Simple Concepts for a Complex System: Employers can Improve their Claims Outcomes by Partnering with the Claims Adjuster

20 Sep, 2022 Bill Zachry

                               

Employers have a direct positive impact on their claims results if they partner with the claims examiners. 

When employers treat the claims examiner as a professional partner, claims results are always better. When employers work well with the claims examiners the examiners are happier and more productive. Employer actions also have a direct impact on examiner retention. In an industry full of negativity, acknowledgements and thank you notes to examiners and positive comments to supervisors from employers are worth their weight in gold. 

Employers’ failure to create a safe working environment, failure to promptly report all claims, failure to provide a complete record of the injury and accurate injured worker information and failure to obtain prompt quality medical care all slow claim progression and increase the claims costs. Employer’s attitude and actions can also significantly increase the workload for the examiners. Employer’s broker representatives who are expected to intervene or manage all workers compensation activity on behalf of the employer may also slow or obfuscate the communication process between the employer, the claims examiner, the treating physician, and the injured workers. * 

Actions that increase the claims examiners workload, create administrative delays, impair prompt closure, and increase claims costs: 

  • Employer hires an employee who is unqualified for the job, or retains a non-performing employee, and expects the clam’s examiner to help get rid of that employee through the workers compensation process.
  • Employer does not create and follow an IIPP program to prevent injuries.
  • Employer does not provide the worker with the proper PPE equipment; or professionally train the worker how to use the equipment.
  • Employer that has a very poor relationships with their workers. This directly increase litigation rates.
  • Employer fails to create a culture where all claims are immediately reported. The delays are usually worse when the employer engages a broker as an intermediary to report claims.
  • Employer does not use the appropriate designated medical facility (Nationally, in some jurisdictions employers do not have medical control).
  • Employer drops off an injured worker at an emergency room and tells the employee to not report the injury as industrial.
  • Employer fails to provide (or delays in providing) the necessary information needed to accurately determine compensability or calculate the correct benefit rates.
  • Employer delays the investigation process by not allowing the examiner to talk to the front-line supervisor or to any witnesses.
  • Employer provides an inaccurate job description with the physical requirements of the job to the treating physician, physical therapist, nurse case manager, or claim’s examiner.
  • Employer fails to provide light and/or modified or transitional return-to-work duties.
  • The front-line supervisor or manager fails to maintain contact with their injured worker who is off on disability.
  • Employer fails to provide notice to the examiner of potential fraud red flags.
  • Employer, believing all claims are fraudulent treats the injured worker and examiner as if they are perpetuating or supporting fraud.
  • Employer does not provide adequate or timely settlement authority.
  • Employer (or their broker) focuses only on reserves when doing a file review rather than focusing on employee recovery, return to work, and claims closure.
  • Employers who never acknowledge a job well done.
  • Employers that make inappropriate personnel comments about the people who are involved with the claim (injured worker, doctor, examiner, investigator, translator, broker) such as politics, disability, race, religion, or sex.
  • Employers who lie about the job classification of the injured worker.
  • Employer does not attend a trial or deposition as a witness when there is a legitimate dispute. 

This list can also generate a checklist for positive actions. 

It is the job of claims leadership to facilitate a positive relationship between the employer and the claims examiner. Occasionally personalities just do not get along. Claims supervisors and managers should be aware of the personalities involved and make sure that if the relationship is toxic that appropriate changes are implemented. This is not a negative reflection on the examiner or the employer, but merely an acknowledgement that some personalities do not always work well together. 

Employers who support and encourage their examiners always get better results and have lower workers compensation costs. As in all relationships, there is great merit and value of a kind word. Employers should be aware of their role and responsibilities.

*This assumes the employer has a sufficient claim volume to create a direct relationship with the claim examiner. Smaller insured employers do not have enough claims to create an ongoing interaction with the clam examiner. In this circumstance, the relationship between the employer and the claims adjuster must develop as the claim progresses. Even with limited pre-injury interaction, employers can still directly impact outcomes through focused and timely communication.


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    About The Author

    • Bill Zachry

      William M "Bill" Zachry is a Board member of the California State Compensation Insurance Fund, Appointed by Governors Arnold Schwarzenegger and Jerry Brown. He served 3 years as a Senior Fellow at the Sedgwick Institute. His term ended in January 2020. Zachry was awarded the Summa CompLaude award in November of 2020, the RIMS Risk Manager of the Year 2014, the CCWC Workers Compensation Professional of the Year 2016, Co-Chair AMICUS Committee California Chamber of Commerce. He is the former GVP Risk management Safeway /Albertson's Former Board Member California Self Insurers' Security Fund, former Co-Chair California Chamber of Commerce AMICUS committee Chair California Fraud Assessment Commission Zenith Insurance Company VP Claims HIH (C.E.Heath) (Care America) S.V.P. Claims. References

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