During a conversation with an industry executive this morning I was reminded of the rather different perspectives, priorities, and incentives for adjusters and managers.
Faced with a virtual pile of incoming mail, messages, bills, documents, and voice mail, adjusters are tasked with determining compensability, closing claims, resolving litigation, getting claimants treated as quickly as possible – but only for covered services, dealing with vendors, catching fraud, setting and managing reserves, taking CEUS, communicating with employers, spouses, lawyers, and judges, approving drugs and medical services, directing to network providers, setting IMEs…the list is both endless and growing.
This while being measured on claim closure rates, three-point contacts (!?), reserving accuracy, litigation rates, network penetration, claimant satisfaction, and whatever the most recent metric du jour happens to be.
Home office folks have somewhat different priorities; managed care execs are evaluated based on network penetration, “savings” rates, staff productivity for bill review and medical management and various other process measures.
While there’s some alignment between the field and home office, what’s really important to one may be much less lower on the priority list for their counterpart.
For example, field folks’ priorities are to get claims moved along, claimants treated/examined/assessed, claims closed, reserves set.
A conflict can, and often does, arise when a network provider can’t see a claimant for a couple weeks, but another treater has an opening tomorrow. What’s the adjuster to do? In most cases, they will go for the quicker appointment as it moves the claim along more quickly. This holds true for IME providers, PTs, dentists, you name it. Time is of the essence.
The conflict here is obvious and happens all day every day, forcing adjusters to balance what are conflicting priorities in what can be a no-win situation.
What does this mean for you?
Clear priorities known and understood by all affected parties can remove a lot of unnecessary stress while eliminating much unneeded back-and-forth.
Joe, thanks for your observations. Speaking to the point of Adjusters having to keep many balls in the air, some years back an informal survey we did as part of a claims reengineering project showed that while medical was greater than 60% of the cost of claims, Adjusters spent only 15% of their time on claims medical management. More broadly speaking, there is an art and science to claims management that tuned in Managed Care Execs internalize into their leadership approach. The call to action for both Claims and Managed Care Execs is to develop a culture that recognizes that outcome metrics such as the overall cost of a claim (recognizing both indemnity and medical expenses) and return to work success trumps the process measurements you cited. Until then, incentives, communications, and efforts won’t be optimally aligned.