Claims Q&A With Kevin Quinley – Claim Auditing Discoveries
We were caught up in a huge Workers Comp consulting project and I have neglected the blog page. OK, so here is the next installment of the Claims Q&A with Kevin Quinley on claim auditing discoveries.
Claim Auditing Questions . . .
In doing claim audits, are there recurring issues or problems you see with claim handling?
There are two that we see the most that heavily affect the outcome of a WC file. Those two are Immediate First Contact and Poor Communication. Often we see where an adjuster writes the injured employee, employer, and treating physician a form letter and then documents that there was immediate three-point contact. Talking with the employer, doctor, and employee about their WC claim ASAP is a great way to start the proper communications in the file.
The other related area is adjusters working the file, but not making any contacts with all or at least some of the parties involved. Good communication is the main job of the adjuster. If this is not done as shown by a trend by an adjuster or by a TPA/Carrier, we become very concerned.
What are the most common findings or observations during claim auditing? See the previous question.
How should claims people prepare for an audit before undergoing one?
Quit stressing when they hear their files are being audited. Some file audit firms consider a very nervous adjuster as a “red flag.” There is nothing that can be done to do a “quick fix” on the files. The one thing that I recommend is to be friendly and smile at the initial meeting. Do not EVER put the auditor on the defensive if they ask you a question. Auditors that are on the defensive tend to be more subjective in their file appraisals.
Are there “red flags” you look for when doing a claim audit?
We do heavy statistical analysis on the 33 areas that we look at for trends. If there is a trend by the adjuster or insurance carrier, then we red flag that one area. This happens very rarely except in one area. Over-reserving or under-reserving the files is a red flag that we notice very quickly. We do a stat analysis to confirm our findings. The numbers speak the loudest.
Over the years, do you sense any differences in skill among the claims profession in general? Is the claim service getting better or worse?
Claims adjusting has followed a definite trend. It is how the industry or a certain carrier decides on the file loads for adjusters. An overloaded adjuster cannot do the job that the insureds are relying on them to do on their files. When the industry/carrier trend is to lighten loads, the file handling improves proportionally.
For a firm looking to tame its workers compensation claim costs, what is the ONE thing they can do to deliver the greatest return on investment?
Time Management training pays big dividends. Stress management seminars seem to help. The old “claims roundtable” is also a great meeting to have for adjusters to discuss difficult files. We can tell the difference in file reviews between trained and untrained adjusting staff. The one word is training.
How do workers compensation claims people avoid getting burned out?
As mentioned before, they must remember that they ARE NOT claims adjusters. That is their job. In other words, leave it all at work. That is the secret to surviving in claims. Forget the files when you walk out the door every evening.
In a blind taste test, can you tell much of a quality difference between TPA claim services and insurer/staff claim services? Comment, please.
Yes, when we compare files a carrier also functions as a TPA. Flat-fee files seem to receive less attention.
If there is indeed a “brain drain” of seasoned claims people retiring, how can companies counteract that trend to salvage acceptable levels of expertise?
Some carriers do a great job of training incoming recruits. They also weed out recruits that will not make it in the adjusting world. Liberty Mutual has an outstanding training program. Training and screening will fight the brain drain.
What are employers’ biggest complaints about workers compensation claim service?
As I mentioned before, it is poor communication. They often do not know what is happening in their files. I always tell employers to request online claim access as they can follow the files without having to disturb the very busy adjusters.
What is the ideal caseload for an adjuster handling lost-time workers compensation files? Comment.
Oh, this is a loaded question. It depends on the state, but I would say 100 for a claims trainee, 150 – 175 for an experienced adjuster, and 200-225 for a Senior Adjuster. In my career, I have had to handle 250 files in 7 jurisdictions/states at one time. I juggled it very well until I burned out from fighting fires.
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