8 Signs that Your Work Comp Claims Examiner is a Rock Star … Or Not

work-comp-claims-examinerWhen it comes to your workers’ compensation costs, there are multiple pieces to the puzzle. But did you know your workers’ comp examiner can be one of the most influential factors in your claims and insurance costs? Just think about the many hats claims examiners have to wear during the claims process. They have to know about law, contracts, medicine, engineering, and construction. Their knowledge of medicine has to cover orthopedics, neurology, internal medicine, and psychiatry. They have to understand human relations, negotiations, and underwriting. On top of it all, they need to be patient, inquisitive, and composed.

That’s why it’s vital to have top notch examiners to handle your injured workers’ claims. But how do you know if your examiner is on the ball? How do you differentiate between an average examiner and a rock star who can save you money?

Start by asking these eight crucial questions:

  1. Do they have a thorough understanding of the workers’ compensation statute? A claims examiner’s job is to fairly and equitably apply the letter of the law in the workers’ compensation statute, so they must fully understand the statute and how it could be interpreted. The best examiners also understand current case law and how it applies to the management of their claims.
  1. Do they follow prescribed protocols and best practices for claims management? Good faith claims management is an absolute necessity for the fair and equitable application of the workers’ compensation statute and for a successful workers’ comp program. Examiners who consistently apply well-defined claims management best practices and procedures bring continuity and equality to the claims process.
  1. Are they champion players at the reserve game? Properly establishing reserves is one of the most crucial aspects of managing a claim. Examiners must be able to promptly and accurately formulate and establish adequate reserves on each claim. The real pros make judicious use of tools such as statistical databases and evidence-based medical guidelines to help them establish reserves.
  1. Do they “get” the experience modification formula? A good examiner knows that the way they manage a claim impacts their insureds’ profit and loss statements and their workers’ comp premiums. Understanding the components and function of the experience modification formula lets examiners see how their actions influence the cost of an insured’s insurance.
  1. Do they coordinate with a loss control specialist to create a comprehensive risk management program for the insured? Loss control is the cornerstone of a comprehensive insurance program, and claims management is just another form of loss control. A proactive claims examiner works closely with a loss control specialist to identify trends in frequency and severity of the insured’s accidents.
  1. Do they understand the impact of subrogation and pursue it vigorously? If a third party causes or contributes to a worker’s injury and subsequent loss, the insurance company can subrogate the loss and sue the negligent third party. Exceptional examiners are always on the lookout for potential third-party recoveries such as second-injury funds, negligent third parties, or reinsurance. 
  1. Do they measure their own performance? The best examiners use a variety of measurement tools to monitor their success in managing claims with such benchmarks as average length of time a claim is open, average cost per claim, accuracy of reserving (loss development), and response time to new claims.
  1. Do they get to know you as a client and understand your business? It is important for a claims examiner to fully understand a client’s business and what unique challenges each client faces. A good examiner will get to know all aspects of a client’s business whether that client is 10% of their case load or 100%. Different clients place higher emphasis on different elements of a claim. Is your focus on closures, reserves, or modified duty? Then your examiner should focus on those areas that matter to you as well.

The workers’ compensation adjusting process is sophisticated and complex and it requires a broad range of specialized knowledge. The best examiners not only have that knowledge, but understand the impact of everything they do and how it affects the entire insurance process.

When you’re ready for your own team of cost-cutting rock stars, call the California workers’ compensation experts at Republic Capital. We hire only experienced examiners with strong backgrounds, and we keep our claim counts low to maximize their success.

Maybe you’re not ready for a full change, but you’re concerned your current examiners may not be rock-star status? Republic Capital’s Claims Oversight Service can help evaluate how your claims are currently being handled and provide your current examiners additional direction to get your files moving toward resolution. Contact us today to learn more or download our brochure.