Good Communication with Claims Adjusters Helps to Speed Resolution of WC Claims

| | Utilization Review

claims adjuster

In workers’ comp, the ultimate goal of employers, physicians, utilization review (UR) providers, claims adjusters and the claimants themselves is to get the injured worker back to work as quickly as possible. To achieve this, UR providers need to work closely and productively with claims adjusters and medical providers. Open communication is key.

A Glance At the Claim Adjuster’s Role

Workers’ comp claims adjusters have challenging roles. They’re charged with helping ensure claimants receive appropriate and timely care through the proper channels (e.g., in-network providers) and must stay in contact with employers and doctors. Furthermore, claims adjusters often juggle multiple claims at a time, often maintaining caseloads of more than 100 active claims.

Take Initiative to Get Adjusters the Information They Need

Claims adjusters have the challenge of trying to appease physicians, employers, and claimants in each case. They often do not have time to carefully scrutinize requests and other information from physicians. As a result, sometimes key information is over looked.

This can lead to problems and unnecessary claim costs. For example, if a physician recommends that an injured employee take two weeks off work, the claims adjuster may have missed the request and therefore, did not explore whether the injured worker could return to work sooner via modified duty (e.g., answering phones instead of lifting heavy boxes). The employer might have a modified duty program that would return the employee to work sooner, but if the adjuster doesn’t have this knowledge from the employer nor notice the request from the medical provider, the injured employee stays out of work longer than necessary.

Medical providers can help by communicating with claims adjusters and UR agents. The medical providers should explore return-to-work options. by speaking with employees, and claims adjusters about possible modified work. By communicating in this way, medical providers can help claims adjusters return injured workers to their jobs as quickly as possible.

Use Tools that Help the Adjusters

Some states make it easier to open lines of communication with claims adjusters. That’s because these states require medical providers to periodically fill out forms during the treatment process. These forms provide valuable information to claims adjusters, including details of the incident, treatment records, prognosis of the worker’s condition, and whether or not the worker can return to their position or to a modified duty role.

These forms give claims adjusters the information they need to perform their duties more productively in an easy to read format. In states that do not require such forms, it may be a good idea to integrate similar forms into the process. Doing so ensures that claims adjusters receive the information they need to help resolve claims and help injured workers return to work.

Claims adjusters are busy, but they share the same goals as employers, claimants, and physicians: they want injured workers to be able to return to their normal, healthy lifestyles as quickly as they can. Clear communication between all parties – especially between claims adjusters and medical providers – can make the goal of a speedy return more feasible.

Karen Atkins

Karen Atkins, Chief Operating Officer with UniMed Direct, is leading the conversation, and the industry, on how to make the utilization review process more efficient for all stakeholders: physicians, insurance companies and, most importantly, patients.