Zachry: Top Cost Drivers III: Claims Examiner 'Churning'

Wednesday, May 6, 2020 | 0

Claims examiners have a difficult job.

Bill Zachry

They may have a very high volume of claims. They are dealing with workers who are in pain, are concerned about the loss of their jobs, are worried about making their next payments, are angry because they sometimes do not have control over which doctor will be treating them, and are confused because of a complex system that makes no logical sense to them.

The insured employers can be upset because every loss contributes to increased expenses. Physicians are asking for the authority to treat, and every step has to be well documented for compliance reasons.

It is this environment that can result in churning by claims examiners. Here is a partial list of events that can cause churning:

• Failure to make sure that the treating doctor is the best option for the injured worker’s injury.
• Failure to promptly investigate, accept or deny claims.
• Failure to personally convey timely and accurate claims decisions (accept, delay, deny) to the injured worker.
• Failure to make sure that treatment approvals are provided promptly, thus resulting in better quality medical care.
• Failure to fully understand the light- and modified-duties programs of the employers and get the worker back on the job as quickly as possible.
• Failure to set an expectation for settlement and closure with the injured worker from the outset of the claim.
• Deer-in-the-middle-of-the-road syndrome when a particular claim is too complex for the level of experience or when the examiner is overwhelmed by the caseload and stops moving toward settlement.
• Failure to resolve issues of delayed settlement authority.
• Failure to convey a settlement offer in a timely manner.
• Having defense attorneys perform much of the day-to-day claims work that should be done by the adjuster.
• Failure to follow up on subrogation potential.
• Failure to recommend and do sub rosa on a timely basis.
• Failure to manage the vendors on the file to the stated standards.
• Failure to educate the employer concerning the status and process of the claim.
• Failure to remain objective and handle the claim as a professional rather than take it personally and handle it as a vendetta.

Bill Zachry is a member of the California State Compensation Insurance Fund board of directors and chairman of State Fund's Audit Committee. He's the former vice president of risk management for Albertsons and Safeway, and a former senior fellow of the Sedgwick Institute.