Working with Your Adjuster Archives

How To Ensure Your Adjuster Is Being All They Can Be

September 25, 2019 by Rebecca Shafer, J.D.

If 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.

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 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/

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Filed Under: TPA and Claims Administration Tagged With: Adjuster Best Practices, Adjuster Performance, Adjuster-Hiring for Work Comp, Meet the Adjuster, workers comp, Workers Compensation, Working with Your Adjuster

How To Make Your Workers Comp Claim Adjusters Dream Come True

June 6, 2012 by Rebecca Shafer, J.D. Leave a Comment

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.

Filed Under: Settling WC Claims, TPA and Claims Administration, WC 101 Tagged With: Adjusters and Claims Handling, Work Comp Information Gathering, workers compensation adjuster, Working with Your Adjuster

Four Biggest Mistakes of Workers Comp Claim Adjusters

June 4, 2012 by Rebecca Shafer, J.D. Leave a Comment

Adjusters are faced daily with the task of making many different decisions on many different types of claims.Every claim is in different stage it is easy to lose track of some of them.

Mistakes can come in a variety of different scenarios, and below we discuss four common oversights that the adjuster can make.[WCx]

1. Wage calculation errors

Many adjusters handle claims in more than one state at a time. Each state has its own way of calculating wage loss (See our State by State guide here for information on your jurisdiction), and some are more intricate than others. Because of this, it is common for an adjuster to make an underpayment or overpayment due to these differing wage calculations.

The most common mistake within this realm is a waiting period calculation error. Almost every state gives the employer and carrier a chance to get the injured worker back to light duty work before having to pay full wage loss benefits. Using Michigan as an example, there is a two-tiered system: the first 7 seven days are the actual waiting period where no wage loss benefits are paid. This gives the employer time to obtain medical restrictions and to find a replacement job. The worker has to accrue this time as being totally out of work.

On the 8^th day the benefits for wage loss begin. If the claimant is still out of work after 14 days, then he also picks up the first 7 days of missed wages.

In Wisconsin there is a 3 day waiting period (See Wisconsin law) and pay benefits start on the 4^th day,. If the claimant is still out of work after 7 days, the first 3 are picked up and paid.

Each state has its own way of calculating wage loss, and it is easy for an adjuster to confuse the waiting period duration. Some states also have other little sidebars, saying that if light duty work is offered and refused, then of course no wage loss will be paid. But how was the job offered to the employee? Was a certified letter mailed and received by the employee? When was it mailed? Did a supervisor just leave a voicemail for the injured worker to come in to work? As you can see, there are a lot of variables within the wage loss genre. The best advice is if there are questions about whether wage loss should be paid, consult local legal counsel.

2. Failing to file State forms timely, resulting in a penalty fine

The filing of state forms is similar to the wage loss waiting period. Some states have a very strict time period which an adjuster must file forms indicating that benefits have or have not been paid. If the adjuster fails to do so, the carrier may receive a nominal fine that must be paid to the State. Some States have no fines at all in this regard.

Even more severe is the failure of the carrier to report a claim to Medicare when the worker is receiving workers compensation medical and wage benefits. At the time of this article, the fine is $1,000/per claimant, per day. Obviously because of the amount and penalty, carriers are very vigilant about making sure to get the required information on the claim to Medicare, but a lot of times this is the duty of the adjuster. The employer is not really affected by this measure, but it is a very important thing to be cognoscente to ensure all parties are aware than an injured worker is a Medicare recipient as well.

3. Failing to follow up with a treating doctor or IME doctor

Since the adjuster has several irons in the fire at once, it is very common to forget to follow up with the doctor. Failure to get the IME report needed can result in an overpayment of workers comp wage loss pay. If the IME was 5/1/12, and the report is not gotten until 6/1/12; the worker can easily be overpaid if the IME terminated benefits due to the worker no longer being injured (since the benefits should not be received at all). Some states require the employer to pay wage loss until the IME report is received, and some only require payment until the actual IME appointment date. Be sure to know what the payment requirements because failure to do so may result in a fine against the carrier and/or bonus wage loss pay to the injured employee.

4. Failure to pay wage loss benefits timely upon completion of the investigation

Most states give the carrier and adjuster time to investigate if a claim will be compensable. If the adjuster needs more time, most states require that a form be filed for an extension to the investigation. Failure for the adjuster to file that form can result in a fine. This is usually payable to the injured worker in the way of extra wage loss benefits to compensate the worker for the time without pay, especially if the claim is deemed compensable. Many states vary wildly in this regard, so consult local counsel on questions regarding investigation timeframes and when the best time is to file for an extension. [WCx]

Summary

These 4 topics discussed above only scratch the surface on potential errors an adjuster can make during the life of a claim. Just because someone is an adjuster does not mean that they are necessarily a great one. Being an adjuster means juggling many things at once, and meeting the employer’s best interests when dealing with the claims of injured workers.

WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com
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.

Filed Under: TPA and Claims Administration Tagged With: Adjuster Performance, Adjusters and Claims Handling, Lost Wages, State forms, Working with Your Adjuster

Not Too Many, Not Too Few, Make Sure Your Adjusters Caseload is Just Right

May 18, 2012 by Rebecca Shafer, J.D. Leave a Comment

The risk manager is perplexed. The workers compensation adjusters on the self-insured program always seem to be behind in the work. Very little is getting accomplished on time. Investigation on new claims took longer than they should, vendors are calling about missed payments, the employer’s workers comp coordinator seems to be doing half of the adjusters’ jobs for them and the cost of the workers comp program keep creeping higher.

A discussion with the claims manager for the third party administrator (TPA) does not provide many answers. The claims manager is reassuring, verifying the 3 dedicated lost time adjusters worked only on the self-insured program and do no work for anyone else. The adjusters know the Best Practices and are striving to meet them, even though they often fall short. The risk manager knows the adjusters are working long hours from the various e-mails and phone messages being sent at night or even on the weekends. (WCxKit)

While the risk manager is reviewing the lost run at the end of the month to see how much the workers compensation cost has increased, he notes the 3 adjusters are handling a combined 513 lost time files, an average of 171 files each. Is that too heavy a caseload? What is a reasonable number of lost time files for each adjuster to handle?

Any discussion of caseloads has to be tempered with consideration of where and what the claims are. An adjuster in California handling construction workers could handle maybe half the claims of an adjuster in Mississippi handling office workers. With that caveat in mind, a TPA caseload of 100-125 is normal without full ancillary support, which is something most adjusters do not have. Most TPAs provide only partial ancillary support, if any.

Best-in-class TPAs provide administrative support for adjusters. This allows them to focus on return to work strategy, communications with employer/employee/medical providers, and making judgments and decisions on the files. Adjuster administrative assistants perform tasks such as paying medical bills, sending requests for medical records, and filing and copying as needed. A lower case loan will be necessary for adjusters without administrative assistance.

In our risk manager example above, depending on the state, a caseload of 171 would be doable if each adjuster had their own personal assistant. The cost of service, however, would be proportionally impacted. State laws, state mandated forms, the level of litigation and the nature/extent of the injuries all impact caseloads.

TPAs have a built-in conflict of interest. The higher the caseload, the more adjusters and support staff the TPA must provide. If the TPA raises the cost per claim to pay for the additional adjusters and support staff, they drive away customers and lower their market share. It is therefore in the interest of the TPA owners to handle as many claims with as few adjusters as possible. When the caseload gets too heavy for the adjuster, mistakes are made, oversights occur, and errors & omissions increase.

Caseloads are a constant balancing act between what is in the best interest of the self-insured employer and what is in the best interest of the TPA owners. When the caseloads get too heavy, the TPA owners profit at the expense of the clients. When the caseloads are full, but not over burdensome, the conflict of interest between the TPA and the clients is kept in check. When the caseloads are too light, which is rare, the TPA loses money, but there is little impact on the clients. When caseloads go up, and all else remains the same, the adjuster’s quality will decline.

Unethical TPAs who intentionally look for clients shopping TPA services by price only, will provide a low price per claim, but then load the adjusters with 200 – 250 files knowing the adjusters will provide mediocre service at best, The clients of these TPAs pay for it with higher indemnity costs and have an overall higher cost of work comp. It is better for the TPA clients to pay more for the TPA services and negotiate into the client instructions and claims handling contract the maximum number of files the designated or dedicated adjusters will be assigned

The employer’s level and nature of involvement in the claims will impact the caseload the adjuster can handle. If the employer is reporting all claims timely, maintaining regular contact with the employee, and providing a transitional duty program, the adjuster can handle a higher caseload. If the employer does not report the claims until a letter of representation arrives from an attorney, the amount of work per claim is increased and the number of claims the adjuster can properly handle decreases proportionally. (WCxKit)

To evaluate whether or not your TPA has assigned too many claims to the adjusters is often a difficult task as the TPA will be reluctant to admit the adjusters have too many files. You can obtain a general idea as to whether the caseload is too high by reviewing the nature and type of claims, as well as the requirements of your states work comp act. To know more precisely what the caseload should be, hire an outside, independent claims auditor to complete a Best Practices Audit of the TPA files. The outside expert can assist you in identifying the issues impacting the claims quality and identifying the appropriate caseload for each adjuster handling your claims.

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. 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.

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.

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Filed Under: TPA and Claims Administration Tagged With: Third Party Administrators (TPA), Working with Your Adjuster

Seven Basic Guidelines for Talking to Your Adjuster

February 13, 2012 by Rebecca Shafer, J.D. Leave a Comment

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.

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).

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.

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.

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.

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.

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]

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?”

WORKERS COMP MANAGEMENT GUIDEBOOK: www.WCManual.com

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

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.

Filed Under: Claim Management, TPA and Claims Administration Tagged With: Communication with your TPA/Carrier, Working with Your Adjuster

7 Things Workers Compensation Adjusters Do All Day

December 22, 2011 by Rebecca Shafer, J.D. 2 Comments

Do you ever wonder what your workers compensation adjuster does all day? If you see the adjuster living easy, you may be surprised. The adjuster’s day is full of activities, requiring the adjuster to prioritize which actions are needed the most. Some of the daily routine you would see from the adjusters would include the following activities.

So, what will you see during your visit to the claims office?

1-The phone rings constantly

The typical workers comp adjuster has 100 to 125 indemnity files, depending on the jurisdiction and the experience level of the adjuster. Each of those 100 to 125 files has a claimant, one or more medical providers, and an employer. That alone makes for 300 to 375 plus potential parties that will want to speak with the adjuster. On top of that you have plaintiff attorneys, defense attorneys, triage nurses, nurse case managers, surveillance companies and state work comp boards that may call the adjuster. On a slow day the adjuster may only spend half of her time on the telephone. (WCxKit)

2-The e-mails come in fast

In this day where everyone expects instant service, the use of e-mail to convey messages and documents has surpassed paper mail. With attorneys, employers, employees and nurse case managers sending information by e-mail, it is normal for the adjuster to get 50 to 100 e-mails per day. While many of them can be copied right into the claim file, a significant portion of them require a response or other action by the adjuster.

3-The paper mail is voluminous

While the amount of paper mail has declined over the years, a two inch or five inch stack of new mail to be reviewed each day by the adjuster is still the norm. The mail has to be evaluated and the appropriate response taken on each piece of mail. Sometimes the response is only to send it to be scanned into the electronic file, but often a written reply or a phone call is needed.

Included in the paper mail are the faxes that come in each day. While most attorneys and employers are transmitting documents via e-mail, most medical providers are still using paper forms, paper bills and paper reports. These items are often easier for the medical offices to transmit by fax than by e-mail, so receiving numerous faxes each day add to the paper mail stack.

4-The consultations are frequent

A major portion of those telephone calls mentioned above are for the purpose of making decisions on what to do. The adjuster will often gather information by consulting with others. The adjuster will discuss the claim with the nurse case manager, the defense attorney, the employer, and other sources to make a judgment on the best course of action on a particular claim.

When the adjuster is not on the phone discussing a claim or reading the e-mails or reading the paper mail including faxes, the adjuster will often enter into consultations within the claims office. The adjuster will confer either with her supervisor or fellow adjusters on various aspects of a particular claim to gain insight or opinions of other claim professionals that have dealt with a particular situation or set of facts.

5-The decisions are major

The primary reason the adjuster enters into the consultations noted above is because the decisions the adjuster makes can have an impact on the life of the injured employee and all of the decisions have a financial impact on the employer. If the adjuster makes the wrong decision, either the employee or the employer or both will be hurt financially.

6-The appreciation is missing

While you are sitting there observing what the adjuster does all day, you will notice that the adjuster’s job often benefits both the employee and the employer. But it is the rare employer or even the rarer injured employee who expresses any appreciation for the work the adjuster does on the work comp claims. The most the adjuster hopes for is the claims supervisor will say “good job” when the claim is concluded. (WCxKit)

7-The adjusters best practices

While the adjuster is in constant modes of communication as noted above, the adjuster has a set of job requirements that have to be met.

Making contact with the employee, the employer and the medical provider on every new claim
Responding to all the communications noted above in a timely manner
Setting and maintaining accurate reserves on all of the assigned files
Making sure all indemnity payments are made timely
Making sure all medical bills are paid
Keeping in touch with the employees, the employers and the medical providers on a regular basis
7. Submitting the appropriate forms to the state work comp boards/industrial commissions
Identifying fraudulent claims
Pursuing subrogation when a third party is the cause of the employee’s injury
Attending mediations, either in person or by phone
Evaluating settlement opportunities and decisions

If you sit chair side by the adjuster, do not count on the adjuster having any time for chit chat, so just observe. They will have planned for your visit, and will have time to show you through your files. As you can see from the above the adjuster’s job fills the entire day, and then some. If you do sit and observe what the adjuster does all day, you will probably leave amazed at the dedication and hard work of the work comp adjusters.

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.

WORKERS COMP MANAGEMENT GUIDEBOOK: 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.

Filed Under: Claim Management, TPA and Claims Administration Tagged With: Adjuster Qualifications & Responsibilities, Working with Your Adjuster

8 Ways to Grade Your Workers Compensation Claim Adjuster

June 16, 2011 by Rebecca Shafer, J.D. Leave a Comment

Often it is assumed the designated adjuster(s) working on your workers compensation files is a good adjuster. But, you know what “they” say about “assuming.” Use these eight tips to judge your adjuster(s) overall ability and effectiveness.

1. Timely Contact with All Parties

Track how often the adjuster makes timely contacts. If your Best Practices say claimants, medical providers, and the employee's supervisor must be contacted within 24 hours of the first report of an accident, expect your adjuster to be making timely contacts with all parties at least 90% of the time. The higher the percentage, the better. Timely initial contacts go a long ways toward establishing the future tone of your claims and establish the adjuster as the person in charge. (WCxKit)

2. The Accuracy of Reserves

When you look at your loss run and compare what the claim settled for against the claim reserves you gain insight into the ability of the adjuster to evaluate the claim. If you see a lot of reserve changes right before the claim settles, then the adjuster is either inexperienced at evaluating the claim or is indifferent to the impact reserves have on your company. If you see the reserves on the claim were established since the adjuster obtained key medical information on the injured employee, you know the adjuster is looking out for your financial interests.

3. Responsiveness

Does the adjuster always answer the phone when you call, or do you often have to leave messages and wait a few days to hear back? When you send e-mails, do you get a prompt response, or do you forget what the subject of the e-mail was by the time the adjuster responds? A good adjuster tries to keep you informed about your claims and takes the time to respond to your questions and needs. The quicker the response from the adjuster, the better the adjuster.

4. Payments Timely

If your employee complains the TTD or TPD check did not arrive on time, then the adjuster is not organized (or may have too many claims to handle properly). You should expect never to hear from an employee about the indemnity check not arriving. If your employees are receiving dunning notices from their doctors on medical bills, then the adjuster is not processing the bills timely. While any adjuster may occasionally have a medical bill or other missed expense, you or your employees should not be constantly getting reminders on medical bills.

5. The Number of Employees Lost to Attorneys

The good adjuster stays in contact with employees out on workers comp. The great adjuster builds rapport with the employees and the employees make an effort to keep their adjuster informed as to their medical progress and their ability to return to work. The poor adjuster has a higher percentage of employees represented by an attorney then the good adjuster. As the percentage of employees represented by attorneys is impacted by the legal climate in your locale, you must consider the results of your adjuster compared to other adjusters in the same locale.

6. Knowledge of Workers Compensation

When you have a question about workers comp in general, the good adjuster can answer it for you, (or at least get you the answer). If the adjuster does not know the answer, or tells you it would be better for you to talk to a workers comp attorney or the adjuster's supervisor, the adjuster's workers comp knowledge is weaker than it should be. The good adjuster knows all the ins and outs of state statutes and is willing to share that information with the employer.

7. Claim Quality Audit Scores

Often claim offices do not want to talk about their claim quality audit scores. This often arises out of a concern that the employer may not understand that the 100% perfect claim file seldom happens. However, the good workers comp adjuster scores in the 90+ percentile. Ask the adjuster for a copy of the most recent audit score. The good adjuster is glad to share it with you. The weak adjuster probably has reasons why it cannot be shared.

8. Closed Files Reopened

Every adjuster knows the best file is the closed file. However, it is seldom a good idea to close a file prematurely. The good adjuster makes sure all aspects of the claim are resolved, all medical bill paid, all indemnity checks issued, and all expenses paid before closing the file. If you see more than a few reopened files on the loss run report, than the adjuster is closing claims prematurely. (WCxKit)

None of these 8 criteria alone indicate a good or poor adjuster. When the adjuster is strong in all 8 areas, you have a great adjuster working your claims. If the adjuster is weak in most of these areas, it is time to consider requesting another adjuster to handle your workers comp claims. Having a strong adjuster on your claim files makes your life easier and saves money. A few select TPA's DO actually "grade" their adjusters, giving monthly bonuses to those that excel, and get high grades – nearing 100.

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 or 860-553-6604.

Our WC Manual: http://corner.advisen.com/partners_wctoolkit_book.html

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

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

WC GROUP: http://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.

Filed Under: Broker Issues & Relationships, TPA and Claims Administration, WC 101 Tagged With: Adjuster Qualifications & Responsibilities, Choosing an Adjuster, Working with Your Adjuster

Pick the Right Adjuster to Negotiate and Settle Your Claims

January 31, 2011 by Rebecca Shafer, J.D. Leave a Comment

Often the Risk Manager or the employer's workers compensation claims coordinator who is actively involved in their work comp claims will wonder: “Why in the world did the adjuster pay that much money to settle that claim?” There could be several reasons why the claim settlement is higher or even much higher than was expected, but the reason in many cases is the adjuster is not a good negotiator.

Some adjusters are excellent negotiators, but many adjusters would rather go to the dentist then aggressively negotiate claim settlements. The reasons some adjusters are not good at negotiating settlement vary. Some adjusters see negotiations as being confrontational and it does not fit in with their personality. Some adjusters are not motivated and would rather let the defense attorney or someone else handle that part of the claim. While personality and laziness are the reasons some adjusters do not negotiate good settlements, the primary reason the majority of adjusters overpay claims when the negotiate a settlement is they do not know how to negotiate. (WCxKit)

A major state university offering an undergraduate program in risk management, a graduate program in risk management and a PhD program in risk management does not offer a single course in settlement negotiations. This holds true for most insurance training.

The insurance companies and schools that train adjuster trainees spend all their time teaching the insurance policy provisions and the necessary information to pass the state's adjuster licensing exam. Insurance companies will often spend weeks training a new adjuster on intricate part of the insurance coverage, but not spend one minute teaching the adjuster how to spend their money.

With this in mind, what should the employer do? The employer should review who the adjusters are that handle the claims for your company. Hopefully, you have previously arranged for your claims to be handled by either a designated adjuster who handles all of your claims or a group of adjusters assigned to your account who handle all of your claims. (If your claims are being assigned willy-nilly to many different adjusters, that is half of your high claim settlements problem right there).

When you have your claims assigned to the minimum number of adjusters, you can use your data management system to sort the claim settlements by adjuster. This will assist you in identifying which adjusters who routinely get good claim settlements and which adjusters routinely seem to pay the most on the work comp claims they handle. If you have an adjuster or adjusters who are routinely overpaying claims, ask the insurer or the third party administrator to reassign your claims to the adjusters who routinely get good settlements. If the adjuster(s) who get the best settlements have a full caseload (and they usually do), that may not be possible. If you cannot get the claims reassigned to the adjuster with the best settlements, at least get your claims reassigned to another adjuster(s).

There are some other approaches to getting better claim settlements you can consider. If the claim is large enough to warrant your time, and you are self-insured, you can instruct the claims administrator for the adjuster to refer the settlement negotiations to yourself. You might find settlement negotiations more difficult than you expect, but you may also find that the half million dollar claim the adjuster was talking about is really only a quarter million dollar claim.

Some large self-insurers who have given up on their adjusters getting a good claim settlement routinely refer all their larger claims to their legal defense firm(s) to negotiate the settlement. As the defense lawyers are working directly for them, and have a lot more practice resolving confrontational situations, they often obtain a much better settlement than the claims adjuster would have. (They are also much more suave in their explanation as to why the claim cannot be settled as the risk manager thought.)

Another approach some large self-insurers have taken on their large claims is to have a structured settlement broker negotiate the settlement. This works if the structured settlement broker has some legal experience and can deal with the vast array of work comp legal system intricacies. (WcxKitz)

In still other companies, the risk manager negotiates the claims to settlement. He gets authority from the carrier then goes to the hearing to settle the claims personally.

While we cannot tell you what the exact, best approach is for controlling the cost of your claim settlements, we do recommend that you spend some time analyzing the situation. Once you have identified the adjusters who routinely overpay your claims, you can take the necessary steps to change the situation.

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 or 860-553-6604.

WC IQ TEST: http://www.workerscompkit.com/intro/

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

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

WC GROUP: http://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.

Filed Under: Settling WC Claims, TPA and Claims Administration Tagged With: Claims Resolution and Settlement, Negotiating, Working with Your Adjuster

10 Things Your Workers Comp Adjuster Will Not Tell You

December 13, 2010 by Rebecca Shafer, J.D. Leave a Comment

1. Your lack of a safety program is job security for me.

My boss is very much like your boss. If there is not enough work for all of the adjusters, someone is going to get laid off. Fortunately for me (but unfortunately for your employees), you either do not have a safety program or you do not enforce it. Either way, I am guaranteed a lot of extra claims being assigned to our office and I will get my share of them. I know better than to criticize some of the dumb things employers do like not requiring hard hats on construction sites or removing safety guards from machinery. While I may think some of the employers we insure are morons for allowing accidents to happen, I will keep my mouth shut and enjoy the job security.

2. Burnout is a real problem.

This is really a stressful job. Not only am I under numerous time deadlines (the Best Practices guidelines we have impose time limits on almost every step of the claim), the phone is constantly ringing and often I cannot see over the stack of mail on my desk. I have to deal daily with people who are unhappy, whether it is the employer questioning a valid claim, an employee who wants to find a doctor with a better “bedside manner,” or the employee's attorney threatening to file a motion for sanctions because the clerical department sent out an indemnity check a day late. When you have never-ending pressure from many different sources, the stress becomes a motivational killer. We have some real zombie adjusters due to job burnout. (WCxKit)

3. We have a revolving door.
While we have some career claims people in our office, the turnover rate is often 25% to 35% a year in some of the claim offices. There are several reasons adjusters are coming and going constantly. The pay is relatively low for the demands of the job. The claims office often hires adjuster trainees fresh out of college who after a few months or even a couple of years, realize this is not the right field for them. If I can make 10% more money somewhere else, I'm gone. If the office is understaffed (and most are), I have more files than I can handle. If my spouse gets a better job and wants to move to a new city, I'm happy to leave.

4. I never tell you my mistakes.
My loyalties are to my employer, not to the employers we insure. If I do an overall lousy job on your claims, I won't tell you. Unless something really blows up bad, my boss won't tell you either when I goof up. If I fail to contact the employee after the accident, and the employee gets an attorney (which will eventually run up the overall cost of the claim), I won't tell you it is my fault. If I fail to investigate the claim and find out it is a fraudulent claim, while the employee will feel he got away with one, you as the employer will just have an uneasy feeling that something is not right, but we paid the claim anyway. (And yes, your premium will go up because I did not do my job).

5. I am overloaded.
If I work in a state that has few requirements for state form completion, if I am good at what I do, I can handle up to 150 work comp claims at a time. If I move to a state that has a different state mandated form to be completed for everything I do, 125 claims at anyone time is a heavy load. My boss in an effort to keep the cost of doing business down, will let my claim inventory drift up 175 or even 200 claims. There is no way I can properly handle that many claims, but I usually have no say in how many claims get dumped on my desk to handle. It is no wonder we have a revolving door and a lot of burned out adjusters.

6. What supervision?
My supervisor is really a nice person. When I work late, which is often as I am overloaded, the light is still on in my supervisor's office. Ideally, depending on the experience level of the adjusters assigned to my supervisor, she would have four to six adjusters reporting to her. Like me, she is overloaded and often has eight to ten adjusters' work product that she is responsible for, in addition to all her other office responsibilities. Instead of her reviewing my work, she has been assigned an inventory of claims to handle in addition to the supervisory duties. In an ideal world, she would check each of my claims every month, but in reality the norm is she will see my file the first month it is open and again when I am ready to settle the claim.

7. Don't ask me for recommendations.
If you ask me for the name of a defense attorney, I will tell you the name of the defense attorney who takes over a claim from me and quietly does the investigation I failed to do. Or, I will tell you the name of the attorney who happens to be my golfing buddy (but I won't mention that fact), or I will tell you the name of the attorney who throws the best Christmas party. If you ask for the name of a nurse case manager, and we don't have our own, I will give you the name of the nurse case manager who showers the office with post-it notes, ink pens and calendars. If you ask for the name of a surveillance company, I will be glad to share the information on one that I know (as we often go out for drinks after work, but I won't mention that fact).

8. Communication is a two way street.
Yes, our Best Practice guidelines require me to call you within 24 hours of the time the claim is reported to my office, and yes I am required to stay in touch with you throughout the course of the claim (but I seldom do). It is easier for me to forget about keeping the employer in the loop. If you are unconcerned about the employee or about the status of the claim, and never call me, it is easy for me to drop you from the information loop. If you don't make any effort to get the employee back to work on modified duty – it's your money – I will put the disability checks on automatic pilot and they will keep going out until you call me to tell me the employee is back to work (which you may forget to do as we have not been communicating throughout the course of the claim).

9. You make my life miserable.
Between your lack of a safety program and your lack of a return to work program, you create a lot of unnecessary work for me. When you fail to report the claim timely, you alienate the employee and whether or not the employee gets an attorney, your failure to report the claim on time creates a lot of extra phone calls, and makes the claim cost more to resolve. When you have no drug testing policy, no fraud prevention policy, no medical management program and no organized approach to handling claims, I bear the brunt of your mistakes. (WcxKit)

10. I'm happy to let someone else do it.
Since I am overloaded with work to do, I have no qualms about letting the nurse case manager do all the contacts with all the medical providers. I have no qualms about letting the defense attorney do the investigation I never had time to get around to doing. When my mistakes and goof ups do come to light, I have no qualms about letting the broker deal with your irritation. It is not because I do not want to do a good job, I'm just have too much to deal with – see all of the above things I won't tell you.

This is a tongue in cheek parody; please take it with a grain of salt.

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. www.LowerWC.com Contact: RShafer@ReduceYourWorkersComp.com

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

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

Filed Under: Risk Management, TPA and Claims Administration, WC 101 Tagged With: Working with Your Adjuster

How to Talk to Your Workers Comp Claims Adjuster

July 19, 2010 by Robert Elliott, J.D. Leave a Comment

Are you nervous talking to your workers compensation adjuster? Don't be. The adjuster works for the insurer (whether the adjuster is a staff adjuster working directly for the insurer, or the adjuster works for a third party administrator (TPA) who is handling the workers comp claims for the insurer) and the insurer wants you to be happy with the claim service. The adjuster knows that ultimately your happiness with the quality of the his/her claim handling is key to the continuation of your company's insurance with the insurer.

While the smart adjuster wants you to be happy with the work product, the adjuster also realizes he/she is the claims professional and it is the adjuster's responsibility to direct and control the claim. WCxKit. The sharp adjuster welcomes your input and the information you provide while continuing to manage the claim.

To create a strong working relationship with the dedicated adjuster (an adjuster whose entire workers comp claim inventory is for your company) or the designated adjuster (an adjuster who handles all of your company's workers comp claims plus claims for other employers), please keep in mind some basic guidelines.

Establish Rapport

Whether you are working with a dedicated adjuster or a designated adjuster, having rapport with the adjuster goes a long ways toward having a good working relationship. Rapport is more than asking about the weather at the start of your conversation. It is knowing your adjuster and something about him/her other than work, whether WCxKit it is asking about vacation or the his/her child's school program. By showing an interest in the adjuster as a person, you build a bond designed to make difficult issues easier to discuss.

Be Focused

After a minute or two of establishing rapport with the adjuster, be ready to address the claim you are calling about. Prior to calling the adjuster, review your file notes on the claim in question. It will be helpful to you to jot down the questions you want to ask the adjuster about the claim and the reasons for asking. Knowing your reason for asking each question allows the adjuster to provide a focused answer. Without an explanation, the adjuster will draw his/her own conclusions and may unknowingly give you an answer not fully covering what you need to know.

Be Respectful

It is always wise to remember the workers comp adjuster is the claims professional. The adjuster should be current in the handling of the claim and handling the claim in accordance to the Best Practices that are included in your service contract with the insurer or TPA. If for some reason the adjuster has not handled the claim correctly (in your opinion), don't berate the adjuster or question the adjuster's competence WCxKit. (if you want any more work done on your claims). You need to learn why the adjuster has not acted and to get the adjuster back on track. The easiest way to do this is to ask questions.

Ask Open Ended Questions

The best way to ask questions is to ask open-ended questions allowing the adjuster to explain what was done, what was not done and what is planned for the future. If you ask only yes or no questions, you get yes or no answers, making the adjuster feel like your questions are an interrogation.

For instance, it is much better to ask: “I don't understand how this accident happened, how did [insert employee name] describe what happened?” rather than to say “You failed to take the employee's recorded statement?” The first approach gives the adjuster the opportunity to say “I have tried several times to reach the employee, but he has not returned any of my phone calls.” The second approach, however, puts the adjuster on the defensive and reduces the desire of the adjuster to do a good job for you.

By asking open-ended questions, you give the adjuster the opportunity to explain the status of the claim and the course of action the adjuster plans to take. If for some reason the adjuster is not volunteering the information you need, explain why you are asking followed by an open-ended question. For example “Nobody saw this accident happen, what can we do to be sure it is compensable?”

Have a Positive Attitude

Always remember the adjuster is working for you and wants to do a good job. Be positive in your approach with the adjuster in both your words and tone of voice. When the adjuster has met your expectations, praise “it sounds like you are doing a good job” and appreciation “thanks for your efforts on this claim” It will motivate the adjuster to continue to strive to do a good job for you and your company.

Be Willing to Listen

Sometimes the efforts of the adjuster just come up short. As you ask about any “failure,” giving your reasons and asking your open-ended questions, listen carefully to what the adjuster says. Often the adjuster has a valid reason activities have not been accomplished or the claim is not going the way you wish. By carefully listening to the adjuster, you will often be able to identify problems and suggest solutions to assist the adjuster in producing a better quality claim product.

Cooperate and Plan

After you have discussed all the questions you have about a workers comp claim, and have a complete understanding of where the claims currently stands, plan your further activity on the claim. Ask the open-ended questions “So I will know when 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?”

Summary

Talking to your workers comp adjuster should be a pleasant experience providing you with the claim information you need for your company. This can be easily accomplished by establishing rapport with the adjuster, keeping focused on the claim you are inquiring about and remembering the adjuster is the claims professional. The easy way to obtain information is to state why you are asking a question and then asking an open-ended question allowing the adjuster to explain the claim to you. Always keep a positive attitude with the adjuster and listen carefully to what the adjuster is saying about the claim. This will allow you to work with the adjuster to bring the claim to a conclusion.

Author Rebecca Shafer, Consultant / Attorney, 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.

FREE IQ Test: http://www.workerscompkit.com/intro/
WC Books: http://www.LowerWC.com/workers-comp-books-manuals.php
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.

Filed Under: TPA and Claims Administration Tagged With: Working with Your Adjuster

How To Ensure Your Adjuster Is Being All They Can Be

How To Make Your Workers Comp Claim Adjusters Dream Come True

Four Biggest Mistakes of Workers Comp Claim Adjusters

Not Too Many, Not Too Few, Make Sure Your Adjusters Caseload is Just Right

Seven Basic Guidelines for Talking to Your Adjuster

7 Things Workers Compensation Adjusters Do All Day

8 Ways to Grade Your Workers Compensation Claim Adjuster

Pick the Right Adjuster to Negotiate and Settle Your Claims

10 Things Your Workers Comp Adjuster Will Not Tell You

How to Talk to Your Workers Comp Claims Adjuster

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