By Anne Llewellyn, MS, BHSA, RN, CCM, CRRN, CMGT-BC, BCPA, FCM

As a long-time nurse case manager specializing in workers' compensation, I quickly learned that building a strong relationship with the Claims Adjuster was essential for the success of a case. The Claims Adjuster plays a pivotal role in ensuring that the case complies with the state's regulations where the claim is filed. They are responsible for staying updated on all aspects of the case, including treatment plans, second opinions, and the necessity of diagnostic tests, procedures, and resources. Effective and proactive communication with all members of the team is crucial, as it keeps everyone informed and provides clear guidance on the case's direction.

By maintaining open lines of communication and providing explanations for the care plan, challenges, and setbacks, you keep the Claims Adjuster informed and assured that the case is progressing as planned. It's crucial to avoid blindsiding the adjuster with unexpected developments in your case.

To maintain a positive and productive relationship, seek the adjuster's preferences for receiving information, whether through email, phone calls, or notes in the case file. Everyone has their communication preferences, so adapting to theirs demonstrates your willingness to collaborate effectively. In complex cases, consider requesting weekly meetings to address multiple ongoing issues, but always use your discretion and proactively manage the case.

A strong working relationship with the Claims Adjuster can significantly impact the case's outcome. Keeping them informed and addressing issues promptly as they arise is essential. Effective communication with all stakeholders is vital to ensure everyone is on the same page and that you are effectively managing the case.

One notable outcome of effective case management is the ability to minimize unnecessary attorney involvement. According to Milliman, a company that establishes clinical guidelines in the workers' compensation field, cases with attorney representation take 2.1 times longer to close and cost 2.3 times more than cases without an attorney. Attorney involvement significantly impacts indemnity costs, which are 3.5 times higher than cases without an attorney.

Additionally, maintaining a positive rapport with the Claims Adjuster can lead to swift approvals for tests, equipment, therapy, transportation, and other necessary recommendations. This fosters trust with the injured worker and healthcare providers, demonstrating that you are in control of the case and are proactively driving it forward.

Earning the trust of injured workers empowers them to become active participants in their care. This can lead to greater receptiveness to treatment and acceptance of return-to-work options, including light-duty assignments and other strategies that promote case progression—another key objective for case managers.

Building strong relationships with Claims Adjusters is an ongoing process that involves effective communication, transparency, and collaboration. If you have any tips or strategies that have helped you build successful relationships with Claims Adjusters, please share them in the comments to help us all learn and improve.

Reference:  How Does Unnecessary Attorney Involvement Impact a Workers Compensation Claim?

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Bio: Anne Llewellyn, MS, BHSA, RN, RN-BC, CCM, CRRN, BCPA, CMF is a healthcare leader with over 40 years of experience as a critical care nurse, case manager, professional patient advocate, educator, digital journalist, and cancer patient. Anne is a past president of CMSA. She was awarded the organizations LifeTime Achievement Award for her work in case management in 2015. She was inducted as a CM Fellow in the first class. Anne is the current president of the All Florida Case Management Network and serves on the editorial board of CMSA and the National Association of Healthcare Advocacy. Anne works as a nurse advocate in the South Florida area.