The "Ideal" Job for a Workers' Compensation Adjuster

Recently, we read an article that gave us encouragement in the workers’ compensation claims business. The article, “The Ideal Workers’ Compensation Adjuster Job”, was written by Michael B. Stack, CPA, a principal in Amaxx Risk Solutions, Inc.

Midland Claims Service, Inc. and Industrial Injury Claims has been leading the workers’ compensation claims industry for two decades. We give the adjuster the ability to create a relationship with the recovering worker to ensure the fastest and most complete medical recovery possible. It is more that an option for the adjuster/examiner, though. For us, it is a job performance expectation. Experience has shown that there is a direct, causal relationship between selecting a specific external vendor, from nurse case manager to vocational rehabilitation consultant to attorney, and the positive outcome that the adjusting team can achieve with the external vendor team. The adjuster is the hub of the claims wheel, no more or no less important that the external rim or each of the stakeholders spokes. It is the hub that holds the process together. The hub is the claims professional.

The article lays out 4 concepts that, if fulfilled, would be a situation that would closely resemble the ideal for most workers’ compensation adjusters/examiners. We agree with these concepts and layout the rationale:

1. Freedom to use any external vendor. Remove the adjuster’s job requirement to select only from a predetermined list of “approved” or contracted vendors, regardless of their specific staffing or experience in the state or situation which the adjuster is working with. Make it smooth and effective for the adjuster to find and utilize the “right” external vendor when properly documented. The article claims that freedom to select a vendor based upon their specific experience and qualifications for the specific situation allows a better match between use of resources and fulfilling the needs of the worker. We have seen, mostly on ‘takeover’ claims, how the use of a finite “approved” list can negatively impact claims. Further, we have shown that by using a loose team approved list, allowing the adjuster to seek out the needs of the parties, demonstrate of a team of peers their rationale and then select, retain the most appropriate vendor for the specific situation, has resulted in a dramatic reduction in a) open lost time claims beyond 18 months and b) litigation.

2. Adjuster keeps the file from day one to closing. As you have read from us, significant cost reductions have been demonstrated in workers’ compensation costs when the process allows for a relationship of confidence to build between the claim professional and the recovering worker. This relationship is built upon trust, bi-directional honest communications and the process of setting an expectation and delivering upon the expectation, time after time after time. From the smallest issues such as setting a medical appointment to weightier issues such as a partial denial for a pre-existing condition, the claim professional talks to the recovering worker, assists them in one way be laying out a schedule for what will happen and when they will be in communication again…and then following up at the date and time (or sooner) agreed upon. The worker feels engaged, included and valued; they do not feel that their claim is part of some faceless, meaningless, inhumane system. When this type of relationship develops between the adjuster and the recovering worker, the worker can focus upon their healing, dealing with the many changes and issues that arise when they are not at work, and take ownership of the recovery process. An engaged, motivated worker heals more quickly and completely than one that feels like the system is taking them for a ride. Allowing the adjuster to keep the file until closure ensures that the relationship that develops between the adjuster and the recovering worker perpetuates; the claim process continues as rapidly as possible while allowing the worker to focus upon getting better and returning to work, not learning someone new that is handling their claim.

3. Allow the adjuster to meet the recovering worker and visit the incident site. Back in “the day”, each adjuster met with the recovering worker, learned about them, their family, their needs to recover and return to work during or after the physical recovery was complete. The adjuster knew the motivating factors and could address them. And for the less legitimate claims, fraud and malingering were much more readily identified and dealt with. But that has changed. The standard and practice in the workers’ compensation claims business has moved to one of a work from home, metrics, reports, score card model. Adjusters are managed and evaluated by the number of ‘buttons pushed’ because of the need of claim facilities to reduce internal expenses. In the case of Third Party Claims Administrators (“TPAs”), the move from Time and Expense to flat rate ‘life of claim’ or ‘life of contract’ income models has significantly moved the day to day, action to action handling at the adjuster level. Daily decisions are made by adjusters with a higher priority placed upon keeping the diary list current than on developing a realist action plan based upon the needs of the legitimately injured worker and executing upon that plan. Regionalization, particularly where multiple states’ claims are handled by one individual directly, with no local claim contact, has further separated the claims professional from the recovering worker. In the case of work from home adjusters, the situation is exacerbated, there is virtually no chance for the adjuster to meet the recovering worker or visit the incident site to a) understand how the incident led to the claimed injury and b) show to other workers at the site that the claims payer is actively involved in the investigation of claims made (fraud deterrent). Many adjusters would benefit by having the option to sit down and talk plainly with the recovering worker, visit the incident site and develop a claim resolution plan based upon this first hand information. While it may be less expensive on the front end (claim allocated expense) to have an office/adjuster situation that allows for direct, eye to eye contact, the savings demonstrated by having this more humane way of handling claims has been epic.

4. Provide assistants to adjusters. It should go without saying that highly paid professionals can accomplish more in a given time period when they spend their predominant time completing professional level tasks, with a minimization of clerical tasks. But the word we hear from others in the workers’ compensation claims industry is that with each passing year, more scanning, letter typing, responding to supervisor best practices inquiries and diary management is being included in the workers’ compensation adjuster/examiner’s job duties. Our experience has been one of common sense, if it is faster and more accurate for the adjuster to do something, they do it. Conversely, if a task is more well suited for a lesser experienced staff member to complete the task, with accuracy and efficiency, the Claims Technical Assistant completes the task. Task assignment can be a subject of much time and motion study. Which we support. However, each task assignment can include the component of the impact that the task has upon the ultimate claim resolution. If a certain task assignment helps the adjuster bring the claim to resolution quicker, more accurately, with a positive outcome, that is the path that we choose. Beyond the simple time component, however, providing assistance to adjusters gives them a strong feeling of inclusion within the claims organization, like they and their role they play in accomplishing the mission of the organization are important, valued. We have seen countless times where the resolutions and outcomes produced by an adjuster who does not feel valued by the organization suffer. Give the adjuster/examiner the support that they need to serve as the hub in the claims wheel, positive results will follow.

Much that we have written here has to do with the ultimate claim resolution. Achieving the best results possible in a system (workers’ compensation) that is challenging on so many levels is a by-product of the input, ingenuity, empathy, planning and execution completed by the adjuster/examiner. In this context, we evaluate our results by the total cost of the program, loss costs plus the allocated and unallocated loss costs. This all inclusive view can lead to remarkably positive results. Looking at the adjuster’s role in the process in a holistic way is a way to achieve positive loss results and increase their job satisfaction and performance.