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Workers Comp Claim File Reviews – Trends Not Individual Files


Workers Comp Claim File Reviews – Avoid Looking At The Trees

Trends (Forest) Are Key

Most Workers Comp claim file reviews tend to lean towards reviewing only one or two large files.  That method remains a good way to analyze only those specific files.

A good associated article is this one on the claim adjuster’s everyday responsibilities.  Check it here.  The article is 11 years old, but still accurate today.

picture trees workers comp claims file review
Wikimedia Commons License – Wing-Chi Poon

The old adage of looking at the trees and not the forest applies here heavily. Discussing claims handling trends from one or two files usually does not work.  Why?  Let us look at the reasons.

Please note that this article is not a critique of adjusters or claims staff.

Reasons Specific File Reviews Do Not Equal Trends

  • Different adjusters – most large files are handled by seasoned  Senior Adjusters.  The files are reviewed often by the Claims Supervisor and Manager.   Having more eyes on a file usually results in much more documentation and a better claim direction.
  • Different adjusters part two – Each individual adjuster handles files differently.   An insured will usually have two or three adjusters working on their files.  If an insured has been with the carrier/TPA for many years, that number can easily total seven or eight adjusters.  Adjuster turnover seemed to increase during the pandemic.
  • Different jurisdictions- adjusters that have multistate claims know this one very well.  Each state has to be adjusted differently.  If the one or two files reviewed cover only one or two states and the claims’ jurisdictions are varied, this only adds to a myopic view of how the claims are being handled.
  • Different TPAs or Carriers – Trends can still be examined across multiple carriers or TPAs.   Specific workers’ comp claim file reviews make the review specific to that carrier or TPA.
  • Claims moved to a different handling office – this is one of those “secret” variations that can make the claims handling very different. Different claims offices handle the files differently.  Nowadays with everything being online, the files can be moved to a different handling office overnight.
  • Medical Only and Lost Time Claims – a good workers comp claims file review should always include medical only files. Check out this article on medical only claim reviews. 

The Rule of 7’s As a Guide

The Rule of 7’s in claims reviews was a term that I invented 20+ years ago.   I adopted it from the investing world.  Dividing a large number of claims by 7 tends to make a review task much smaller – and remember to include the medical only claims.  See the prior link in red on how to choose which ones to add to the total number set of claims.

Please avoid using “every 7th claim.”   This would not be a random sample.   The total number of claims would need to be at least 140 claims which would mean that 20 should be reviewed.  The larger the total claims count, the better.  Picking a few of the large files is great if you wish to have a review of those specific claims for some reason.  However, this defeats the random component.

Using a random number generator to pick the claims you wish to review will save time and effort.   Try this random number generator. 

***Please note that this article does not apply if you are reviewing files in a legal situation.  I recommend reviewing all available files for the workers comp claim file reviews as an expert witness.

(c) J&L Risk Management Consultants, Inc.  (c) Rule of 7’s



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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