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Who Is Your Medical Only Claim Adjuster – Name Please


Your Medical Only Claim Adjuster Important Team Member

The Medical Only claim adjuster is the person that are usually handling the more serious medical only claims.A large number of our clients have received our heavy recommendation to get to know their lost time claim adjuster(s). The adjuster(s) have a huge effect on your company’s Workers Compensation premium. We are often brought in as consultants to discuss files with the claims adjusters.

Vector Graphic Of Doctor Claim Adjuster Medical

One group of personnel that almost no employer or risk manager establishes a working relationship with is the Medical Only adjuster. Why is this so important? I have coined the term – festering claims. The Medical Only adjuster is the person that are usually handling the more serious medical only claims. The Medical Only adjuster also handles the claims by paying the medical bills on a very large group of claims. I have rarely seen a carrier where the lost time adjuster handles medical only claims.

I have seen so many serious claims not being handled properly as there seems to be a communication breakdown when the lost time adjuster is not handling the file. The employer will inform the lost time adjuster of a development on a medical only file. The lost time adjuster then has to hand off the info to the medical only adjuster. Often the necessary attention for a “festering file” is not given.

Medical Personnel Claim Adjuster Holding File And Pen

The file will then not have the proper investigation initiated until the loss control on the file is beyond repair. This type of file is much worse than a file that has had the attention of the lost time adjuster since day one.

I am not blaming anyone. This is just the nature of the beast in the Workers Comp claims industry. The claims industry is a sink or swim business.

Who is your medical only claims adjuster?The largest concern that we have with Medical Only files is not the normal files. In our reviews, we almost always see a few or many festering medical only claims. The file has made a turn for the worse and the proper investigation is delayed as the medical only adjuster’s job is to facilitate the timely payment of medical bills, not adjust the file. They are usually overloaded with hundreds upon hundreds of files.

Graphic of Folder And Mouse Claims Adjuster document

The other situation we see with festering medical only claims is when the employer has not informed the medical only adjuster that the file is now becoming a more serious matter.

The backstop for both of these situations is when the file reaches a large amount of medical payments and the file pops up on the carrier’s or TPA’s radar. These can turn out to be very expensive files in the long run.

As I have posted very often, an employer that has online access to their Workers Comp claims will usually have a great advantage. While it is the job of the adjusting staff to watch over claims that are becoming more serious, the employer can call attention to the claims that are reaching large $ amounts but are not classified as lost time files. One of the huge red flags is a very large medical bill or bills with numerous dates of treatment.

As the title indicates, knowing your medical only adjuster or adjusters makes the process of alerting the carrier of to a more serious medical only. An email to the medical only adjuster with a cc: to the lost time adjuster works very well. It is not a good idea to assume the claims adjusting process will take care of itself.

Picture Young Female Doctor Using Laptop at Desk in Clinic Claims Adjuster Medical Only

All of our clients do know who their Workers Comp lost time adjusters and medical only adjusters are on their company’s files and have realized premium savings on this simple tip.

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James J Moore - Workers Comp Expert

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Management Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications


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