Simple Concepts for a Complex System: Employers Can Make the Claims Adjuster's Job Easier

14 Mar, 2022 Bill Zachry

                               

Employers have an underappreciated direct impact on the workload of the 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 claims examiners are happier and more productive.  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’ actions can significantly increase the workload for the examiners.  Employers’ failures to create a safe working environment, handle an injury correctly, promptly report a claim, or obtain prompt medical care slow the clams’ administration and slow claims closure thereby increasing caseloads.    

Employers’ relationships with their workers have a direct impact on litigation rates.  Some employer’s broker representatives slow or obfuscate the communication process between the employer, the claims examiner, the treating physician and the injured workers. [1]  

Examples of actions that increase the claims examiners workload, delays closure and impairs claims results include:  

  • 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. 

  • Employer does not implement appropriate safety programs and then blames the injured worker for the injury. 

  • Employer fails to immediately report all claims. (This is particularly true when the employer’s broker is used as an intermediary to report the claims). 

  • Employer does not use the appropriate designated medical facility (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 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 employers’ front-line supervisor failure to maintain contact with injured worker who is off on disability. 

  • Employer fails to provide notice to the examiner of any fraud red flags. 

  • Employer, believing all claims are fraudulent, pushes for broader/deeper investigation when the injury is clearly compensable. 

  • Self-insured 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 call the examiners every five minutes to get updates on the claims. 

  • Employers who never acknowledge a good job, but constantly complain to claims leadership about the claims examiner. 

  • Employers that make inappropriate peronal comments about the injured workers, including topics like  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 dispute. 

  • Employer does not acknowledge the work put into a successful Arising out of Employment or Course of Employment defense.  

These bullet points identify potential shortcomings, but the list  can be turned into a checklist for positive actions.  

It is the job of claims leadership to facilitate a positive relationship between the employer and the claims examiner.    

Some personalities just do not get along.  Claims managers should make sure that if the relationship is toxic that appropriate changes are implemented immediately. 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.  

[1] This assumes the employer has a sufficient claim volume to create a direct relationship with the claims examiner. Some insured employers do not have enough claims to create an ongoing interaction.  In this circumstance, the relationship between the employer and the claims adjuster needs to be developed as the claim develops.  In these circumstances employers can still directly impact outcomes through accurate focused and timely communication. But, in any relationship, the merit and value of patience and a periodic kind word cannot be underestimated.  

 

 


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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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