Best Practices for Working With Claims Adjusters

As an employer, the worker’s compensation claim process can often be a stressful and challenging feat. Nevertheless, there are several ways to help simplify this process and promote the best possible outcome for your organization (e.g., a speedy recovery for the ill or injured employee and minimal claim expenses). In particular, it’s vital to foster a strong partnership with the claims adjuster.

After all, the claims adjuster is responsible for analyzing various aspects of a claim in order to determine how much the insurance carrier should pay for the associated loss. That being said, partnering with the claims adjuster may allow you both to reach the common goal of settling claims in a fair and cost-effective manner. Review these best practices to ensure a smooth and successful relationship with the claims adjuster in your workers’ compensation program.

Selecting the Right Insurance Carrier

The first step in creating a solid partnership with the claims adjuster is to select a workers’ compensation insurance carrier that meets your organization’s needs. Specifically, it’s crucial to confirm that your insurance carrier’s loss control techniques and claim management philosophy aligns with your organization’s approach to these topics.

Selecting an insurance carrier with contrasting loss control procedures or inadequate claim handling tactics could lead to increasingly adversarial claim experiences—thus significantly limiting your ability to develop a strong relationship with the claims adjuster.

In order to select the right carrier, it’s best to work with a qualified insurance professional. This professional will be able to leverage their insights from past experiences with insurance carriers to better identify carriers that are willing to provide coverage for your organization and have compatible perspectives regarding loss control and claim management.

Keep in mind that these elements are not the only aspects to consider when selecting a carrier. Other coverage components—namely, premium costs— may also play a role in your decision. In any case, being in alignment with your insurance carrier shouldn’t be overlooked, as it is essential to the development of a proper partnership with the claims adjuster.

Understanding Your Level of Authority

Once your organization has selected the right workers’ compensation insurance carrier, it’s important to gain an understanding of how much authority you will hold during the claim process. This is critical, seeing as different insurance carriers have varying distinctions on the specific claim management responsibilities between employers and claims adjusters. What’s more, state workers’ compensation laws outline how much control employers retain when it comes to claim decisions.

Knowing how much authority your organization holds will allow you to fully comprehend your role in the claim process, while also minimizing the risk of potential conflicts with the adjuster. Generally, most employers aim to have as much authority as possible. However, take note that smaller organizations may have a harder time establishing authority than larger organizations.

Regardless, be sure to review these main topics to grasp your organization’s level of authority:

1. Adjuster assignments—Assess how many claims adjusters could potentially be assigned to work with your organization. If possible, request that a single claims adjuster be assigned to all of your claims. This adjuster should be knowledgeable, experienced and treat your employees with respect. Working with the same claims adjuster each time a claim occurs will allow you to build a relationship and establish rapport with the adjuster, as opposed to starting from scratch at the onset of each claim.
2. Key claim decisions—Evaluate who gets the final word in major claim decisions—such as when to fight a claim versus pay it. This can be a difficult topic, as your organization may favor fighting claims in certain scenarios, whereas the adjuster may prefer to move forward with paying them. With this in mind, it’s important to develop an effective dispute resolution agreement between your organization and the claims adjuster. This agreement should outline how each party will appropriately respond and reach a compromise if they disagree on how to manage a claim. Although, remember that all claims must be handled in compliance with applicable workers’ compensation laws.
3. Claim investigation protocols—Ensure you know what measures can be implemented in order to investigate a claim. Investigation procedures may include conducting video surveillance of the ill or injured employee, scheduling an independent medical examination or visiting the employee alongside the nurse case manager. Further, make sure you know when it is appropriate to launch these protocols, as well as whether your organization or the claims adjuster is responsible for doing so.

Assisting in the Claim Process

Lastly, it’s crucial to do what you can to help the claims adjuster throughout the claim process. This practice will make the adjuster feel as though they can trust you and encourage them to listen to any input you may have regarding the management of a claim. Such a practice will also help resolve tensions in the event that you and the adjuster disagree on certain claim aspects (e.g., compensability or fraud concerns).

Follow these claim assistance tips:

• Keep detailed documentation during a claim— including an illness or injury investigation report, the employee’s latest medical records and return-to-work plans. Regularly share this documentation with the claims adjuster to help them better understand your organizational practices and the nature of the employee’s ailment.
• Routinely communicate with the claims adjuster to provide them with any updates regarding a claim. Refrain from communicating too much or too little with the adjuster. Develop a schedule that works best for them.
• Consider working with the claims adjuster to engage in periodic claim reviews. If they haven’t already, request that all claims be closed out once the impacted employees have healed or their treatment has concluded to avoid leaving claims open longer than necessary.
• Always share any extra knowledge you may have on a claim, as this information could help the adjuster. In turn, be sure to listen to the adjuster’s expertise as well.

Overall, make sure you establish a solid relationship with your claims adjuster and advocate for your inclusion within claim management procedures. Doing so will demonstrate your commitment to your organization’s workers’ compensation program and motivate the claims adjuster to view you as a valued partner in the claim process.

Contact us today for additional workers’ compensation resources.

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This article is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel or an insurance professional for appropriate advice. ? 2021 Zywave, Inc. All rights reserved.