Top Ten Service Standards for Workers' Compensation Carriers

When insurance carriers and claims administrators downsize and claims demands escalate, your adjusters may be overwhelmed by their caseloads. What minimum service standards you should expect from your workers' compensation carrier? Here are a few of the key claims-handling components to successfully investigate and manage injury claims.

1. Each claim, unless the injury is minor, should receive "three-point contact." This means the adjuster talks with the employee, the supervisor and the medical provider. This sends an important message to the employee and provider, one that says, "This injury is important to us."
2. On any questionable injury, you adjuster should complete a thorough investigation. This includes employee and witness statements, supervisory reports and statements from coworkers who may have information about the injury.
3. The adjuster should obtain a complete medical history whenever possible. After an injury, your legal duty is to return an employee only to pre-injury status. If there are preexisting conditions or problems such as diabetes that inhibit a return to full function, then your insurance carrier must know about these problems to correctly evaluate the claim.
4. Your carrier should assist you in return-to-work efforts. If your organization does not have a transitional work programs modifying job duties temporarily to bring an injured employee back to work, your insurance company should help you implement this critical program.
5. Your adjuster should receive a current, complete job description. If not, the doctor bases his or her work restrictions on the job duties your employee reports. These may not be factual, which often results in extra time off work.
6. Medical bills and lost wages should be paid promptly. In many states, payment timeliness is regulated by law. However, payments are often late due to a variety of communication snafus. Employees get frustrated when they must handle billings for work injuries or do not receive their wage replacement timely. A frustrated worker is more likely to hire an attorney or delay returning to work.
7. Questionable claims should be managed carefully. If you feel a claim is questionable, tell your adjuster. Adjusters see some red flags when they begin handling some claims, like a late report or a Monday morning injury. However, employers often suspect deception yet fail to tell their carriers. When you suspect fraud or that employees are working elsewhere or going beyond their job restrictions, ask your adjuster to hire an investigator to allay or confirm your suspicions.
8. Insist that the same pool of adjusters work on your files. This ensures your adjusters get to know your administrative staff, helps you with return-to-work issues, understands your payroll system and gets to know your supervisors. The adjuster should know whom it the organization to call to get information.
9. Medical cost containment should be a priority. Medical costs continue to escalate in workers' compensation. Your carrier should use managed care providers and prescription benefits managers whenever possible to decrease costs. Narcotics use should be closely monitored. According to the National Council on Compensation Insurance, one-fourth of all workers' compensation prescription costs are for narcotics. There are many issues associated with narcotics usage, including addiction, dental decay and stomach problems, which the employer often pays for, as well. Pain management specialists should be assigned early in the claim cycle if narcotics continue to be prescribed.
10. Your insurer should protect your financial interests if your employee is injured due to another's negligence. This is known as "subrogation." For example, if your employee is injured on the jobsite of another contractor or if equipment malfunctions, your insurance carrier should investigate and when appropriate pursue reimbursement from other negligent parties.

Workers' compensation costs continue to climb. Setting service expectations early in the relationship with your carrier or claims administrator will help your company save costs and ultimately improve employee morale.