the damages and exposures so that the adjuster’s supervisor will extend excessive settlement authority, allowing the adjuster to make a quick (but overpaid) settlement
  21. Providing the employee’s personal information to parties who do not have a legitimate need to know
  22. Having a financial interest in any vendor utilized on the claim

 

Mistakes, oversights, and poor claim handling are not unfair claims practices. The workers compensation adjuster often has more work to do than it is possible to get done. With the telephone ringing constantly, the e-mail flooding in, having numerous deadlines for filing forms, numerous deadlines to prepare for mediations or conferences, and numerous other items that need to be completed, it is normal for some things to fall through the cracks. When the adjuster does not contact the injured employee timely, or does not respond to a settlement demand from the employee’s attorney, it is normally because the adjuster has more to do than is possible to get done. It only becomes an unfair claims practice when the adjuster intentionally decides not to take a needed action in an effort to impact the overall outcome of the claim. [WCx]

 

 

Almost all adjusters are honest and have the best interest of both the employee and the employer at heart. If you do notice any of the above 22 issues occurring, stop and discuss the issue with the adjuster. Often there is an ethical and valid reason for the adjuster’s action which will become apparent when you learn more about the reason for the adjuster‘s actions. Only when the adjuster sets out to act dishonestly should you be greatly concerned.

 

 

 

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

 


WORKERS COMP MANAGEMENT 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.

 

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