Mandatory Continuing Education for Claims Professionals

Saturday, December 20, 2003 | 0

An important theme to the recent wave of California workers' compensation reform bills running through Sacramento is claims examiner continuing education and certification. SB 228 added to the Insurance Code section 11761 mandating training, and California Insurance Commissioner John Garamendi has routinely said that carriers need to improve education of the claims work force. 11761 requires carriers to now certify basic levels of competency for claims departments.

There is no question that workers' compensation requires special competency and knowledge. A unique blend of medical knowledge, legal education and strict regulation makes workers' compensation a different, yet pervasive, animal in the insurance industry. It's interesting to note that the first legal topic certified by the California State bar for specialization was workers' compensation. Throw a general liability claims adjuster into a work comp case load, and you'll have a person pleading for mercy in just a couple of hours, after the anxiety of a significantly higher case load wears off.

And yet, for a variety of reasons, despite the high degree of special knowledge and skill required of a workers' compensation claims professional, the state of education in work comp claims departments over the last 10 years has significantly declined (which of course provoked the addition of section 11761). But the trend is reversing, not because of legislative mandate, but because the ranks of experienced professionals is thinning as people retire and general employment attrition takes its toll, leaving carriers without the experience necessary to run efficient claims departments.

Voluntary continuing education opportunities have always been available to workers' compensation claims professionals, typically not to preserve core competencies, but to move forward with special certifications, such as self-insurance claims administration.

But now that education is mandated, what does this mean to the day to day claims person? More work? Stagnant pay? Or will these requirements thin out the ranks of professional claims persons and increase the career prospects of those committed to the claims profession? We can't answer these questions (yet ... we're pending a survey), but we can raise questions, and draw on earlier studies as well as anecdotal evidence to identify some of the trends.

Other professional groups have studied whether continuing education improves the performance of the professionals within that group, and whether the group as a whole performs at a higher professional level. In general, there is sufficient data to support the proposition that continuing education does raise the level of competency for any professional group - doctors, lawyers, accountants, and claims professionals.

A recent report by the American Council on Pharmaceutical Education (ACPE) reviewed 99 studies conducted from 1975 to 1994, in which continuing professional education programs were evaluated. The research study, "Continuing Medical Education and the Physician as a Learner," headed by P.E. Mazmanian and D.A. Davis (JAMA 2002; Vol. 288), was designed to evaluate eight educational interventions on physician performance and health care outcomes. Its primary question was "They may have received CE credit, but what have they learned, how have they developed professionally, and what will be the impact on their practice and their patients' health care?"

The results, according to the article, showed that:

* 70 percent of studies evaluated reported a positive change in performance
* 48 percent of students evaluated a positive change in health-care outcomes.

Studies of other professions that require mandatory continuing education have seen similar results. Efforts by attorneys in California to dismantle mandatory continuing education in the state have failed largely because the empirical evidence that continuing education results in better service and a higher level of professional performance cannot be challenged.

Insurance Code section 11761both makes continuing education a requisite part of the claims person's professional life and a part of the carrier's reporting duties:

"(a) The commissioner shall adopt regulations setting forth the minimum standards of training, experience, and skill that workers' compensation claims adjusters must possess to perform their duties with regard to workers' compensation claims. The regulations adopted pursuant to this section shall, to the greatest extent possible, encourage the use of existing private and public education, training, and certification programs.
"(b) Every insurer shall certify to the commissioner that the personnel employed by the insurer to adjust workers' compensation claims, or employed for that purpose by any medical billing entity with which the insurer contracts, meet the minimum standards adopted by the commissioner pursuant to subdivision (a).
"(c) For the purposes of this section, "medical billing entity" means a third party that reviews or adjusts workers' compensation medical bills for insurers.
"(d) For the purposes of this section, "insurer" means an insurer admitted to transact workers' compensation insurance in this state, the State Compensation Insurance Fund, an employer that has secured a certificate of consent to self-insure pursuant to subdivision (b) or (c) of Section 3700 of the Labor Code, or a third-party administrator that has secured a certificate of consent pursuant to Section 3702.1 of the Labor Code."

One aspect of 11761 that has not received much attention is the requirement that medical billing entities, or in more common parlance, medical bill review companies, maintain minimum educational levels of their employees.

In addition, as of the date this article was authored in late December 2003 there were no proposed regulations from the Insurance Commissioner's office regarding continuing education. The number of hours, the minimum standards, required course work and standards for vendor certification, are all up in the air. How carriers are to record, maintain records, and report continuing education compliance for certification in accordance with section 11761 is also unclear.

However, starting 1/1/04 mandatory continuing education will be a part of the professional claims person's life. Expect mandatory course work to range from legal and medical topics, to generalized reading, writing and fundamental business practices such as time management. The industry will not only end up better educated, but will be able to justify to the premium paying public the value added service in professional claims management.

The views and opinions expressed by the author are not necessarily those of workcompcentral.com, its editors or management.