You Get What You (Don't) Pay For

Wednesday, May 21, 2008 | 0

By Joe Paduda

With a case load of 160 lost-time claims, how does any workers comp claims adjuster have any time to "manage" any case?

That's the point Bob Kulbick, CMO at Cypress Care (HSA consulting client) made in a talk last week, a point I've been thinking about since that meeting.

The obvious answer is, "They don't." There is no possible way an adjuster can dedicate the time and brain power necessary to effectively manage claims with a case load that high. And that is not an unusual case load -- in fact most third-party administrators  keep case loads well above 120. Even that load is excessive -- it breaks down to about an hour a month per case.

Yes, an hour a month per case.

I'll grant that some of those cases are old and there's little going on - little except continued use of medications, in many cases physical therapy, and the odd surgery to repair an older fix or replace a surgical implant worn out by use or otherwise defective.

That is certainly not the situation with newer claims. Adjusters have to initiate the three point contact (actually four in most cases) within a predetermined time, set up the case, conduct an investigation into causality, establish liability, ensure reports are filed in a timely manner, determine the initial reserve, and coordinate with medical management.

Established cases require ongoing contact with case management, voc rehab, the injured worker, attorney(s) if represented, employer, and likely the injured worker's family. Medical bills have to be approved, drugs authorized, surgeries and hospital cases ok'ed, voc rehab plans reviewed, and then discussed with management.

This just hits the highlights - there are dozens of other discrete tasks involved in the process of adjusting comp claims, tasks that take time, careful thought, and professional judgment.

All of which are going to be in short supply with a case load of 160 LT cases.

Here's the message. Employers who buy claims adjusting services on the cheap will get exactly what they bargain for - poor quality from overburdened, frustrated, ineffective adjusters.

Joe Paduda is principal of Health Strategy Associates, a Connecticut-based employer consulting group. This column was reprinted from his daily blog, managedcarematters.com