Every adjuster has an individual style when it comes to handling claims. Like snowflakes no two adjusters are exactly the same. Yes ? they may be similar in deciding if a claim is compensable or not, but it is how they arrive at that result that varies. It is safe to say claims supervisors must monitor each adjuster differently. Here are seven?areas supervisors wish their adjusters would improve upon.
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1. Document The Files
When it comes to documentation in the file, everyone is different. You want the notes to be succinct, but also tell the story without droning on and on. Adjusters are very busy handling several different issues at once, and at times, some information is overlooked. What a supervisor may think is important to document in the file notes the adjuster may not, and some facts can be overlooked. That does not mean the adjuster is not aware of these facts, it just means they are not in the actual file notes. open-ended it is all about documentation when it comes to handling files since you do not know who at the executive level is looking in the file. A happy medium needs to be reached when deciding what HAS to be in the file, versus what can be skipped. (open-ended)
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2. Research?Medical Diagnoses
No matter how many years experience an adjuster has, the brutal truth is the adjuster is not a medical doctor. Diagnoses are becoming more and more complicated, with several types of degenerative conditions complicating acute injuries. The job of the adjuster is to separate what is pre-existing from what is acute and possibly work-related. Sometimes when adjusters see the word ?degenerative? or ?arthritis? they automatically lean towards denial of the claim.
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However, in the world of workers comp a common issue is
exacerbation of pre-existing conditions, seen constantly in back strains. Someone may have a pre-existing disc herniation. That does not mean when attempting to lift that box the back was not strained a little leading to a temporary exacerbation of the pre-existing condition. Adjusters can be quick to wrongfully deny a claim, and in the end it comes?back to haunt them in litigation.
Adjusters need to know the type and duration of treatment needed before they can correctly deny ongoing treatment or set up an IME to terminate ongoing benefits. Using medical guidelines can help.?Consulting with a board-certified MD is even better. Consider subcontracting with a Physician?Review Service so your adjusters?have the services of MDs to review?claims; these services can be purchased on an outsourced basis.?Include?Senior Nurse Reviewers in the process.?Let your clients know about these services.
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3.?Communicate with Insureds
With caseloads increasing for the average adjuster, it is hard to find the time to sit down and explain to the employer about a medical condition, or discuss why a claim was denied, or pick up the phone and update the employer on open files. Adjusters need to remember the employer is their client, and proper customer service is what can separate their insurance company from their competition. Giving adequate time to every employer, leads to a great relationship between all parties and, in turn, makes dealing with future issues much easier.
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4.?Communicate With Claimants
Many adjusters forget the average claimant knows little about the way the claims process works. Without proper communication, the claimant has no idea what is going on, why the claim was denied, why they cannot see their own doctor, or why it is taking so long to receive a check if the claim is deemed compensable. This can lead to litigation, and even worse bad faith claims made against the carrier, which can become a severe issue for the insurance company and the client employer.
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If an injured worker comes back to work and complains about the way the claim was handled to the supervisor, you can bet that will result in a phone call to the claims manager, which in turn can lead to discipline for the adjuster. It should be mandatory (but it's not) on every claim that the adjuster takes the time to explain to the claimant what their rights are, what the insurance company?s rights are, and be able to address any questions or issues a claimant has in regards to their claim at anytime.
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5. Balance Aggressiveness
This varies by adjuster. Some are overly aggressive, whereas some are a bit more liberal in the way they interpret the claims statutes. This can be both good and bad, since if a claim is denied due to over-aggressiveness it can lead to wrongful litigation and possibly penalties against the carrier for bad faith claims. In turn, some claims are accepted when they should be denied. Obviously, that is a serious issue as well and the financial leakage ensuing on a wrongfully accepted claim can be disastrous for the carrier, including embarrassment and possible discipline for the adjuster handling the claim as well as ramifications for the manager of that adjuster.
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6. Background Checks &?Investigation
An adjuster has several tools to do background checks on claimants, including the ISO database, the SIU (special investigatin unit)?department background research, outside vendor surveillance, and court research. There are a lot of repeat offenders out there who make a living going from employer to employer, settlement to settlement.? Due care needs to be taken on the part of the adjuster to put the time in on claims where background checks are needed, since the results can lead to a denial of the case.
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7. Vendor Use
When vendor marketers come in to an insurance carrier?s office, they are typically very personable and offer a variety of services to make the adjuster?s life easier. Sometimes, adjusters use a certain vendor because they like that company or are personal friends with the marketer. Even though that particular vendor is ineffective or overly expensive, the adjuster continues to send them business for the sake of the personal relationship. Do not tolerate this scenario and include manager involvement to be sure vendor use is appropriate, effective, and performed at the time the services are needed. (WCxKit)
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Summary
Every adjuster is different. The manager?s role is to make sure the claims are being handled ethically and properly within the practices set by the carrier. Typical adjusters wear several hats during the course of a day in their job, and each one deserves proper attention and care. If adjusters fail at any of their tasks, it makes everyone look bad and costly penalties can be assessed when someone fails to take appropriate care of the situation at hand.
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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. ?
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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?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. This entry was posted on Sunday, May 22nd, 2011 at 6:00 pm and is filed under Claim Management, TPA and Claims Administration, WC 101. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.
Source: http://blog.reduceyourworkerscomp.com/2011/05/7-things-claim-office-supervisors-wish-adjusters-did-better/
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