First, for adjusters, retaining specialists involves additional costs and expenses. Upper management often evaluates and grades adjusters by how well they lower expenses, even if incurring an initial expense will yield savings downstream in the form of lower medical payouts or lost-time payouts. The latter phenomenon is harder to measure but up-front costs are easier to gauge. Most insurance companies are under extreme pressure to minimize costs in order to boost their financial ratings. Insurance rating agencies like A.M. Best track expense ratios as close as Major League Baseball batting averages. If a company is above the norm in its expense ratios, it could be career-threatening for some. Thus, the pressures to conserve and not incur unnecessary costs may deter adjusters from referring cases to occupational medicine and health specialists.

Second, adjusters may have only a vague idea of how these specialists could add value to a claim. Here the occupational medicine specialist might try to do a better job selling their services to claim adjusters and the industry by explaining how they can add value and make adjusters' jobs easier. Often, this message is lost on claim professionals. Thus, out of ignorance, they overlook situations where they are at the deep end of the pool and where it might be wise to retain an occupational medicine specialist.

A third factor relates to the typical workers' compensation claim adjuster's job environment. Unfortunately, many such adjusters are burdened with excessive caseloads. It is not unusual for lost-time adjusters to have 200 or 300 open cases. Not even the best adjusters could do a quality job on handling that many claims, dotting each “i” and crossing every “t”. They are relegated to putting out fires and trying to stay a step ahead. Desperate to keep their heads above water, they forgo involving occupational medicine specialists, even where such practitioners could help the adjuster trim his caseload.

The situation is like the parable about the woodsman felling trees with a dull axe. A passerby notices that the woodsman is working harder and harder but is getting less and less accomplished due to the axe blade's dullness. The passerby asks, “Why don't you stop and sharpen your axe?”

The woodsman replies, “I'd love to, but I'm too busy chopping down these trees!”

Many claim people and risk managers are so busy chopping down trees with dull axes, they feel constrained from taking time to involve another player on the file.

A fourth factor relates to the fact that engaging an occupational medicine specialist invites one more cook into the proverbial kitchen. While the benefits theoretically exist, the adjuster might view it as more of a hassle than it is worth. One more person involved in a file means more phone calls, more meetings, additional e-mails to initiate and respond to, all of which translate into more time and work for the already harried and overworked adjuster. The hassle factor may be perceived as excessive, given the murky benefits.

Another common explanation is that insurers cannot, for the most part, direct medical care. This is, frankly, a lame excuse because not only do many workers voluntarily go to recommended providers, but also they want to be advised on provider options.

A more deeply rooted problem is that, in an era in which supply chains have become incredibly more streamlined compared with the past, claim staffs do not approach medical providers as part of a de facto supply chain. Compare the high level of collaboration between claim staffs in other lines with independent inspectors, repair services, and more to see the difference. The root cause may be a cultural one; adjusters do not like to work closely with doctors, but they do with other professions. How many claim executives want to have lunch with doctors on a regular basis?

One can go to major employers, however, and see them developing very close and elaborate relationships with medical providers. You will find that the folks at the employer coordinating the effort are typically much more confident about working with doctors.

This collaboration will happen more and more among large employers. Currently, for example, Concentra, with 300 clinics, has 10 percent or more of all occupational medicine clinics in the U.S. and can negotiate an array of services with employers, TPAs, or insurers. It would be interesting to ask a sample of adjusters if they have ever considered sitting down with occupational medicine clinics to explore collaborations.

Finding Solutions

Here are some specific ways that risk managers can negate the typical adjuster bias in retaining occupational medicine specialists:

• Before placing coverage with a workers' compensation carrier, ask about the frequency and use of occupational medicine specialists.
• Request the right to have the insurer retain an occupational medicine specialist on any open claim that hits a certain reserve threshold.
• Ask the workers' compensation carrier for a list of its occupational medicine specialists.
• Consider hiring an occupational medicine specialist or putting one on retainer to come in periodically to review your open workers' compensation claims and make suggestions.
• Intervene with the handling adjuster on any case in which you think an occupational medicine specialist could add value.

Risk managers and claim professionals should take a fresh look at their knotty workers' compensation cases and consider involving an occupational medicine specialist. The rewards reaped can include lower claim costs, avoidance of unnecessary and harmful treatments, and earlier return to work. That's the “triple crown” of workers' compensation claim success. You need not be a medical professional to realize that this is a prescription for healthy claims.

Kevin Quinley CPCU, AIC, ARM, is senior vice president of Medmarc Insurance Group in Chantilly, Va. He can be reached at [email protected].